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DEPARTMENT of ZOOLOGY 
 STIMSON HALL 
 
 CORNELL 
 
 UNIVERSITY 
 
 LIBRARY 
 
 FROM 
 
 Tne Dept. oi" Zoology 
 
Cornell University Library 
 arV18926 
 Report of Professor Delafield's lectures 
 
 3 '1924 031 268 604 
 olin,anx 
 
The original of tliis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31 924031 268604 
 
INFLAMMATION. 
 
 I. Exudative Inflammation, 
 
 The blood-vessels take the active share in the inflam- 
 matory process, and the elements of the blood, which 
 escape from them, constitute the inflammatory products. 
 
 The steps of the process can be observed in the blad- 
 der and mesentery of the frog. The arteries and veins 
 are dilated, the blood-current is slower ; in the veins the 
 peripheral layer of white blood-cells becomes thicker 
 and slower ; in the capillaries the white blood-cells ac- 
 cumulate. There is emigration of the white blood-cells ; 
 diapedesis of the red blood-cells, and exudation of serum 
 rich in albumen, or in fibrino-plastic substances. 
 
 There must be changes in the walls of the blood-ves- 
 sels, but we are ignorant of their nature. 
 
 Varieties of Exudative Inflammation, i. Sim- 
 ple acuie exudative inflammation,— ^S^t changes in the 
 blood-vessels, and the production? ef serum, fibrin, and 
 pus, are associated with feWT^^^o changes in the sur- 
 rounding tissues. --* ' 
 
 a. In connective tissue'. — ^Connective tissue is com- 
 posed of a basenient:;st!bstance and of cells. Imbedded 
 in it are the blood-vessels, nerves, and lymphatics. 
 
 ^ 
 
2 INFLAMMATION. 
 
 There are congestion, swelling, and infiltration with 
 serum, fibrin, and pus in variable quantities. 
 
 b. In mucous membranes. — The structure of these 
 membranes is more complex than that of connective tis- 
 sue. They are all composed of a layer of epithelium, 
 of a connective-tissue stroma containing the blood-ves- 
 sels, nerves, and lymphatics, and of mucus glands. 
 There are congestion, swelling, emigration of white blood- 
 cells, diapedesis of red blood-cells, transudation of 
 serum. The quantity of inflammatory products is usually 
 small. The production of mucus is at first arrested, 
 afterward increased and altered. There may be ex- 
 cessive desquamation of epithelium and the formation 
 of superficial ulcers. Such an inflammation is also 
 called " Acute Catarrhal Inflammation." 
 
 c. In the viscera. — The viscera are all composed of a 
 connective-tissue stroma containing the blood-vessels, 
 lymphatics, and nerves, and of cells. The cells are 
 peculiar to each viscus, and are concerned in performing 
 the functious of the viscus. Congestion and swelling 
 are present ; the quantity of inflammatory products is 
 usually moderate ; there is derangement of the functions 
 of the viscus. 
 
 The inflammation is of the same nature in connective 
 tissue, the mucous membranes, and the viscera. The 
 differences are due to the different structures of these 
 parts. The process is always a transitory one, and does 
 not change the tissues of the inflamed part. After the 
 termination of the inflammation the congestion subsides, 
 the inflammatory products are absorbed, and the parts 
 return to their natural condition. 
 
INFLAMMATION. 3 
 
 2. Acute exudative inflammation, with excessive emi- 
 gration of the white blood-cells. — This is often called 
 purulent inflammation. The excessive quantity of pus- 
 cells may or may not be accompanied by serum and 
 fibrin. 
 
 The inflammation is of a more severe type than is 
 simple exudative inflammation. 
 
 Connective tissue is infiltrated with the inflammatory 
 products. 
 
 In the mucous membranes the pus-cells are mixed 
 with the mucus on the surface of the inflamed membrane. 
 
 In the viscera the stroma is infiltrated with the pus- 
 cells. 
 
 3. Exudative inflammation with degeneration, or death, 
 of tissue. — The changes in the blood-vessels, and the 
 consequent congestion and production of serum, fibrin, 
 and pus, exist, but there is added death or degeneration 
 of parts of the tissues in which the inflammation exists. 
 This additional change is apparently due to the presence 
 of pathogenic bacteria. 
 
 In connective tissue there are congestion, exudation 
 of serum, emigration of white blood-cells, and death of 
 portions of tissue. The dead tissue softens, breaks 
 down, and cavities are formed which contain serum, pus- 
 cells, and portions of dead tissue. Such cavities, with 
 their contents, are called abscesses. 
 
 In mucous membranes there are congestion, exudation 
 of serum rich in fibrino-plastic substances, emigration of 
 white blood-cells, and necrosis of tissue. 
 
 The fibrin infiltrates the stroma and coagulates on the 
 surface of the mucous membranes, so as to form false 
 
4 INFLAMMATION. 
 
 membranes. The pus-cells are entangled in the fibrin. 
 The necrosis involves only the epithelium, which passes 
 into the condition of coagulation necrosis and forms part 
 of the false membranes ; or it involves also the stroma. 
 The death of the epithelium forms superficial erosions, 
 that of the stroma, ulcers of varying size and depth. 
 
 Such an inflammation of the mucous membranes is 
 called "croupous," or "diphtheritic." 
 
 In the viscera the congestion is more or less marked, 
 there are exudation of albuminous serum and emigration 
 of white blood-cells. In addition there may be either 
 swelling and degeneration of the visceral cells, or death 
 of portions of the stroma with groups of cells, and the 
 formation of abscesses. 
 
 This variety of exudative inflammation is of severe 
 type, is accompanied with marked symptoms, and after 
 it has subsided, leaves changes in the tissues. 
 
 In connective tissue the cavities of the abscesses are 
 filled first with granulation tissue, and afterward with 
 cicatricial tissue. 
 
 In the mucous membranes the dead epithelial cells 
 may be replaced by new cells of the same kind, but the 
 ulcers formed by the death of the stroma have to be 
 filled first with granulation tissue, and later by cicatricial 
 tissue. 
 
 In the viscera the degenerated cells may be replaced 
 by new visceral cells, but the abscess cavities are filled 
 first with granulation tissue, and later with cicatricial tis- 
 sue. 
 
 4. Exudative inflammation with the production of new 
 tissue. — The changes in the blood-vessels, and the forma- 
 
INFLAMMATION. 5 
 
 tion of the inflammatory products, are well marked, but 
 there is added from the first a growth of new tissue. 
 This new tissue is at first of indifferent type, or like 
 granulation tissue ; later it may take the form of connec- 
 tive tissue. 
 
 In connective tissue the fibrin, serum, and pus are 
 found in varying quantities. The new tissue forms 
 thickenings and adhesions. 
 
 In the mucous membranes the serum, fibrin, and pus 
 are present only in small quantities. The function of 
 the mucus-glands is at first arrested, and afterward in- 
 creased ; the stroma is infiltrated with the new tissue. 
 
 In the viscera the quantity of the inflammatory pro- 
 ducts varies. The new tissue is produced in the stroma ; 
 there may also be degeneration of the visceral cells. In 
 the viscera this may be called a "diff'use " inflammation. 
 The most marked features of this form of exudative inflam- 
 mation are its tendency to persist for a long time, and 
 the frequency with which it runs a subacute rather than 
 an acute course. 
 
 II, Productive Inflammation. 
 
 The blood-vessels take no active share in the inflam- 
 matory process. The changes begin and continue in 
 the cells and basement substance of connective tissue, 
 whether by itself or forming part of mucous membranes, 
 or viscera. 
 
 In the connective tissue of the pia mater and peri- 
 toneum this inflammation may run an acute course, and 
 the inflammatory product consists only of new cells re- 
 sembling the normal connective-tissue cells of these 
 
6 INFLAMMATION. 
 
 iiietnbranes. This may be called " cellular " inflamma- 
 tion. 
 
 Much more frequently, this form of inflammation in 
 connective tissue runs a chronic course with the forma- 
 tion of indifferent tissue, or of dense connective tissue. 
 In this way thickenings and adhesions are formed. It 
 may happen that portions of this new tissue will degen- 
 erate, or be calcified. The slower examples of this form 
 of inflammation are often called " sclerosis." 
 
 In mucous membranes the growth of new tissue is in 
 the stroma. This is thickened, either diffusely, or in the 
 form of polypoid growths. The layer of epithelium may 
 be thickened or thinned. The mucus-glands are atro- 
 phied, or hypertrophied, or become cystic. The pro- 
 duction of mucus is diminished, or increased, or altered. 
 This condition in the mucous membranes is commonly 
 called a " chronic catarrhal " inflammation. 
 
 In the viscera there is a growth of indifferent tissue, or 
 of connective tissue, in the stroma. The visceral cells 
 are compressed, or degenerated, or fatty, or disappear. 
 The functions of the viscus are seriously interfered with. 
 In the viscera this is often called an "interstitial" in- 
 flammation. 
 
 The most marked features of this form of inflamma- 
 tion are its slow course and its tendency to continue. 
 The lesions of chronic productive inflammation, especial- 
 ly in old persons, are by some believed to be due to 
 chronic degeneration. 
 
 Tubercular and syphilitic inflammations are varieties 
 of productive inflammation. The special poisons of 
 tuberculosis and of syphilis may indeed give rise to exu- 
 
INFLAMMATION. 7 
 
 dative inflammations also. But tubercle tissue and 
 gummy tumors are the most constant accompaniments 
 of the tubercle bacillus and the syphilitic microbe. 
 
 Tubercle tissue is developed in connective tissue, in 
 the mucous membranes, and in the viscera. It is com- 
 posed of a basement substance, at first delicate, after- 
 ward firmer, which encloses large and small polygonal 
 cells and giant cells. It possesses few or no blood-ves- 
 sels, is of low .vitality, and is apt to undergo cheesy de- 
 generation. The tubercle tissue is arranged in little 
 spherical masses, called tubercle granula, or in diffuse 
 infiltrations. Its gross appearance is that of miliary 
 tubercles, less frequently of larger tubercular plates, in- 
 filtrations, or tumors. 
 
 Gummy tumors are found in connective tissue, in 
 mucous membranes, and in the viscera. They are com- 
 posed of a basement substance, and of small round, oval, 
 and fusiform cells. They possess few or no blood-ves- 
 sels, and frequently undergo cheesy degeneration. Their 
 gross appearance is that of irregular tumors of some size, 
 but occasionally they are small and resemble miliary 
 tubercles of small size. 
 
 With the formation of tubercle tissue and of gummy 
 tumors, there is often associated an obliterating endar- 
 teritis of the smaller arteries of the tissues involved in 
 the inflammation. 
 
 Acute Degeneration. 
 
 The introduction into the body of certain poisons, 
 such as arsenic, phosphorus, and mercury, and of the 
 poisons of the infectious diseases, is regularly followed 
 
8 INFLAMMATION. 
 
 by acute degeneration or death of the cells of the vis- 
 cera. 
 
 A small quantity of one of these poisons produces 
 simply a swelling of the visceral cells. 
 
 A larger quantity not only causes the cells to become 
 swollen, but they are also infiltrated with granules of 
 albuminoid matter and of fat, and are prone to disinte- 
 grate and break down. To these changes may be added 
 a secondary exudative inflammation. 
 
 In the more intense forms of poisoning there is a rapid 
 death of the visceral cells. They either disintegrate and 
 break down, or pass into the condition of coagulative 
 necrosis. With such a rapid death of the cells a well- 
 marked secondary exudative inflammation is often pres- 
 ent. 
 
THE DURA MATER. 
 
 The dura mater is a dense connective-tissue membrane, 
 which lines the inner surfaces of the cranial bones, forms 
 an investing membrane for the brain, and encloses the 
 large venous sinuses. 
 
 Its external surface is adherent to the bones and 
 forms their periosteum. Its inner surface is lined with 
 endothelium, and is in more or less close apposition with 
 the pia mater. 
 
 All inflammations of the dura mater, all forms of 
 pachymeningitis, are apt, therefore, to be associated 
 with lesions of the bones, the pia mater and the venous 
 sinuses. 
 
 Acute External Pachymeningitis. 
 
 Causes. — The ordinary causes are inflammation of the 
 external periosteum of the cranial bones, fractures, os- 
 teitis, chronic otitis, and suppuration in the orbit. 
 
 Lesions. — The inflammation is circumscribed and cor- 
 responds to the position of the exciting cause. There is 
 a collection of pus and fibrine between the dura mater 
 and the bone. 
 
 Symptoms. — By itself this lesion gives few symptoms 
 except the localized pain. Its importance consists in 
 the liability to the development of meningitis and throm- 
 bosis of the venous sinuses. 
 
THE mjRA MATER. 
 
 Treatment. — The proper treatment is to trephine the 
 skull and treat the inflammation antiseptically, or to 
 apply continuous cold. 
 
 Acute Internal Pachymeningitis. 
 
 Causes. — It is secondary to external pachymeningitis, 
 to chronic otitis, to pyaemia, puerperal fever, the exan- 
 themata, facial erysipelas, and chronic Bright's disease. 
 
 Lesions. — The inflammation is occasionally circum- 
 scribed, but much more frequently diffuse. The inner 
 surface of the inflamed dura mater is lined with a layer 
 of fibrine and pus. In most cases the inflammation ex- 
 tends to the pia mater. There may also be thrombosis of 
 the venous sinuses. 
 
 The symptoms and treatment are the same as those of 
 acute meningitis, or of thrombosis of the sinuses. 
 
 Chronic Internal Pachymeningitis. 
 
 Causes. — It may be secondary to diseases of the bones, 
 but more frequently occurs without discoverable cause. 
 It is especially frequent in persons whose health has 
 been enfeebled by other causes. In New York it is often 
 observed. 
 
 Lesions. — There is formed on the inner surface of the 
 dura mater a layer of new tissue, usually over the con- 
 vexity, either on one side or both. This new tissue is 
 closely adherent to the dura mater, it is composed of 
 connective-tissue cells, a scanty basement substance, 
 and numerous blood-vessels. In many cases the lesion 
 advances no farther than the production of this very thin 
 and delicate membrane. In other cases, however, there 
 
THE DURA MATER. 3 
 
 are hemorrhages into the new tissue, this becomes 
 thicker and denser, and so a mass may be formed thick 
 enough to compress the surface of the brain. This may 
 be followed by a chronic inflammation of the pia mater. 
 It occasionally happens that a single large hemorrhage 
 from the vessels of the new tissue will cause death within 
 a few hours or days. 
 
 Symptoms. — The lesser degrees of this form of pachy- 
 meningitis give no symptoms. A large hemorrhage may 
 occur even in such mild cases and, with no premonition, 
 at once give the symptoms of severe cerebral apoplexy, 
 which continue until death. 
 
 In the advanced cases there is continuous dull head- 
 ache, gradual impairment of intellect ; the walk becomes 
 unsteady, the articulation confused ; there may be attacks 
 of temporary loss of consciousness, drowsiness, and 
 stupor. 
 
 The course of the disease is slow and the symptoms 
 intermittent. It is said that some of the patients re- 
 cover. Usually they continue to grow worse, but are apt 
 to die of some intercurrent disease. 
 
 Treatment. — The only measures likely to be of service 
 are those directed to the general health of the patient. 
 
 Syphilitic Pachymeningitis. 
 
 Lesions. — The inflammation results in the production 
 of gummy tumors, which are situated either in the outer 
 or inner layers of the dura mater, or in both. At the 
 same time there is more or less chronic meningitis. Not 
 infrequently gummy tumors also exist in other parts of 
 
4 THE DURA MATER. 
 
 the body, especially in the periosteum of the cranial 
 bones and in the pia mater. 
 
 Symptoms. — -Headache continuous, but with exacerba- 
 tions, and often very severe. Attacks of unconscious- 
 ness, or of general convulsions. The intellect is im- 
 paired, there are alternating stupor and delirium, there is 
 often vomiting. , 
 
 The pressure of the gummy tumor on the brain pro- 
 duces, according to its situation, blindness, deafness, 
 localized convulsions, paralyses or rigidity, hemiplegia. 
 
 Treatment. — If the disease has not advanced too far, 
 the regular antisyphilitic treatment is of great service. 
 Mercury and the iodide of potash, given alternately or 
 together, may cause the entire disappearance of the 
 symptoms. 
 
 Thrombosis of the Venous Sinuses. 
 
 Causes. — Primary. Marantic — diarrhoea, phthisis, can- 
 cer, prolonged suppuration. Cases without discoverable 
 cause. Young infants and old persons are especially 
 liable, but it may occur at any age. Secondary. From 
 some inflammation situated near the sinuses — osteitis, 
 fractures, pachymeningitis, meningitis, abscess of the 
 brain, otitis ; from the pressure of tumors ; from ery- 
 sipelas of the face. 
 
 Lesions. — The sinus is partly, or completely filled. 
 The thrombi are red or white and firm, or softened and 
 puriform. The veins entering the sinuses are congested 
 or contain thrombi. The corresponding portion of 
 brain tissue is congested, oedematous, softened, and hem- 
 orrhagic. There is often a complicating meningitis. If 
 
THE DURA MATER. 5 
 
 the thrombus is broken down, there may be infaf ctions in 
 the lungs and in other parts of the body. 
 
 Symptoms. — There will be first the history of the pre- 
 ceding disease, or inflammation, then the symptoms of 
 the thrombosis. These symptoms are due to the change 
 in the brain tissue, the complicating meningitis, and the 
 septicaemia. Headache may precede the other symp- 
 toms for weeks or months. When the disease is estab- 
 lished there are headache, neuralgic pains in the face, 
 restlessness or delirium alternating with stupor, general 
 convulsions, vomiting, fever, prostration, the pysemic 
 condition. There may also be strabismus, paralysis or 
 rigidity of the muscles of the neck, arm, or leg. If the 
 thrombus is in the longitudinal sinus, there may also be 
 congestion and oedema of the forehead and sides of the 
 head, epistaxis, and in children prominence of the fon- 
 tanelle. In the cavernous sinus, cedema of the eyelids 
 and temples, swelling of the veins in the orbit, exoph- 
 thalmos. In the lateral sinus, congestion and oedema 
 over the mastoid process. 
 
 Histories. — Case I. A fairly healthy male, forty-eight 
 years of age, for thirty-four days before death suffered 
 from occasional headache. After a time there was added 
 neuralgia of the left side of the face. After nine days 
 there was severe right hemicrania. After three days more 
 he was in bed with alternating stupor and delirium, the 
 pulse 56, the temperature normal, no paralysis. Seven 
 days before death the pulse was 99, the temperature 
 100° F. He became comatose, and so died. 
 
 There was a pinkish thrombus filling the straight sinus 
 and the right lateral sinus. Over the posterior end of 
 
6 THE DURA MATER. 
 
 the second right frontal convolution there was thrombosis 
 of the large veins of the pia mater, the pia was infiltrated 
 with pus and serum, part of this convolution was mot- 
 tled with hemorrhages. There was no lesion in any 
 other part of the body. 
 
 Case II. A woman, twenty-three years of age, for 
 two months before her death was antemic and troubled 
 with headache. Five days before death the headache 
 grew worse, there was vomiting, dry tongue, stupor, pulse 
 70, temperature 98° F. One day before death she was 
 restless, there were twitchings of the muscles of the arms 
 and legs, she was unable to swallow. Just before death 
 the temperature rose from 100° to 107° F. There were 
 red and white thrombi in the straight sinus, in both lat- 
 eral sinuses, and in the. veins of Galen. Both optic 
 thalami were softened and hemorrhagic. No other 
 lesions were found. 
 
THE PI A MATER. 
 
 The pia mater is the investing membrane of the brain. 
 It is composed of lamellae of connective tissue so ar- 
 ranged as to form a spongy membrane. Its free surface 
 is covered with endothelium, and the lamellae of which 
 it is composed are also coated with connective-tissue 
 cells. It contains numerous blood-vessels which are 
 continuous with those of the cortex of the brain. 
 
 The pia mater may be the seat of acute, chronic, 
 tubercular, or syphilitic inflammations. Its inflamma- 
 tions are called meningitis or leptomeningitis. 
 
 Acute Meningitis. 
 Lesions. — There are two anatomical forms, both of 
 which give rise to the same symptoms. 
 
 1. Cellular meningitis. After death the pia is found 
 congested, dry, lustreless. It contains little or no 
 serum, fibrine, or pus. The inflammatory product is new 
 cells of connective-tissue type formed on the surfaces of 
 the lamellas. 
 
 2. Exudative meningitis. The pia mater is infiltrated 
 with serum, fibrine, and pus in variable quantities. There 
 may be little collections of pus between the pia and 
 brain. The cortex of the brain and the cranial nerves 
 may be involved in the lateral ventricles. The lateral 
 ventricles contain clear or purulent serum, and in chil- 
 
8 THE PIA MATER. 
 
 dren the quantity of serum may be so great as to distend 
 the ventricles. There is often added inflammation of the 
 pia mater of the cord. Both forms of meningitis are 
 regularly diffuse, involving the larger part of the pia, 
 although the inflammation may be more intense either 
 over the convexity or the base. 
 
 Causes. — Meningitis occurs without discoverable 
 cause, after injuries and inflammations of the cranial 
 bones, otitis, pachymeningitis. It complicates Bright's 
 disease, pysemia, pneumonia, the exanthemata, typhus 
 and typhoid fever, rheumatism. It is the characteristic 
 lesion cf epidemic cerebro-spinal meningitis. 
 
 Symptoms. — The idiopathic cases. There may be a 
 prodromic period characterized by headache, irritability, 
 sleeplessness, vomiting, conjunclivitis, and general 
 malaise, or the invasion may be sudden. Severe head- 
 ache, frontal, occipital, or general, begins early in the 
 disease and continues throughout. Restlessness or de- 
 lirium and stupor alternate throughout the disease ; either 
 one may be the more marked. General or unilateral 
 convulsions may mark the invasion of the disease, or be 
 developed at any time during its course. 
 
 General or local hyperaesthesia of the skin belong to 
 the earlier days of the disease. Involuntary twitchings 
 of the muscles of the face, and rigidity of the muscles 
 along the vertebral column, are frequently present. At 
 first there is photophobia, then insensibility to light, then 
 blindness, often internal strabismus. The hearing is at 
 first acute and painful, later dull. 
 
 Vomiting may mark the invasion of the disease, or be 
 continued ; in some cases it is a marked symptom. The 
 
THE PIA MATER. 9 
 
 tongue is at first coated and moist, afterward dry. Con- 
 stipation is the rule, but toward the close of the disease 
 there may be diarrhcea. The urine is diminished in 
 quantity, and often contains small quantities of albumen. 
 
 The temperature ranges from ioo° to 104° F., some- 
 times higher ; it follows an irregular course. The pulse 
 during the invasion is rapid, then becomes slow, and in 
 fatal cases, toward the close of the disease is rapid and 
 feeble. Toward the close of the disease, the patients 
 may become completely unconscious. 
 
 In children the disease may follow the same course as 
 in adults, or be characterized only by convulsions, 
 stupor, and a febrile movement, or resemble tubercular 
 meningitis. In young adults we sometimes see pro- 
 tracted cases tesembling tubercular meningitis, but 
 terminating in recovery. 
 
 The Duration of the disease is from thirty-six hours to 
 four weeks ; most of the cases last for one or two weeks. 
 
 The Prognosis is always serious, but yet a considerable 
 number of patients recover. 
 
 The meningitis which follows injuries and inflamma- 
 tions of the cranial bones, otitis, or pachymeningitis, 
 and which complicates Bright' s disease and the infectious 
 diseases, is accompanied with the same symptoms as 
 have just been described ; but these symptoms are pre-, 
 ceded by those which belong to the original injury, in- 
 flammation, or disease. 
 
 Treatment. — The treatment consists in the general 
 management of the patient, the use of means to control 
 the inflammation, and in relieving the pain and discom- 
 fort. The patients are to be put to bed at once, even in 
 
lO THE PIA MATER. 
 
 the prodromic period. They are to be kept from every 
 exertion or excitement. The food should be entirely 
 fluid, the constipation should be relieved by laxatives or 
 enemata, the skin is to be kept clean. 
 
 Treatment directed to the inflammation is most effica- 
 cious during the early days of the disease. The most re- 
 liable measure is the application of continuous cold over 
 the entire external surface of the cranium by the cold- 
 water coil or ice-bags. Counter-irritation is less effica- 
 cious and more disagreeable. 
 
 Of drugs the best are calomel, sulphate of magnesia, 
 iodide of potash, and opium. The calomel and sulphate 
 of magnesia are given only for one or two days, in such 
 doses as will act on the bowels. The iodide of potash 
 and the opium are given throughout the active period of 
 the disease, in moderate doses. To relieve the headache, 
 restlessness, and delirium we employ cold to the head, 
 the bromides in full doses, chloral hydrate, or opium. 
 
 Chronic Meningitis. 
 
 Lesions. — Either the pia mater over the base, or that 
 over the convexity, or both, may be involved ; the in- 
 flammation being more often localized than with acute 
 meningitis. The pia mater is thickened and opaque, 
 succulent, infiltrated with serum, fibrine, pus, and new 
 cells. There may be adhesions between the pia mater 
 and the dura mater. The cortex of the brain may show 
 an increase of the neuroglia cells, softening, or sclerosis. 
 The ventricles of the brain may contain an increased 
 quantity of serum, and their ependyma may be thick- 
 ened. 
 
THE PIA MATER. I I 
 
 Causes. — Chronic meningitis belongs to adult life. It 
 may be secondary to fractures and inflammations of the 
 cranial bones, to pachymeningitis, to chronic Bright's 
 disease, and to alcoholism. It may be associated with 
 chronic endarteritis of the cerebral arteries. It occurs 
 in persons who are badly nourished and of dissipated 
 habits. 
 
 The Symptoms are the same as those which have al- 
 ready been described as belonging to chronic internal 
 pachymeningitis. The disease is usually protracted 
 over many years, its course interrupted by periods of 
 apparent improvement. It terminates in insanity, or in 
 death from exhaustion with cerebral symptoms. 
 
 The Treatment is the same as that for chronic pachj - 
 meningitis. 
 
 Tubercular Meningitis. 
 
 I. In Children. Lesions. — The dura mater is usually 
 unchanged, but sometimes there are miliary tubercles on 
 its inner surface. The surface of the brain is flattened 
 by the distention of the ventricles. In the pia mater we 
 find miliary tubercles and inflammatory products, most 
 frequently at the base of the brain, but sometimes over 
 its entire surface. The tubercles are most numerous in 
 the pia mater over and in the sulci. 
 
 The tubeicles are very small and transparent, or larger 
 and white. They are composed of simple aggregations 
 of round and epithelioid cells, or of masses of tubercle 
 tissue surrounding small arteries. Tubercle bacilli are 
 present in moderate numbers. The adjoining small 
 arteries are often the seat of obliterating endarteritis. 
 
12 THE PIA MATER. 
 
 The accompanying inflammatory products are serum, 
 fibrine, and pus, which infiltrate the pia mater in varying 
 quantities ; or small cells alone, which hardly change the 
 gross appearance of the pia. ' The ventricles of the 
 brain are much dilated and distended with serum. Their 
 ependyma is thickened and contains very small tubercles. 
 The brain tissue around the ventricles is often soft. 
 There may be similar lesions in the pia mater of the 
 spinal cord. 
 
 In young children the tubercular meningitis is regular- 
 ly only part of an acute general tuberculosis, so that we 
 find tubercles in many other parts of the body: 
 
 Causes. — The children affected are usually under five 
 years of age. There is often a family history of tuber- 
 cular disease. The acute general tuberculosis may fol- 
 low a localized tuberculosis, or be primary. 
 
 It is to be remembered that in children, although 
 we call the disease tubercular meningitis, it is really 
 an acute general tuberculosis with meningeal symp- 
 toms. 
 
 Symptoms. — There may be a prodromic period, prob- 
 ably due to the development of the general tuberculosis, 
 which usually lasts for only a few days, but may be pro- 
 tracted for several weeks. During this period there are 
 loss of flesh and strength, slight evening fever, irritabil- 
 ity, sleeplessness, frontal headache, vomiting, constipa- 
 tion, and a coated tongue. These symptoms are not 
 continuous, but are interrupted by periods of improve- 
 ment. • 
 
 When the disease is fairly established the child is in 
 bed, the face flushed, anxious, or apathetic. There are 
 
THE PIA MATER. 1 3 
 
 headache, convulsions, stupor alternating with restless- 
 ness or delirium. During the periods of restlessness the 
 child moans or cries out. The bowels are constipated, 
 there may be vomiting. Photophobia, aphasia, and 
 hypergesthesia of the skin may be present. The pulse is 
 slow in proportion to the temperature, and irregular ; the 
 breathing is often irregular ; the temperature is raised and 
 irregular, not always corresponding with the severity of the 
 disease. The urine is scanty and contains albumen. At 
 about the end of the first week, sometimes earlier or 
 later, there are strabismus, inequality of the pupils, 
 ptosis, changes in the optic disk. In the second week 
 the stupor becomes more profound, the delirium more 
 marked. There may be rigidity of the muscles of the 
 back of the neck, the arms, and the legs ; or local con- 
 vulsions or paralyses, which are transitory or permanent ; 
 automatic movements of the arms and legs ; anaesthesia 
 of the skin. The pulse becomes more frequent, and the 
 temperature higher. There is no longer photophobia, 
 but insensibility to light, with dilated pupils. 
 
 The children die in convulsions, or in coma, or be- 
 come extremely feeble and emaciated ; the urine sup- 
 pressed, the breathing rapid, the temperature still high 
 or below the normal. 
 
 It is said that, when the meningitis involves only the 
 pia mater over the convexity of the brain, there is no 
 strabismus and but little vomiting. Headache, delirium, 
 convulsions, and rigidity of the muscles are the chief 
 symptoms. During the course of the disease there are 
 often short periods of improvement. 
 
 The Duration of the disease is from one to four weeks. 
 
14 THE PIA MATER. 
 
 It is said to be shorter when the convexity alone is in 
 volved. 
 
 The Prognosis is very unfavorable. 
 
 Treatment. — When we remember that the disease to 
 be treated is not merely a meningitis, but an acute gen- 
 eral tuberculosis, it is evident that treatment can do 
 nothing but alleviate the patient's suffering. There are, 
 however, some cases, with active cerebral symptoms, in 
 which the diagnosis is uncertain, and for these we may 
 employ the same means that are useful in acute menin- 
 gitis. 
 
 II. In Adults. Lesions. — The changes in the pia 
 mater are the same as in children, but the ventricles of 
 the brain are not usually involved. 
 
 The meningitis is less often part of a primary general 
 tuberculosis ; it is more often a localized tubercular in- 
 flammation, or secondary to a localized tuberculosis 
 already existing in some other part of the body. 
 
 Symptoms. — An adult may suffer from general tuber- 
 culosis, involving the pia mater, without symptoms of 
 meningitis. He may have a primary, localized tuber- 
 cular meningitis with marked symptoms. He may have 
 a localized tuberculosis in some other part of the body, 
 which has given few or no symptoms, and then suddenly 
 develops the tubercular meningitis, as if it were a primary 
 inflammation. He may have an acute general tuber- 
 culosis with marked cerebral symptoms. He may suffer 
 from a well-marked localized tuberculosis, such as pul- 
 monary phthisis, and develop a complicating meningitis 
 with marked symptoms. 
 
 Most ®f the well-marked cases of tubercular meningitis 
 
THE PIA MATER. 1$ 
 
 are in young adults, between the ages of fifteen and 
 twenty-five years. 
 
 Symptoms. — The invasion is sudden, with chill, fever, 
 headache. Vomiting, and marked prostration ; or gradual, 
 with headache, malaise, but so little prostration that the 
 patient does not go to bed. When the disease is estab- 
 lished, the headache is severe and continuous. Alter- 
 nating stupor and restlessness, sleeplessness, or delirium, 
 conjunctivitis, photophobia, strabismus, ptosis, invol- 
 untary contractions of the muscles of the face, arms, 
 and legs, hyperaesthesia of the skin, and vomiting, are 
 regular symptoms. There is an irregular febrile move- 
 ment. The pulse is sometimes slow, sometimes rapid : 
 the urine contains albumen and casts. 
 
 Paralysis of the face, of the muscles of the throat, of 
 the arm, or of one side of the body, may be develope,d 
 later in the disease. The symptoms may be marked and 
 continuous, the temperature high, and the patient die 
 comatose in from seven to fourteen days ; or the symp- 
 toms are less marked, the temperature is lower, the pa- 
 tients go on for weeks, and die in a typhoid condition. 
 
 The Prognosis is bad, and yet it must be admitted that 
 some patients, who give a well-defined clinical history of 
 tubercular meningitis, do eventually recover. 
 
 Treatment. — This is the same as that for the tubercular 
 meningitis of children. 
 
 Syphilitic Meningitis. 
 
 Inflammations of the pia mater, due to syphilis, re- 
 gularly behave in one of three ways : 
 
1 6 THE PIA MATER. 
 
 1. They give the clinical history of an acute" menin- 
 gitis. 
 
 2. They give the history of a chronic meningitis. 
 
 3. They give the symptoms of an intra-cranial tumor. 
 The Treatment is the regular antisyphilitic course with 
 
 mercury and the iodide of potash. In the cases which 
 behave like an acute meningitis, the application of cold 
 to the head may also be indicated. 
 
THE BRAIN. 
 
 The cortical motor tract of the brain is composed of 
 the two ascending central convolutions, the paracentral 
 lobule, and the anterior two-thirds of the superior parietal 
 lobule. The upper third of this tract controls the motions 
 of the leg, the middle third those of the arm, the lower 
 third those of the face. 
 
 Destruction of any part of thi^ motor tract causes 
 parilysis of the opposite side of the body, with degener- 
 ation of the pyramidal tract, and rigidity of the limbs. 
 
 The number and position of the muscles paralyzed de- 
 pend upon the extent and position of the lesion. 
 
 Irritating disease and stationary partial lesions of the 
 same tract cause convulsive movements, beginning in the 
 corresponding muscles. These movements may remain 
 confined to these muscles, or may extend to all the 
 muscles of the same side, or to the muscles of both sides 
 of the body. 
 
 This local commencement of the convulsive move- 
 ments is characteristic of cortical lesions. 
 
 Lesions of the third left frontal convolution impair or 
 destroy the power of uttering language. 
 
 Lesions of the first left temporal convolution impair 
 or destroy the power of understanding spoken or written 
 language. 
 
2 THE BRAIN. 
 
 Lesions of the apical region of the occipital lobe, es- 
 pecially of the cuneus, produce hemianopia. 
 
 Extensive lesions of the cortex around the fissure of 
 Sylvius, extending over much of the central, parietal, and 
 temporal convolutions, may cause hemiplegia and he- 
 miansesthesia, loss of all the special senses, with blind- 
 ness of the opposite eye. , 
 
 Lesions of the white matter of the hemispheres pro- 
 duce symptoms resembling those of lesions of the cortex 
 or of the internal capsule, according to the position of the 
 lesions near one or other of these portions of the brain. 
 
 The internal capsule. Lesions of the angle and the 
 posterior segment are the most common causes of 
 hemiplegia. There is paralysis of the lower part of the 
 face, the tongue, the arm, the leg, and, if on the left side, 
 temporary aphasia. There may also be hemiansesthesia 
 and hemianopia. 
 
 The corpora striata. Lesions of the caudate or lenti- 
 cular nucleus generally produce hemiplegia, which is not 
 permanent unless the internal capsule is also damaged. 
 Small or chronic lesions may not produce hemiplegia. 
 
 Lesions of the crura cerebri produce loss of motion 
 and sensation of the face and limbs of the opposite side, 
 and paralysis of the muscles supplied by the third nerve 
 on the same side. There are seldom convulsions. 
 
 The pons Varolii. Unilateral lesions produce paralysis 
 of the limbs on the opposite side, and of the muscles sup- 
 plied by the fifth and sixth nerves on the opposite side. 
 Bilateral lesions produce paralysis on both sides, difficulty 
 in sw.allowing, and inarticulation. Convulsions are rare 
 in chronic, but common in acute, lesions. 
 
THE BRAIN. 3 
 
 The medulla oblongata. Severe lesions cause sudden 
 death. Lesser lesions cause paralysis of the muscles sup- 
 plied by the hypoglossal, glosso-pharyngeal, and spinal 
 accessory nerves (Gowers). 
 
 Hemiplegia of the face, tongue, arm, leg, and side of 
 the thorax is due to lesions of : 
 
 The pons Varolii, the crura cerebri, the corpus striatum, 
 with the internal capsule, the ascending central convolu- 
 tions and the lobulus paracentralis. 
 
 Sudden paralysis of the arm and leg, without affection 
 of the cranial nerves, is most often due to lesions of the 
 paracentral lobule and upper part of the central convo- 
 lutions ; less frequently to lesions in the medulla, pons, 
 crura cerebri, and internal capsules. 
 
 Sudden paralysis of one arm alone usually indicates 
 a lesion of the middle third of the ascending central con- 
 volution. 
 
 General convulsions, beginning always in the same 
 group of muscles after paralysis, indicate a cortical lesion. 
 
 Aphasia. Impairment of the function of expressing 
 thought by spoken or written language, indicates a lesion 
 of the third left frontal convolution. 
 
 Impairment of the capacity of understanding spoken 
 or written language, indicates a lesion of the first left tem- 
 poral convolution (Nothnagel). 
 
 The Cerebral Arteries. 
 
 The anterior cerebral arteries supply the .first frontal 
 convolution, the anterior two-thirds of the second frontal, . 
 the upper end of the anterior central, the orbital surface 
 
4 THE BRAIN. 
 
 of the frontal lobe, and the anterior part of the caudate 
 nucleus of the corpus striatum. 
 
 The posterior cerebral arteries supply the occipital lobe, 
 the lower part of the temporal lobe, the optic thalami, 
 and the corpora quadrigemina. 
 
 The middle cerebral arteries supply the third frontal 
 convolution, the posterior end of the second frontal, most 
 of ths anterior and posterior central, the orbital surface 
 outside of the orbital sulcus, the parietal lobes, the island 
 of B eil, the superior and middle parts of the temporal 
 lobes, the corpora striata, the inner parts of the optic 
 thalami, and the internal capsule. 
 
 The medulla and pons are supplied by branches from 
 the anterior spiuals, vertebrals, basilar, and posterior 
 cerebrals. 
 
 The cerebellum is supplied by branches from the basi- 
 lar and vertebrals, 
 
 Inflammation of the Cerebral Arteries. — The 
 arteries throughout the body are frequently the seat 
 of chronic inflammation, which follows one of two ana- 
 tomical types. 
 
 I. There is a growth of cells and basement substance 
 from the inner surface of the wall of the artery, which 
 obstructs the lumen of the vessel, or may occlude it en- 
 tirely. This is called " obliterating endarteritis." It 
 terminates by cutting off the supply of blood from the 
 tissues belonging to the diseased vessel. 
 
 a. There is a growth of dense connective tissue in the 
 inner coats of the artery, which renders the arterial walls 
 thick and rigid, and projects in flat masses into the lumen 
 of the vessel. The new tissue thus produced is prone to 
 
THE BRAIN. 5 
 
 degenerate ; it may be converted into granular matter, or 
 infiltrated with the salts of lime. In this way the walls 
 of the artery become thickened/ in some places and 
 thinned in others, its lumen is irregular, its inner surface 
 is roughened. This is called " deforming endarteritis.'' 
 It results in the rupture of the diseased vessel, in the 
 formation of aneurismal dilatations, in the closure of the 
 arteries by thrombi, or in rendering the supply of arterial 
 blood to the parts belonging to the diseased artery un- 
 certain and irregular. 
 
 Either of these forms of endarteritis may involve at the 
 same time many of the arteries in different parts of the 
 body, or a single set of arteries in one part of the 
 body. 
 
 Causes. Chronic endarteritis is especially common in 
 persons over forty years old. It is frequently associated 
 with chronic gout, constitutional syphilis, pulmonary 
 emphysema, chronic Bright's disease, and chronic en- 
 docarditis. But it may also occur by itself and without 
 discoverable cause. 
 
 The cerebral arteries are often the seat, either of 
 obliterating endarteritis or of deforming endarteritis. 
 
 According to the development of the lesion, we have 
 extravasations of blood from rupture, softening of por- 
 tions of the brain from occlusion or thrombosis, the 
 formation of aneurisms within the cranial cavity, or an 
 irregular supply of blood to portions of the brain. 
 
 We see very frequently patients in whom no cerebral 
 clots, or areas of softening, or aneurisms, or thrombi are 
 to be found, but who yet exhibit marked, and even fatal, 
 cerebral symptoms. The cause of these symptoms is ap- 
 
6 THE BRAIN. 
 
 parently the change in the walls of the cerebral arteries 
 and the consequent irregularities of the circulation. 
 
 The symptotns presented by these patients are at first 
 in the form of temporary attacks, which last for hours or 
 days, and then disappear. Such attacks are repeated at 
 irregular intervals during months or years, the patient 
 presenting few or no cerebral symptoms during the inter- 
 vals. As time goes on the attacks become more severe 
 an more frequent. It is, however, possible for the patient 
 to die during the first attack. 
 
 The temporary attacks are not all of the same char- 
 acter. There may be only headache, or anxiety, restless- 
 ness, and insomnia, or vertigo, or aphasia, or hemianopia, 
 or loss of consciousness, or general convulsions, or spas- 
 modic contractions of groups of muscles, or paralysis of 
 one arm, of one leg, or of the whole of one side of the 
 body, or loss of sensation in different areas of the skin. 
 
 The first attack may prove fatal, but the patient of- 
 ten continues to live for months or years. Even after 
 recovering from the first attack, however, there is a per- 
 ceptible change in the patient's mental and bodily con- 
 dition, sometimes very marked. The attacks are repeated 
 until finally the patient develops the symptoms of chronic 
 meningitis, or becomes completely hemiplegic, or dies 
 with general convulsions or coma. 
 
 Treatment. Apart from antisyphilitic treatment in 
 the proper cases, the most important points to enforce 
 are abstinence from all alcoholic drinks, and exercise in 
 the open air. 
 
THE BRAIN. 
 
 Cerebral Hemorrhage. 
 
 I. Hemorrhage Between the Skull and the 
 Dura Mater. — Extravasations of blood in this position 
 are produced by severe blows or falls on the head. 
 
 Lesions. There is the external bruise or wound of the 
 scalp, beneath this often a fracture of the bone-, and be- 
 neath this a clot between the bone and the dura mater. 
 There may also be lacer,ation of the cortex of the opposite 
 side of the brain, and after some days inflammation of 
 the membranes near the clot. 
 
 The symptoms, therefore, are due to the shock of the 
 injury, the pressure of the clot, the laceration of the brain, 
 and the meningitis. 
 
 The shock often causes temporary unconsciousness. 
 
 The clot produces general convulsions, coma, or paral- 
 ysis, according to its size and position. 
 
 The laceration of the brain may cause general convul- 
 sions. 
 
 The meningitis is attended with its regular acute symp- 
 toms. 
 
 In all the cases, after twelve to twenty-four hours, 
 there is a rise of temperature. 
 
 Immediately after the receipt of the injury the patients 
 are usually unconscious for some hours, although some- 
 times they are conscious and even able to walk for several 
 hours. If unconscious, they may remain so only for a 
 few hours, or until death. Later come the rise of tem- 
 perature, general convulsions, hemiplegia, coma, the 
 symptoms of meningitis. 
 
8 THE BRAIN. 
 
 Treatment. The only treatment likely to be of use is 
 to make a sufficiently large opening in the skull and re- 
 move the clot. 
 
 II. Hemorrhage Between the Dura Mater and 
 THE PiA Mater. — Lesions. The clot is found between 
 the pia mater and the dura mater, over the convexity of 
 one cerebral lobe, or over both lobes, or over the base of 
 the brain. It varies in size from a thin layer to a mass 
 large enough to compress the brain. 
 
 Causes. Such clots are found at all ages. They 
 are due to blows or falls on the skull, to injuries received 
 during parturition, to diseased arteries, to chronic internal 
 pachymeningitis, to the rupture of aneurisms, and occur 
 without known cause. 
 
 Symptoms. There may be a prodroniic period, lasting 
 for several days, characterized by heaviness of the head, 
 vertigo, headache, mental slowness, and vomiting ; or 
 the attack may be sudden. 
 
 There is a good deal of variety as to the number and 
 severity of the symptoms in Ihe different patients. 
 
 Loss of consciousness is developed gradually or sud- 
 denly ; it is complete, partial, transitory, or perma- 
 nent. 
 
 The intelligence, if there is no loss of consciousness, 
 may be unimpaired. Delirium is often present. 
 
 The speech remains intact, or is lost, or partly im- 
 paired. 
 
 There may be strabismus ; the pupils may be dilated, 
 or contracted, or unequal. 
 
 There may be general or local convulsions, either at 
 the beginning of the attack, or later. 
 
THE BRAIN. 9 
 
 There may be no motor paralysis, or hemiplegia, or 
 bilateral jiaralysis. The paralysis may be developed 
 gradually or suddenly ; it may be incomplete or com- 
 plete, transitory or permanent. It is not as constant as 
 with cerebral hemorrhage. 
 
 Sensation may be unchanged or impaired. 
 
 The pulse may be slow or rapid. There is regularly 
 a febrile movement after the first twenty-four hours. 
 
 Vomiting often accompanies the beginning of the attack. 
 
 The following are sOme of the attacks which I have 
 seen : 
 
 Large clots at the base producing sudden death. 
 
 Large clots over the whole of one hemisphere, with 
 delirium, coma, a rise of temperature, and death in 
 twenty-four hours. 
 
 A clot over the convexity of both frontal lobes, with 
 bilateral paralysis, but without loss of consciousness. 
 
 A clot over the convexity of the right hemisphere, with 
 convulsions, delirium, dilated pupils, coma, high tem- 
 perature, death after several days. The symptoms re- 
 sembled those of an acute meningitis. , 
 
 A clot over the whole of the right hemisphere, with, 
 for twenty-four hours, coma, contracted pupils, pulse 140, 
 urine albuminous, and partial paralysis of the left arm 
 and leg ; then for five days improvement, and then sud- 
 den death. 
 
 A clot over the whole convexity of the brain, with re- 
 peated convulsions, and death in twenty-four hours. 
 
 A clot over the whole convexity, with alternating coma 
 and convulsions, and albuminous urine ; the whole at- 
 tack resembling one of uraemia. 
 
lO THE BRAIN. 
 
 The Prognosis seems to depend upon the size of the 
 clot. 
 
 The Treatment is symptomatic. 
 
 III. Hemorrhage between the Pia Mater and 
 THE Brain. — This is usually only an accompaniment of 
 cerebral or meningeal hemorrhage, but it may occur by 
 itself. When this is the case the clot is frequently 
 situated at the base of the brain, and causes death within 
 a short time. 
 
 IV. HeMORRHAGE IN THE SUBSTANCE OF THE BrAIN. 
 
 — Lesions. The clots are small or large, usually single, 
 sometimes multiple, not infrequently repeated at inter- 
 vals. The blood forms a cavity for itself by lacerating 
 the brain tissue ; it may break through into the cavity 
 of the ventricles, or beneath the pia mater. With a 
 large clot the surface of the brain is somewhat flattened 
 and the pia mater dry. 
 
 If the hemorrhage is due to traumatism, we find the 
 evidences of this ; if not, we find diseased arteries or 
 miliary aneurisms. 
 
 If the patient continues to live, the clot shrinks and 
 there is more or less inflammation of the surrounding 
 brain tissue. Finally, there remains only a connective- 
 tissue cicatrix, or a cyst. 
 
 Causes. Cerebral hemorrhage may be caused by in- 
 juries inflicted on the skull ; more frequently it is due to 
 the rupture of diseased arteries, or of miliary aneurisms. 
 The tendency to rupture seems to be increased by high 
 arterial tension. With cerebral apoplexy we often find 
 associated atrophied kidneys, and hypertrophy of the left 
 ventricle of the heart. 
 
THE BRAIN. II 
 
 The greatest liability to cerebral hemorrhage is be- 
 tween the ages of seventy-one to eighty, next in order 
 from sixty-one to seventy, fifty-one to sixty. The 
 least liability is between the ages of one to ten 
 years. 
 
 Symptoms. Excluding the traumatic cases, a pro- 
 dromic period is not uncommon. It is characterized by 
 emotional irritability, dulness of the mental faculties, 
 temporary attacks of drowsiness or loss of consciousness, 
 temporary paralysis of the arm or leg, disturbances of 
 sensation, and hemorrhages in the retina. All these 
 symptoms are apparently due to the chronic inflamma- 
 tion of the cerebral arteries which already exists. 
 
 The symptoms at the time of, and just after, the hemor- 
 rhage depend upon the size and position of the clot, and 
 the rapidity with which the blood escapes from the rupt- 
 ured vessels. 
 
 Large clots in the. corpora striata, internal capsule, 
 crura cerebri, and central convolutions produce sudden 
 coma, hemiplegia with facial paralysis, and death within 
 a few days. 
 
 Clots in the pons Varolii, medulla oblongata, and cor- 
 pora quadrigeraina produce sudden coma, hemiplegia, and 
 death. 
 
 Large clots outside of the motor tract and the basal 
 ganglia produce alternating convulsions and delirium, 
 coma, and death withiaa few days. 
 
 Smaller clots in the corpora striata and internal cap- 
 sule, if they are formed rapidly, cause temporary un- 
 consciousness, hemiplegia, and when on the left side, 
 aphasia. 
 
12 THE BRAIN. 
 
 If they are formed gradually the mind is confused, the 
 speech is affected, there is vomiting, and a gradual de- 
 velopment of coma, hemiplegia, and aphasia. 
 
 Small clots in the central convolutions give no, or tem- 
 porary, loss of consciousness, with localized paralyses of 
 the face, arm, or leg. 
 
 Small clots in the third left frontal convolution give no, 
 or temporary, loss of consciousness, with aphasia, either 
 partial or complete. 
 
 Small clots outside of the motor tract may give tem- 
 porary loss of consciousness, without paralysis. 
 
 In all the cases the pupils may remain natural, or be 
 dilated, or contracted, or unequal. There is regularly 
 deviation of both eyes toward the non-paralyzed side. 
 
 The pulse is usually slow and full. The temperature 
 is at first lowered, but after twenty-four hours rises 
 above the normal. 
 
 After two or three days, with the secondary fever, there 
 are headache, stupor, delirium, congestion and oedema 
 of the lungs, and rigidity of the paralyzed muscles. 
 
 After the lapse of weeks or months some of the patients 
 recover entirely, some show failure of the mental facul- 
 ties and emotional irritability, in some the motor paraly- 
 sis persists either completely or incompletely. The pa- 
 ralyzed muscles are often contracted, the limbs swollen 
 and painful. 
 
 Prognosis. Complete coma lasting more than twenty- 
 four hours, pronounced congestion and oedema of the 
 lungs, bilateral paralysis, a very low initial temperature, 
 a high secondary temperature with delirium and stupor, 
 all indicate an early and fatal termination of the disease. 
 
THE BRAIN. 1 3 
 
 For months afterward there is danger to life from men- 
 ingitis, pneumonia, cystitis with suppurative nephritis, 
 and bed-sores. 
 
 If the patients do not die and are to do well, there 
 should be some improvement in the paralysis, the 
 aphasia, and the mental condition within a month after 
 the commencement of the attack. 
 
 Some patients, even with small clots, do badly on ac- 
 count of the changes in the cerebral arteries. 
 
 The Treatment is symptomatic. 
 
 Embolism and Thrombosis of the Cerebral Ar- 
 teries. — Lesions. Apart from septicemia, most of the 
 cerebral emboli come from the aortic and mitral valves, 
 the endocardium of the left ventricle, and the arch of the 
 aorta. 
 
 Most frequently there is a single embolus in one of the 
 branches of the left, or right, cerebral artery. Less fre- 
 quently the plug is in the anterior or posterior cerebrals, 
 or emboli find their way into different arteries at different 
 times, or one of the large arteries at the base of the brain 
 is occluded, or all the arteries are filled at once with a 
 mass of detritus. 
 
 Thrombi are found most frequently in the internal- 
 carotids, middle cerebrals, basilar, vertebral, and poste- 
 rior cerebral arteries. 
 
 Occlusion of an artery, either by an embolus or a 
 thrombus, is followed by ansemia, or less often by venous 
 congestion of the corresponding portion of brain tissue,. 
 After about twenty-four hours this portion of brain de- 
 generates and softens ; finally it is replaced by a cicatrix 
 or a cyst with fibrous walls. 
 
14 THE BRAIN. 
 
 The softened areas of brain are found in the cortex, 
 corpora striata, optic thalami, pons Varolii, medulla ob- 
 longata, and cerebellum. 
 
 Causes. The regular causes of cerebral embolism are 
 endocarditis affecting the aortic or mitral valves, or the 
 endocardium of the left ventricle ; or chronic inflam- 
 mation of the arch of the aorta. But it must be admitted 
 that in some cases we cannot find the source of the em- 
 bolus. 
 
 Cerebral embolism occurs in both sexes. It is most 
 frequent between later childhood and middle age, but is 
 not uncommon in older persons. 
 
 Thrombosis is due to chronic endarteritis, or to changes 
 in the blood and the circulation. The puerperal con- 
 dition, the infectious diseases, and the chronic exhausting 
 diseases may be complicated by thrombosis. 
 
 Symptoms. The symptoms of embolism are developed 
 suddenly. 
 
 Those of thrombosis may be preceded by the symptoms 
 of cerebral endarteritis, and may be developed sud- 
 denly or gradually. 
 
 The sudden plugging of most of the cerebral arteries 
 causes sudden death. 
 
 An embolus filling one of the large arteries causes 
 coma, hemiplegia, and death within a few days. 
 
 Emboli in one of the smaller arteries produce symp- 
 toms at the time when they lodge, by their sudden inter- 
 ference with, the functions of a portion of the brain tissue ; 
 later, by the death of the same portions of the brain. 
 
 At the commencement of the attack the symptoms 
 vary with the size and position of the artery occluded. 
 
THE BRAIN. 15 
 
 With embolism loss of consciousness is less frequent 
 and of shorter duration than is the rule with cerebral 
 hemorrhage. 
 
 With thrombosis loss of consciousness is said to be less 
 frequent than with embolism. 
 
 General convulsions occur oftener with embolism than 
 with thrombosis. Vomiting often accompanies the at- 
 tack. There is usually no change in the temperature, or 
 only a slight fall. In the patients, who do not lose con- 
 sciousness, there- may be headache, vertigo, incoherent 
 speech, delusions, or hallucinations. 
 
 According to the position of the occluded artery, we 
 have motor paralysis, convulsive movements, or rigidity 
 affecting only the arm, face, or leg, or one side of- the 
 body, or both sides. 
 
 If the third left frontal convolution is involved, there 
 is motor aphasia ; if the first left temporal convolution, 
 there is sensory aphasia ; if the posterior part of the oc- 
 cipital lobe, there is hemianopia. 
 
 After from twelve hours to four days there is a rise of 
 temperature, sometimes accompanied with other symp- 
 toms, due to the development of inflammation around 
 the area of softening. 
 
 After two or three days there is often a temporary im- 
 provement in the paralysis or aphasia. 
 
 Later in the disease the patients may : 
 
 1. Continue comatose, hemiplegic, and die. 
 
 2. Remain permanently hemiplegic, with or without 
 aphasia. The mental faculties return nearly to the nor- 
 mal, or are impaired. The paralyzed muscles often 
 become contractured, there may be general convul- 
 
l6 THE BRAIN. 
 
 sions, the patients may develop a complicating menin- 
 gitis. 
 
 3. Recover, either partly or completely, the power of 
 speech and of voluntary motion. It is to be noted that 
 in some of these apparently mild cases there is marked 
 and permanent impairment of the mental faculties. 
 
 4. Recover either partly or completely, but have sub- 
 sequent attacks of the same character. 
 
 Diagnosis. Cerebral embolism differs from cerebral 
 hemorrhage in that : 
 
 It occurs regularly in younger people. The lesion is 
 apt to be smaller, situated in the cortex and on the left 
 side. 
 
 Loss of consciousness is less constant and more tem- 
 porary ; local paralyses and aphasia alone are more com- 
 mon. 
 
 Prognosis. The lesion seems to be less fatal than is 
 cerebral hemorrhage, but yet complete recovery is not 
 so very common. 
 
 The Treatment is symptomatic. 
 
 Abscess of the Brain. 
 
 The small multiple abscesses of the brain, which occur 
 with pyasmia, form part of that disease and require no 
 separate description. 
 
 The large single abscesses, occurring under different 
 conditioris, are those to which the names of " Abscess of 
 the Brain " is usually applied. 
 
 Lesions. These abscesses occur in two forms : 
 
 The non-capsulated abscess, an irregular cavity con- 
 
THE BRAIN. 1 7 
 
 taining a thin pus and softened brain tissue. The walls 
 of the cavity are ragged and infiltrated with pus, and 
 outside of the walls is a zone of oedematous and softened 
 brain tissue. If the abscess is near the pia mater it may 
 set up a meningitis ; if it is near the lateral ventricles it 
 may rupture into them ; if it is near the sinuses of the 
 dura mater it may cause thrombosis. 
 
 The encapsulated abscess has a capsule of connective 
 tissue, and contains thin or cheesy pus. 
 
 Abscesses of the brain are usually single ; they may at- 
 tain a considerable size. They are most frequent in the 
 cerebral and cerebellar hemispheres, rare in the central 
 ganglia, the pons, and the medulla oblongata. 
 
 Causes. The most common cause of this disease 
 seems to be chronic suppurative otitis (42.5 per cent., 
 Gowers), while acute otitis is a comparatively rare 
 cause. With the otitis there may also be caries of the 
 temporal bone, suppuration of the mastoid cells, and in- 
 flammation of the dura mater. The abscess is usually 
 situated deep in the brain, only rarely is it continuous 
 with the inflamed dura mater and bone. When the 
 abscess is deeply situated, and the bone and dura mater 
 are not diseased, it is difficult to tell how the infection 
 travels from the ear to the brain. Abscesses due to this 
 cause are situated in the temporo-sphenoidal, the fiontal, 
 the occipital, and the parietal lobes, or in the cerebellum. 
 
 Another frequent cause of abscess of the brain is trau- 
 matism — ^blows or falls on the head (twenty-four per 
 cent., Gowers). Such injuries may not hurt the skull, 
 or may produce fractures, or necrosis. There is often a 
 considerable interval between the time when the injury 
 
1 8 THE BRAIN. 
 
 is inflicted and that when the symptoms of the abscess 
 are developed. 
 
 IVhen the bones are uninjured, the abscess is situated 
 deep in the brain ; when there is necrosis of the bones, 
 the abscess may be superficial ; when the bone is fract- 
 ured, the abscess may be either superficial or deep. The 
 abscess is regularly situated beneath the point of injury, 
 rarely in the opposite side of the brain. 
 
 Chronic disease of the nose, either the mucous mem- 
 branes or the bones, has been the cause of a few ab- 
 scesses in the frontal lobes. Disease of the orbit has 
 also given rise to abscesses in the same position. In a 
 few cases the abscesses have been due to caries of va- 
 rious portions of the cranial bones. 
 
 In a considerable number of cases (J, Gowers) no 
 cause for the abscess has been discovered. 
 
 Symptoms. There are general symptoms common to 
 all abscesses of the brain, and local symptoms due to 
 the precise position of each abscess. 
 
 With the acute, non-capsulated abscesses the inflam- 
 mation and the symptoms go on acutely until the death 
 of the patient, the disease usually running its course 
 within four weeks. 
 
 With the chronic, encapsulated abscesses, the course 
 of the disease is much longer, and may be conveniently 
 divided into an initial, a latent, and a terminal period. 
 
 The initial symptoms may be absent altogether ; they 
 may be mild, or ihey may be severe. They are espe- 
 cially marked with the traumatic cases. When well de- 
 veloped they resemble an acute meningitis ; headache, 
 local or general, general convulsions, a febrile move- 
 
THE BRAIN. 1 9 
 
 ment, stupor and delirium, vomiting, and prostra- 
 tion. 
 
 The latent period may last for months or years. There 
 may be no symptoms during its course, or headache, 
 mental disturbances, and general convulsions, which 
 come and go. 
 
 The terminal stage is developed gradually, or suddenly. 
 Rarely, the patient dies from some intercurrent disease 
 before he has reached the terminal stage. 
 
 Usually, however, the symptoms of the terminal period 
 are well marked. There are headache, vomiting, optic 
 neuritis, general convulsions, alternating stupor and 
 delirium, a slow pulse, a febrile movement often with 
 chills. The patient passes into the typhoid state. 
 
 The local symptoms. Abscesses situated in the frontal 
 lobes give no local symptoms. 
 
 Those situated in the motor tract cause paralysis, con- 
 vulsive movements, or rigidity of the corresponding mus- 
 cles. 
 
 Those situated in or beneath the speech tract cause 
 motor or sensory aphasia. 
 
 Those situated in the occipital lobes may produce 
 hemianopia. 
 
 Those situated in the cerebellum are very often latent. 
 
 The Diagnosis is between such abscesses, tumors of 
 the brain, and acute meningitis. 
 
 The Prognosis is unfavorable. 
 
 Treatment. It is to be remembered that chronic 
 otitis is the most common cause of abscess of the brain, 
 and that for this reason special attention should be given 
 to the treatment of such an otitis. 
 
20 THE BRAIN. 
 
 While the synipionis are acute the treatment is the 
 same as for acute meningitis. 
 
 When the abscess is so situated that it can be reached, 
 surgical interference has proved very satisfactory in a 
 number of cases. 
 
TUMORS OF THE BRAIN. 
 
 Intracranial tumors are syphilitic, tubercular, glio- 
 mata, sarcomata, fibromata, osteomata, or chrondromata. 
 There are also found in the brain cysticercus cysts and 
 hydatid cysts. 
 
 The syphilitic gummy tumors are single or multiple. 
 They originate in the dura mater or pia mater, and com- 
 press or invade the brain. They are, therefore, regularly 
 cortical tumors, most frequently situated over the cere- 
 bral hemispheres. 
 
 The tubercular tumors are often multiple. They may 
 constitute the only tubercular lesion in the body, or 
 there may be similar lesions elsewhere. They are regu- 
 larly formed in the brain-tissue, and are found in the 
 cerebellum, cerebrum, pons, central ganglia, crura cere- 
 bri, medulla oblongata, and corpora quadrigemina. 
 
 The gliomata are composed of tissue resembling the 
 neuroglia, but with an excess of cells. They are often 
 soft and hemorrhagic. They are usually single, originate 
 in the brain-tissue, and may be found in any part of the 
 brain. 
 
 The sarcomata are composed of connective-tissue, 
 with an excess of round, oval, and fusiform cells. They 
 
2 TUMORS OF THE BRAIN. 
 
 originate in the brain-tissue, the membranes, and the 
 cranial bones, and compress or infiltrate the brain. They 
 are usually single, but may be multiple. 
 
 Sarcomata, composed of flat endothelial cells arranged 
 in alveoli, originate in the pia mater. They are usually 
 single, but may be multiple, and in rare cases are found 
 in large numbers on the dura mater and pia mater, both 
 of the brain and spinal cord. 
 
 Causes. — Syphilitic tumors may be developed at any 
 time from twelve months to fifteen years after the initial 
 lesion. They are said to be most frequent at intervals 
 of from five to twelve years. 
 
 Tubercular tumors are most common in persons under 
 twenty years of age. There may be a family history of 
 tuberculosis, or tubercular lesions in other parts of the 
 body. 
 
 The gliomata and sarcomata are most common in per- 
 sons between the ages of twenty-four and forty years. 
 
 The cysticercus and hydatid cysts are found regularly 
 between the ages of ten and twenty years. 
 
 Symftoms. — It is possible for a tumor of the brain to 
 give no symptoms at all. The patient dies from some 
 other disease and the tumor is discovered at the autopsy. 
 
 In a few cases, although the tumor has existed for 
 some time, no symptoms are developed until just before 
 the patient's death. 
 
 Ordinarily the presence of the tumor is attended with 
 symptoms. There are general symptoms common to all 
 intracranial tumors, and local symptoms due to the 
 position of each special tumor. 
 
 I. The general symptoms. Headache is rarely ab- 
 
TUMORS OF THE BRAIN. 3 
 
 sent. It is usually severe, either localized or general, 
 often constant, with exacerbations, sometimes intermit- 
 tent. 
 
 Optic neuritis is a frequent symptom. The retinal 
 veins are swollen, the optic disc and retina are infiltrated 
 and swollen, there are extravasations of blood in the re- 
 tina. Later these changes are followed by atrophy of 
 the optic disc. Such an optic neuritis may be developed 
 with any intracranial tumor. It is less frequent with 
 tumors of the membranes only compressing the convexity 
 of the hemispheres, than with tumors involving the sub- 
 stance of the brain. The degree of disturbance of 
 vision varies in the different cases. It is most marked 
 with hemorrhage and after the nerve has become atro- 
 phied. 
 
 Stupor and coma belong to the later stages of the dis- 
 ease. 
 
 Gradual failure of the mental powers, loss of memory, 
 depression, emotional excitement, delusions, or hysterical 
 phenomena are often present. 
 
 General convulsions followed by temporary uncon- 
 sciousness occur in some cases. 
 
 Vertigo, either constant or paroxysmal, may exist with 
 tumors in any part of the brain. It is most marked with 
 tumors of the pons, the corpora quadrigemina, and the 
 cerebellum. 
 
 Vomiting is especially common with tumors of the 
 medulla, the middle lobe of the cerebellum, and the cor- 
 pora quadrigemina. With cerebellar tumors vomiting, 
 headache, and optic neuritis are often, for a time, the 
 only symptoms. 
 
4 TUMORS OF THE BRAIN. 
 
 Slowness of speech and difficulty in articulation may 
 exist with tumors of the pons, the medulla, or the pos- 
 terior fossa at the base of the brain. 
 
 Temporary loss of consciousness is a symptom of some 
 intracranial tumors. 
 
 The local symptoms. 
 
 Motor aphasia is produced by tumors of the third 
 left frontal convolution, sensory aphasia by tumors of 
 the first left temporal convolution. 
 
 Paralysis. 
 
 1. Gradual development of hemiplegia belongs to tu- 
 mors in, or compressing, the pons, the crura cerebri, and 
 the internal capsule. 
 
 2. Paralysis of the arm, the arm and face, or the leg 
 is associated with tumors in or beneath the cortical 
 motor tract. The paralysis begins in the hand or foot. 
 
 3. Bilateral paralysis is produced by symmetrical tu- 
 mors on both sides of the brain, or by a single tumor 
 compressing both motor tracts. The paralysis, however, 
 is not usually equally developed on both sides of the 
 body. 
 
 The paralyzed muscles are often contractured. 
 
 There may be convulsive movements of the muscles 
 of the face, hand, or foot, and extending thence to the 
 adjoining muscles. 
 
 There may be feelings of pain, tingling, and formi- 
 cation in the paralyzed or convulsed limbs. 
 
 Hemianaesthesia may be produced by tumors involv- 
 ing the posterior part of the internal capsule. 
 
 The cranial nerves are compressed and their functions 
 interfered with by tumors situated at the base of the brain. 
 
TUMORS OF THE BRAIN. 5 
 
 The duration of life with intracranial tumors is con- 
 siderable, many of the patients live for years. 
 
 The treatment varies with the character and position 
 of the tumor. Syphilitic tumors require the regular 
 treatment with mercury and the iodide of potash. Tu- 
 bercular tumors require the same management as chronic 
 phthisis. Tumors of any nature in accessible situations 
 are proper subjects for surgical operation and removal. 
 
 INTRACRANIAL ANEURISMS. 
 
 Lesions. — These aneurisms are usually sacculated, from 
 the size of a pea to that of a pigeon's egg. The relative 
 frequency of their origin is given by Gintrac as follows : 
 Basilar artery, 20; middle cerebral arteries, 18; internal 
 carotid arteries, 1 7 ; anterior cerebral arteries, 7 ; verte- 
 bral arteries, 5 ; posterior communicating arteries, 5 ; 
 cerebellar arteries, 4 ; posterior cerebral arteries, 3 ; an- 
 terior communicating arteries, 2 ; arteries of corpus cal- 
 losum, 2. 
 
 Rather more than half of these aneurisms rupture 
 within the cranial cavity. 
 
 Symptoms. — The smaller aneurisms may give no 
 symptoms ; or the first symptoms will be those of menin- 
 geal apoplexy from their rupture. The larger aneurisms 
 give the symptoms of tumors at the base of the brain. 
 
 Causes. — These aneurisms, like others, are due to 
 chronic endarteritis. They are most frequent in males 
 between the ages of thirty-four and fifty-one years. 
 
 Treatment. — The only plans of treatment, so far known, 
 seem to be the systematic administration ot the iodide 
 of potash, or ligature of the carotid artery. 
 
6 THE VENTRICLES OF THE BRAIN. 
 
 The Ventricles of the Brain. 
 
 Inflammations of the pia mater are often accompanied 
 by lesions of the ventricles of the brain. Less frequent- 
 ly we find lesions of the ventricles occurring by them- 
 selves, with little or no change in the pia mater. We 
 distinguish : 
 
 Acute ependymitis. 
 
 Acute dilatation of the ventricles in adults. 
 
 The chronic hydrocephalus of children. 
 
 Chronic hydrocephalus due to injuries, or secondary 
 to meningitis. 
 
 1. Acute Ependymitis. — Of this we find two varieties : 
 an acute and a subacute form. 
 
 In the acute form we find the ependyma congested, 
 infiltrated with pus-cells, and coated with a layer of 
 fibrine and pus. The ventricles contain purulent serum. 
 
 The patients exhibit a decided febrile movement, 
 general convulsions, alternating stupor and delirium, 
 local paralyses, and finally coma. The disease runs its 
 course within a few days. The symptoms resemble 
 those of an acute tubercular meningitis. 
 
 So few of these cases have been observed that we are 
 ignorant of the prognosis. 
 
 The treatment would seem to be the same as that for 
 acute meningitis. 
 
 In the subacute form the ventricles are dilated and 
 full of serum. The ependyma is thickened, the endo- 
 thelial cells on its surface are multiplied, and there is a 
 growth of cells around the blood-vessels. 
 
 The patients have headache ; vomiting ; at first pho- 
 
THE VENTRICLES OF THE BRAIN. 7 
 
 tophobia, later dilated pupils ; hyperaesthesia of the skin ; 
 an irregular rise of temperature, never very high, and 
 sometimes below the normal ; finally coma. The 
 disease lasts for weeks or months. The symptoms re- 
 semble those of a subacute tubercular meningitis. 
 
 These cases again are so seldom recognized that we 
 do not know how many of them may recover. 
 
 2. Acute Dilatation of the Ventricles in Adults — Ser- 
 ous Apoplexy — Lesions. — Either one lateral ventricle, or 
 both, or all the ventricles are dilated and filled with clear 
 serum. The ependyma is white, somewhat thickened, 
 its surface smooth or finely granular. The convolutions 
 of the hemispheres are somewhat flattened. 
 
 Causes. — The disease is, in New York, not an uncom- 
 mon one. It occurs both in strong and vigorous adults 
 and in persons who have suffered from chronic diseases. 
 In some persons there is a previous history of injuries to 
 the head, or of mental or bodily overwork. In some 
 cases the condition is complicated- by chronic endarteri- 
 tis, or chronic meningitis. It is said that there may be 
 an obstruction of the veins or of the passages between 
 the ventricles. 
 
 The disease may be confounded with cerebral apo- 
 plexy,' embolism, chronic endarteritis, or tumors of the 
 brain. 
 
 Symptoms. — The patients at first suffer from attacks of 
 headache, noises in the ears, loss of memory, dulness of 
 the mental faculties, slowness of speech, sleeplessness, 
 disturbed digestion, sometimes temporary aphasia, or 
 local paralyses. These symptoms come and go for from 
 one to four weeks, rarely they only last for twelve hours. 
 
8 THE VENTRICLES OF THE BRAIN. 
 
 Then there is a sudden change in the condition of the 
 patients. 
 
 Some of them either gradually or rapidly pass into the 
 condition of complete coma. In this condition they re- 
 main and die in a few days, the temperature rising be- 
 fore death. 
 
 Others develop an acute delirium, blindness, internal 
 strabismus, convulsive movements of some of the mus- 
 cles, a febrile movement, and finally become comatose. 
 
 3. The Chronic Hydrocephalus of Children — Lesions 
 — There is an accumulation of serum in the ventricles of 
 the brain, so large in quantity that the brain is thinned, 
 the dura mater stretched, and the cranial bones sepa- 
 rated from each other. The ependyma appears to be 
 normal, or is somewhat thickened. 
 
 Causes. — We are ignorant of the causes of this lesion. 
 It seems to begin during in tra-uterine life. It may reach 
 a considerable development before birth, or remain 
 latent for months or years after birth. 
 
 Symptoms. — If the disease is so much developed dur- 
 ing intra-uterine life that the large head prevents the birth 
 of the child, craniotomy must necessarily be performed. 
 
 If the disease is moderately developed during intra- 
 uterine life, the child can be born alive. But it is at 
 once evident that the head is too large ; the child does 
 not perform its functions well, and dies in a short time. 
 
 In many cases at the time of birth the child shows no 
 evidences of the disease, and it is not till after months or 
 years that its symptoms are developed. Of these later 
 developed cases we may distinguish a mild and a severe 
 form of the disease. 
 
THE VENTRICLES OF THE BRAIN. 9 
 
 In the mild cases the head is large, the fontanelles 
 and sutures open, the face small. The intelligence re- 
 mains good. -From time to time, for periods of several 
 days, the child suffers from disturbances of digestion and 
 nutrition, a febrile movement, fits of crying, restlessness, 
 and drowsiness. 
 
 In these mild cases the disease is not of itself fatal, 
 but the children are apt to be carried off by some of the 
 diseases of childhood. 
 
 In the severe cases there is marked impairment of nu- 
 trition ; the children are dull and stupid, irritable and 
 drowsy ; there are often strabismus, nystagmus, dilated 
 pupils, protruded eyeballs, blindness, deafness, general 
 convulsions, and paraplegia. There may be a febrile 
 movement. These symptoms are interrupted by periods 
 of improvement, but the course of the disease is usually 
 downward and the children die in an attack of convul- 
 sions, or of inanition, or from some intercurrent disease. 
 Rarely they grow up to adult life, but remain more or less 
 idiotic. 
 
 Tke treatment is mainly directed to the general con- 
 dition of the patient. Careful feeding, a clean skin, good 
 air, the administration of iron and of cod-liver oil are the 
 essentials. During the exacerbations of the symptoms 
 the idodide of potash may be of service. 
 
 4. Chronic Hydrocephalus in Older Children. — In older 
 children and in adolescents we meet with cases of chronic 
 hydrocephalus, not congenital, but occurring after men- 
 ingitis, after injuries, and without discoverable cause. 
 
 In some cases of acute meningitis the patient, after 
 going through the symptoms of this disease and begin- 
 
lO THE SPINAL CORD. 
 
 ning to improve, makes only an attempt at convalescence, 
 again becomes worse, is alternately delirious and stupid, 
 has a moderate febrile movement and emaciates. After 
 continuing in this condition for weeks, he may recover 
 or die. 
 
 In the cases which occur after injury and without dis- 
 coverable cause the clinical history is like that of the 
 chronic hydrocephalus of young children, but without 
 the enlargement of the head. 
 
 The Spinal Cord. 
 
 The spinal cord is composed of the gray matter, con- 
 sisting of nerve-cells and fibres, with a very delicate con- 
 nective-tissue stroma ; and the white matter, composed 
 of nerve-fibres, held together by a more abundant stroma. 
 
 The gray matter is divided into the anterior and pos- 
 terior cornua, from which are given off the anterior and 
 posterior nerve-roots. 
 
 The white matter is divided into a number of columns. 
 
 The cord acts : 
 
 I. As a conductor from the brain to the peripheral 
 nerves. Motor impulses originate in the brain and 
 travel downward through the cord to the motor nerves. 
 Sensory impulses originate in the sensory nerves, and 
 travel upward through the cord to the brain. 
 
 Disease of the motor tract — the pyramidal columns, 
 the anterior gray cornua, and the anterior nerve-roots — 
 causes loss of motor power. 
 
 Disease of the sensory tract — the antero-lateral col- 
 umns and the posterior median columns — causes loss of 
 sensation to pain and to touch. 
 
THE SPINAL CORD. II 
 
 Irritation of the posterior nerve-roots gives rise to 
 pain referred to the peripheral sensory nerves. 
 
 2. As a series of centres for reflex action. 
 
 Loss of reflex action is due to interruption by disease 
 of some part of the reflex arc at any point between the 
 peripheral endings of the sensory and motor nerves. 
 
 Excess of reflex action is due to irritation of the nerve- 
 centres, or to disease between the centres concerned and 
 the brain. 
 
 3. It contains centres that ultimately govern nervous 
 action in structures under the immediate control of the 
 sympathetic system, such as the bladder and the rectum. 
 
 4. It controls nutrition. 
 
 Disease of the motor nerve-cells, or fibres, is followed 
 by wasting of the muscles. 
 
 Myelitis. 
 
 Lesions. — The stroma of the cord is changed into gel- 
 atinous matter, the nerve-cells and fibres degenerate, 
 there is an exudation of serum, an emigration of white 
 blood-cells, and a diapedesis of red blood-cells. All 
 these changes, however, are not present in every case 
 of myelitis. Either the exudation or the degeneration 
 of the nerves, or the changes in the stroma, may consti- 
 tute the principal or the only part of the lesion. In 
 some cases the walls of the arteries are thickened. 
 
 The affected portions of the cord are either swollen, 
 or softened and diffluent. 
 
 The lesions may involve the whole length of the cord 
 — diffuse myelitis ; or only a segment of the cord — 
 transverse myelitis. 
 
12 THE SPINAL CORD. 
 
 Causes. — Injuries, exposure, over-fatigue, the infec- 
 tious diseases, and sexual excesses are often assigned as 
 causes, but many cases occur for which no cause, can be 
 discovered. 
 
 Symptoms. — i. There are cases of myelitis character- 
 ized by an acute development of paraplegia, with con- 
 stitutional symptoms. 
 
 The patient is suddenly attacked with vomiting, head- 
 ache, delirium, a febrile movement, marked piostration, 
 sometimes blindness. At the same time loss of motion 
 and sensation, and increased reflex action are rapidly 
 developed in the portions of the body situated below the 
 lesion of the cord. The disease runs a rapid course 
 and terminates fatally. 
 
 Such a severe and rapid course of the symptoms be- 
 longs to the forms ®f myelitis with the production of 
 pus, and to those which are diffuse. 
 
 2. There are cases characterized by a rapid develop- 
 ment of paraplegia without constitutional symptoms. 
 
 The patient, while in his ordinary health, finds that he 
 is losing power in his legs, and within twenty-four hours 
 is completely paraplegic. Such a myelitis is not usually 
 fatal, unless it is followed by an ascending myelitis ex- 
 tending up the cord. 
 
 3. There are cases characterized by a gradual devel- 
 opment of the local symptoms without any constitu- 
 tional disturbance. 
 
 First, there are disturbances of sensation in the parts 
 which are afterward to be paralyzed ; numbness, tin- 
 gling, formication, pricking, etc. Then there are gradual 
 loss of muscular power and of sensation, a feeling of con- 
 
THE SPINAL CORD. 1 3 
 
 striction around the body, paralysis of the bladder and 
 rectum, and increased reflexes. 
 
 These symptoms may occupy weeks or months before 
 they terminate in complete paraplegia. They may ad- 
 vance continuously, or with intermissions. 
 
 The myelitis does not of itself usually cause death, but 
 life may be destroyed by bed-sores, by cystitis with sup- 
 purative nephritis, or by pneumonia. 
 
 Treatment. — While the disease is active the patients 
 should be kept in bed, with the most careful attention to 
 the skin and the bladder. If constitutional symptoms 
 are present, the patients should be kept on fluid diet, 
 otherwise they may eat ordinary food. 
 
 If the myelitis is of acute type, we may apply wet or dry 
 cups, continuous cold or hot douches over the spine, and 
 give internally calomel, sulphate of magnesia, or opium. 
 
 If the myelitis is of subacute type, we may use hot 
 douches over the spine, and give internally iodide of pot- 
 ash, ergot, belladonna, nitrate of silver, the chloride of 
 gold and sodium, arsenic, or strychnia. 
 
 When the disease has run its course the patient 
 should be out of bed and out of doors as much as possi- 
 ble. No further treatment of the disease is necessary, 
 but much attention should be given to the bladder, and 
 to the skin and muscles of the paralyzed parts. Massage, 
 passive motion, and electricity are now of real service. 
 
 Anterior Polio-myelitis. — Infantile Paralysis. — 
 Z««V«J.-— There is an inflammation of exudative type, 
 with congestion and emigration of the white blood-cells. 
 The nerve-cells and fibres may remain unchanged, or a 
 small number of them may degenerate and die. When 
 
14 THE SPINAL CORD. 
 
 the disease has run its course the cord may return to its 
 normal condition, or a small part of it may be perma- 
 nently destroyed. The inflammation involves only a 
 part of the anterior cornua, and is usually limited to a 
 segment of the cord, but is sometimes diffuse. 
 
 Causes. — The disease occurs most frequently in young 
 children during the period of dentition. In some cases 
 there is a history of exposure, or of injury, or of excessive 
 fatigue. The attacks are more frequent in summer than 
 in winter. Healthy children areas liable to the disease 
 as are others. It is said that it may complicate the 
 exanthemata, typhus and typhoid fever, bronchitis, and 
 pneumonia. 
 
 Symptoms. — The invasion of the characteristic symp- 
 tom — the paralysis — is acute or subacute. The paraly- 
 sis may, or may not, be accompanied by constitutional 
 symptoms. 
 
 The constitutional symptoms are : Fever, with the 
 accompanying headache, loss of appetite, nausea, vomit- 
 ing, restlessness, and prostration ; cerebral symptoms — 
 general convulsions, alternating delirium and stupor; 
 disturbances of sensation — tingling, formication, pain 
 along the nerves, in the muscles, and in the joints. 
 
 The motor paralysis involves some or all of the mus- 
 cles of one or more of the limbs, less frequently the 
 muscles of the neck and throat. The muscles of the 
 bladder and rectum are but seldom involved. The full 
 development of the paralysis may be effected within a 
 few hours, or may require days or weeks. After reach- 
 ing its full development the paralysis remains stationary 
 for from two to six weeks, and is then followed by more 
 
THE SPINAL CORD. 15 
 
 or less return of motor power. The return of motion 
 begins in the muscles which were paralyzed the latest. 
 The improvement continues for weeks or months, and is 
 finally complete or incomplete. If it is incomplete, 
 while some of the muscles return to their natural condi- 
 tion others are left paralyzed. The muscles thus left 
 paralyzed then become atrophied. A permanent paraly- 
 sis and atrophy is followed by deformities and arrest of 
 development of the affected limbs. 
 
 There is no loss pf sensation. The reflexes of the 
 skin and muscles are diminished. 
 
 The Course of the Disease — ^The invasion of the symp- 
 toms is usually acute, less frequently subacute ; the con- 
 stitutional symptoms are absent, or present in varying 
 degrees of severity. The paralysis is fully developed in 
 a few hours, or not until after days or weeks. 
 
 The stationary period lasts for days, weeks, or months. 
 It may be interrupted by fresh invasions of the disease 
 with constitutional symptoms and paralysis of new 
 groups of muscles. 
 
 The return of motor power in the paralyzed muscles 
 is rapid or slow, occupying weeks or months. It is 
 complete, all the muscles returning to their natural con- 
 dition ; or incomplete, some of the muscles recovering 
 while others remain paralyzed for a long time, or perma- 
 nently. 
 
 Prognosis. — The disease is seldom fatal. It is possi- 
 ble, however, for the patients to die with unusually 
 severe constitutional symptoms, or with a paralysis in- 
 volving the trunk as well as the extremities. 
 
 The prognosis as to the paralysis is determined by 
 
l6 THE SPINAL CORD. 
 
 examining the affected muscles with the faradic current. 
 No loss of faradic irritability is followed by rapid recov- 
 ery. 
 
 If there is no loss of faradic irritability until two or 
 three weeks after the invasion, ultimate recovery is prob- 
 able. 
 
 If there is loss of faradic irritability within ten days 
 after the invasion, the muscles will become atrophied and 
 remain paralyzed for a long time, or permanently. 
 
 Treatment. — During the active stage of the disease 
 the patient is to be kept in bed, on a restricted diet, 
 with mild counter-irritation over the spinal column. 
 During the stationary period the counter-irritation may 
 be continued, and the use of massage, passive motion, 
 and electricity commenced. During the stage of im- 
 provement the patient is no longer to be kept in bed, is 
 to be well fed, and the massage, passive motion, and 
 electricity are to be continued. 
 
 If any muscles are left permanently paralyzed great 
 care must be used for a long time to keep up the nutri- 
 tion of the limb, and to prevent deformities by proper 
 mechanical appliances. 
 
 Amyotrophic Lateral Sclerosis — Chronic Spinal 
 Muscular Atrophy — Lesions. — The disease involves 
 the anterior gray cornua and the pyramidal tracts on both 
 sides of the cord. In the pyramidal tracts there is degen- 
 eration of the nerve-fibres and hypertrophy of the con- 
 nective tissue stroma ; in the anterior gray cornua there 
 is degeneration of the nerve-cells and fibres. The lesion 
 begins in the cervical portion of the cord and extends 
 downward, and later upward. 
 
THE SPINAL CORD. 17 
 
 Causes. — The disease is more common in males than 
 in females. It occurs in persons between the ages of 
 twenty-five and forty-five years. There may be a previ- 
 ous history of syphilis or of exposure, or no cause may 
 be found. 
 
 Symptoms. — The symptoms of the disease are devel- 
 oped slowly and gradually, and may become stationary 
 at any time. They begin first in one arm and then ex- 
 tend to the other. 
 
 There are disturbances of sensation : formication, 
 tingling, numbness, pains along the course of the nerves, 
 and exaggerated tenderness of the muscles. There is 
 gradual and incomplete loss of power in the muscles. 
 The muscles become atrophied and may exhibit involun- 
 tary fibrillary contractions. 
 
 Then the loss of power gradually extends to the 
 muscles of the legs, but without much ^atrophy. Sensa- 
 tion is preserved. In the atrophied muscles reflex action 
 is lost, and the faradic and voltaic irritability are dimin- 
 ished. In the muscles which are not atrophied the reflex 
 action is exaggerated. 
 
 As the disease advances the muscles become con- 
 tracted and rigid ; at first temporary spasmodic rigidity, 
 later a permanent contracture of both flexors and exten- 
 sors, with occasional spasmodic action. The cases vary 
 as to whether the atrophy of the muscles or their rigidity 
 is the most developed. 
 
 Finally the muscles of the neck, the throat, and the 
 tongue become involved, and the patient dies from star- 
 vation. 
 
 The course of the disease is a long one, protracted 
 
1 8 THE SPINAL CORD. 
 
 over years, and it may at any time become stationary 
 and not advance further for a long time. 
 
 Locomotor Ataxia. — Lesions. — There is a degener- 
 ation of the nerve-fibres and a growth of new connective- 
 tissue in the stroma, beginning in the lateral portion of 
 the posterior columns, in the lower dorsal and lumbar 
 regions. Opinions differ as to whether the degeneration 
 of the nerve-fibres or the growth of new connective-tissue 
 is the primary part of the lesion. 
 
 The disease, beginning in the lateral portions of the 
 posterior columns, extends first to the posterior nerve- 
 roots and the columns of Goll. Later it may involve the 
 rest of the posterior and lateral portions of the cord, and 
 even invade its anterior portions. 
 
 Similar changes are also developed in the optic nerves, 
 the third, fifth, and sixth pair of nerves, and in the periph- 
 eral nerves. 
 
 Causes. — The disease is more common in males than 
 in females. Most of the cases are developed between the 
 ages of twenty and fifty years. In a considerable number 
 of the patients there is a history, of constitutional syphilis. 
 
 Symptoms. — The disease, if it runs its full course, runs 
 through three stages, but very often it does not advance 
 beyond the first or second stage. 
 
 The first stage is characterized by disturbances of 
 sensation, pains, lessening of the reflexes, affections of 
 the ocular muscles. The lessening of the muscular re- 
 flex is most readily determined by striking the tendon of 
 the patella. This loss of reflex is almost constant, and 
 occurs early in the disease. 
 
 The pains are severe and occur in paroxysms. They 
 
THE SPINAL CORD. I9 
 
 may follow the course of the nerves, or occur in circum- 
 scribed regions. They may remain confined to a single 
 nerve or a single region, or involve several nerves or 
 several regions, or skip about from one place to an- 
 other. They are most common in the legs, but may also 
 occur in other parts of the body. The paroxysms vary 
 in different cases a,s to their frequency, their severity, 
 and their duration. 
 
 The Crises. — This name is given to attacks of pain 
 and spasmodic muscular contraction occurring in the 
 larynx, the stomach, the intestines, and the bladder. 
 
 In the larynx the attack of pain and spasmodic mus- 
 cular contraction may assume one of two forms. 
 
 (i.) The patients have an attack of pain in the larynx, 
 with a paroxysmal cough, like that of whooping-cough. 
 Each paroxysm only lasts for a few seconds, but a num- 
 ber of such paroxysms are repeated at short intervals 
 before the attack is finished. 
 
 (2.) The patients have attacks like those of laryngis- 
 mus stridulus. There is a spasmodic contraction of the 
 glottis, with urgent dyspnoea, which may last for a few 
 minutes or for several hours. In the severe and pro- 
 tracted attacks the patients may lose consciousness or 
 havegeneral convulsions. 
 
 With the gastric crises there are pain and vomiting. 
 The attacks may last for a few hours or for several 
 days. 
 
 The intestinal crises are characterized by pain and 
 diarrhoea. 
 
 The crises affecting the bladder are attended with fre- 
 quent and painful micturition. 
 
20 THE SPINAL CORD. 
 
 The disturbances of sensation. There is hypersesthesia 
 or anaesthesia of circumscribed portions of the skin. 
 There is the feeling of constriction around the thorax, 
 the abdomen, or the legs. There may be the sensations 
 of numbness, pricking, and tingling, or as if something 
 were interposed between the soles of the feet and the 
 ground, or of muscular fatigue. 
 
 The aifections of the ocular muscles. The iris and 
 the ciliary muscle lose their capacity for reflex action 
 and do not contract under the stimulus of light ; later 
 they become paralyzed altogether. 
 
 There is either transitory or permanent paralysis of 
 one or other of the recti muscles, with consequent 
 diplopia or strabismus. 
 
 Additional symptoms. The patients may develop 
 blindness of one or both eyes as the result of the changes 
 in the optic nerves. 
 
 There maybe retention or incontinence of urine. 
 
 There may be very obstinate constipation. 
 
 In males the sexual power is often diminished, or lost. 
 
 In a moderate number of cases there is disease of the 
 joints — the knee, shoulder, elbow, hip, or wrist joints. 
 There is a rapid swelling of the joint, due to the disten- 
 tion of the synovial sac with serum, but without heat or 
 pain. This swelling may last for a time and then dis- 
 appear without further trouble, or it may be followed by 
 more serious changes. There is developed a chronic 
 inflammation of the articular ends of the bones, with 
 destruction of the cartilages, and rarefying osteitis. 
 
 The first stage of the disease lasts for months or years, 
 and the disease may never advance beyond this first stage. 
 
THE SPTNAL CORD. 21 
 
 In the second stage of the disease the symptoms of 
 the first stage continue, but there is added a new symp- 
 tom — muscular ataxia. 
 
 The ataxia is developed slowly or rapidly. If it is 
 developed rapidly it may be preceded by a febrile move- 
 ment lasting for a few days. 
 
 The affected muscles retain their power, and are still, 
 to a certain extent, under the control of the patient. 
 But he cannot control the degree of contraction, nor can 
 he co-ordinate the contraction of different groups of mus- 
 cles. The muscles most frequently affected are those of 
 the legs, but those of the arms may also be involved. 
 
 There is a great difference in the p3,tients as to the 
 degree of the development of the ataxia. It may never 
 advance farther than to make walking somewhat difficult, 
 or it may make the legs, and even the arms, almost use- 
 less. 
 
 The mental faculties may remain entirely normal ; or 
 there may be loss of memory, emotional excitability, 
 restlessness and sleeplessness, and inability for mental 
 exertion. 
 
 The second stage of the disease lasts for years, and 
 most of the patients never advance beyond this stage. 
 
 In the third stage the ataxia is succeeded by an entire 
 loss of control of the affected muscles and paralysis is 
 established. 
 
 The entire duration of the disease extends over many 
 years. Its progress is slow, but the development of the 
 ataxia may be rapid. There are often periods of inter- 
 mission and improvement, and the disease may stop 
 altogether at any time in its course. 
 
22 THE SPINAL CORD. 
 
 The prognosis is not good, but yet there may be long 
 periods of arrest and improvement, and the disease may 
 never advance so far as to interfere with the usefulness 
 of the patient. 
 
 Treatment. — During the first stage of the disease at- 
 tention to the general health and mode of life, anti- 
 syphilitic treatment, and hot douches or the actual 
 cautery over the spine seem to be of service. The 
 pains may be alleviated by rest, antipyrine, antifebrine, 
 and opium. The laryngeal crises may be relieved by 
 inhalations of the nitrite of amyl. 
 
 During the second stage the regulation of the mode of 
 life is still of importance, the hot douches may be con- 
 tinued, the application of the galvanic, or faradic current 
 to the affected muscles may perhaps be of service. 
 
 Peripheral Neuritis. 
 
 Lesions. — In persons who die while still suffering from 
 this disease, one of two lesions are found. The affected 
 nerves may be swollen, congested, infiltrated with serum 
 and pus, the nerve-fibres degenerated ; or there is sim- 
 ply degeneration of the nerve-fibres, with or without an 
 hypertrophy of the interstitial connective-tissue. 
 
 The smaller nerve-trunks are the ones regularly in- 
 volved. 
 
 Causes. — Chronic poisoning with lead, arsenic, or al- 
 cohol ; syphilis; malaria; and the infectious diseases, 
 especially diphtheria, seem to be real causes of this 
 disease. The disease called beriberi seems to be an 
 infectious disease, with peripheral neuritis as its charac- 
 
THE SPINAL CORD. 23 
 
 teristic lesion. There are also a considerable number of 
 cases for which no cause can be discovered. , 
 
 Symptoms. — The Alcoholic Cases. — These are more 
 common in females than in males. There are first the 
 symptoms of the alcohol-poisoning — chronic gastritis, 
 insomnia, general feebleness. Then disturbances of sen- 
 sation — feelings of numbness and tingling ; hyperaes- 
 thesia of the skin and muscles ; pains along the course 
 of the nerves, in the joints, the limbs, and other parts of 
 the body ; loss of tactile sensation ; lessening of the 
 reflexes. Then suddenly or gradually loss of motor 
 power, first of the legs, later of the arms. The paralysis 
 is especially marked in the extensor muscles. It is usu- 
 ally confined to the muscles of the arms and legs, but 
 may involve those of the trunk also. The paralyzed 
 muscles become soft, atrophied, and lose their faradic 
 irritability. 
 
 In the severe cases there are also marked prostration 
 and cerebral symptoms : loss of memory, mental feeble- 
 ness, alternating delirium and stupor. 
 
 The severe cases get steadily worse and die — feeble, 
 emaciated, and unconscious. 
 
 The milder cases run a course of many months. They 
 get worse for a time, then remain stationary, and then 
 gradually improve. The recovery is complete, or some 
 of the muscles are left paralyzed and atrophied. 
 
 The Idiopathic Cases. — These are said to be more 
 common in males than in females. 
 
 There are disturbances of sensation — numbness and 
 tingling ; hyperesthesia of the skin and muscles ; pains 
 along the nerves, in the joints, in the limbs, and in other 
 
24 THE SPINAL CORD. 
 
 parts of the body ; diminution of tactile sensation and of 
 the reflexes. 
 
 The motor paralysis is developed rapidly or slowly. 
 It begins in the muscles of the legs and then extends j or 
 it involves the muscles of the legs and arms at the same 
 time. The muscles of the legs and forearms are the 
 ones usually affected, less frequently those of the thighs, 
 arms, and trunk. The paralyzed muscles become atro- 
 phied and lose their faradic irritability. 
 
 There may be oedema of the skin of the feet and 
 hands, and around the joints. The joints themselves 
 may become inflamed. 
 
 In the severe cases there are a febrile movement, 
 marked prostration, and alternating stupor and delirium. 
 These symptoms extend over months or years. Most 
 of the cases recover, either completely, or with the pa- 
 ralysis of only a few muscles. But the severe cases may 
 terminate fatally. 
 
 Treatment. — A previous history of lead-poisoning, or 
 of syphilis, or of malaria gives an indication for the special 
 treatment belonging to these diseases. 
 
 For the idiopathic cases the drugs most highly recom- 
 mended are salicin, the salicylate of sodium and the 
 bromides. The severe pains can only be relieved by 
 morphine. 
 
 After improvement has begun, massage, passive mo- 
 tion, electricity, strychnia, and arsenic are of service. 
 
ACUTE CATARRHAL INFLAMMA- 
 TION OF THE PHARYNX, AND OF 
 THE TONSILS. 
 
 Lesions. — In acute catarrhal pharyngitis the mucous 
 membrane of the pharynx is congested, swollen, at first 
 dry, later covered with mucus. Usually the mucus is in 
 moderate quantity, but sometimes it covers most of the 
 posterior wall of the pharynx. 
 
 In acute catarrhal tonsillitis one or both tonsils are 
 congested and swollen, and their crypts are filled with 
 mucus and desquamated epithelium, so that the surface 
 of the congested tonsil is mottled with small white 
 patches. 
 
 Causes. — Some persons, and the members of some 
 families, are unusually liable to these inilamniations. 
 They are especially frequent during the winter months, 
 and in cold and damp localities. They may be^produced 
 by the inhalation of irritating gases, or contaminated air. 
 
 Symptoms. — The symptoms are constitutional and 
 local. The constitutional symptom is fever, with the 
 accompanying prostration, vomiting, headache, and pains 
 in the limbs. This often precedes the sore throat, and 
 disappears before the latter has subsided. 
 
2 THE PHARYNX AND TONSILS. 
 
 The principal local symptom, besides the appearance 
 of the throat, is pain, which is increased by any move- 
 ment of the muscles of the pharynx. 
 
 The intensity of the fever and the severity of the pain 
 vary in the different cases. 
 
 The inflammation is regularly a self-limited one, lasting 
 for from four to seven days, but occasionally the cases 
 are protracted for a longer period. 
 
 Treatment. — During the earlier stages of the disease 
 the use of calomel, the sulphate of magnesia, sweating of 
 the entire skin, aconite, and the salicylate of soda, either 
 separately or combined in various ways, are of service. 
 During the later stages, mild astringents applied by the 
 spray, the brush, or used as gargles, give relief to the 
 patient. 
 
 Croupous Tonsillitis. 
 
 Lesions. — Either one or both tonsils are congested, 
 swollen, and covered with a layer of false membrane. 
 The false membrane is composed of fibrine, pus-cells, 
 epithelium in the condition of coagulation necrosis, 
 and contains bacteria. The mucous membrane beneath 
 is infiltrated with fibrine and pus-cells. 
 
 Causes. — Croupous tonsillitis occurs most frequently 
 as one ofjhe lesions of diphtheria ; but it is also found 
 as an independent local inflammation, and as a compli- 
 cation of the infectious diseases. 
 
 Symptoms. — A croupous tonsillitis, not belonging to 
 diphtheria, gives the same symptoms as does a catarrhal 
 tonsillitis, but in a more marked degree. 
 
 The febrile movement, with its accompanying symp- 
 
THE TONSILS. 3 
 
 toms, is more decided ; the appearance of the inflamed 
 tonsils is different. The duration of the inflammation is 
 only for a week, but the prostration may last for several 
 days longer. 
 
 Treatment. — The cases may be managed in the same 
 way as a catarrhal tonsillitis.- But a more speedy cure 
 may be effeeted by an hourly, gargle of a solution of bi- 
 chloride of mercury of the strength of i to 4,000. 
 
 Suppurative Tonsillitis. 
 
 Lesions. — There is a suppurative inflammation begin- 
 ning in the tissue of the tonsil, which goes on to the for- 
 mation of an abscess. Either one or both tonsils may 
 be involved. The suppurative tonsillitis may be pre- 
 ceded, or accompanied, by a catarrhal tonsillitis and 
 pharyngitis. 
 
 Causes. — There is a decided predisposition in some 
 persons and in some families to this form of tonsillitis. 
 Exposure to cold and wet seems often to be an exciting 
 cause. 
 
 Symptoms. — There is a febrile movement which pre- 
 cedes and~ accompanies the local inflammation, and 
 which,[often subsides before the latter has run its course. 
 
 The inflamed tonsil becomes more and more swollen, 
 it fills up the pharynx, pushes the soft palate forward, 
 and forms a tumor in the neck. The mucous mem- 
 brane of the pharynx is swollen, the throat and mouth 
 are constantly filled with mucus and saliva. 
 
 There are great pain in the throat, inability to swallow, 
 fear of suffocation, sleeplessness, and much general dis- 
 comfort. 
 
4 THE LARYNX. 
 
 In a few cases respiration is interfered with by swell- 
 ing of the uvula, or oedema of the glottis. 
 
 If only one tonsil is inflamed, the abscess regularly 
 ruptures at the end of a week, the pus is discharged, and 
 the patient rapidly recovers. If both tonsils are inflamed 
 the disease may be prolonged for two weeks. 
 
 The patients almost uniformly recover, but it is pos- 
 sible for death to be produced by oedema of the 
 glottis. 
 
 Treatment. — During the first twenty-four hours of the 
 tonsillitis we may try to abort the inflammation by the 
 use of calomel, sulphate of magnesia, salicylate of soda, 
 and cold applied to the neck. 
 
 After the abscess has been formed, the inhalation of 
 hot steam and the application of moist heat to the neck 
 are of service. The excessive production of mucus 
 can be partly controlled by astringent washes and the ad- 
 ministration of belladonna. The pain and distress can 
 only be alleviated by opium. 
 
 Swelling of the uvula and oedema of the glottis de- 
 mand free scarification. 
 
 Laryngismus Stridulus. 
 
 This name is given to two different forms of spasmo- 
 dic contraction of the muscles of the larynx. 
 
 I. There is a spasmodic closure of the glottis, which 
 is almost complete, lasts for a few seconds, and is then 
 followed by a loud, stridulous inspiration. 
 
 This occurs in young children, usually under two years 
 of age, who are badly nourished, or who suffer from 
 rickets 
 
THE LARYNX. ' 5 
 
 It occurs in attacks, which are repeated after short or 
 long intervals. 
 
 The child suddenly stops breathing, the face and lips 
 become pale, or slightly livid, the appearance is almost 
 that of a dead person. Then, after a few seconds, there 
 is a long, stridulous inspiration, and the attack is over. 
 Sometimes the attacks are accompanied by rigidity of 
 the muscles, or by general convulsions, or by uncon- 
 sciousness. Occasionally the attacks are fatal. 
 
 At the time of an attack, if it is an alarming one, we 
 may give inhalations of nitrate of amyl, or pass a tube 
 through the larynx. 
 
 To prevent the attacks the nutrition of the child is to 
 be improved in every possible way. 
 
 2. There is a spasmodic partial closure of the glottis, 
 attended with difficult and stridulous breathing, which 
 lasts for several hours. 
 
 This occurs in young children of all kinds, whether 
 their previous health has been good or not. There is a 
 decided predisposition in families and in individuals. 
 Some of the attacks are due to indigestion, for others no 
 cause can be discovered. 
 
 The attacks usually begin in the night and last until 
 the next day. The child wakes up in the night with 
 laryngeal dyspnoea, which after a time is followed by 
 more or less venous congestion of the skin. But there 
 is no fever, and, except for the dyspnoea, the child does 
 not look ill. Although the dyspnoea may appear alarm- 
 ing, it always eventually subsides, even if it is left to it- 
 self; but an emetic will cause it to disappear more rapidly. 
 The best emetics are those which act the quickest : the 
 
6 THE LARYNX. 
 
 yellow sulphate of mercury, apomorphia, ipecac, and an- 
 timony are those ordinarily used. 
 
 Acute Catarrhal Laryngitis. 
 
 Lesions. — The mucous membrane of the larynx is con- 
 gested, and at first dry. The stage of dryness lasts for 
 from twelve to forty-eight hours, and is then succeeded by 
 an increased production of mucus. With the production 
 of the mucus the congestion and swelling of the mucous 
 membrane diminish. The inflammation may extend to 
 the trachea and bronchi or to the pharynx. It occurs 
 both in adults and children. 
 
 I. In Adults. Causes. — The inflammation occurs 
 without discoverable cause, after exposure to cold, from 
 the inhalation of smoke or steam, with syphilis, phthisis, 
 measles, scarlatina, variola, erysipelas', typhus and ty- 
 phoid fevers. 
 
 Symptoms. — In the more severe cases there is a febrile 
 movement, in the milder cases this is absent. 
 
 The patients have a laryngeal cough, at first dry, after- 
 ward with mucous expectoration. The voice is husky, 
 or stridulous, or reduced to a whisper. There is more 
 or less discomfort or pain in the larynx. In some of the 
 cases there is laryngeal dyspnoea, continuous, but with 
 exacerbations. The most alarming feature about this 
 dyspnoea is that occasionally the patients stop breathing 
 suddenly and die. 
 
 The inflammation usually runs its course within two 
 weeks, but it may be protracted for a much longer 
 period. 
 
 Treatment. — -During the acute stages of the laryngitis 
 
THE LARYNX. 7 
 
 the continuous application of hot sponges to the neck, 
 and the inhalation of steam, are of decided service. The 
 internal administration of tartarized antimony, or of the 
 iodide of potash, may also be useful. When the dyspnoea 
 is urgent the patients are to be constantly watched, in 
 order that intubation or tracheotomy may be performed, 
 if necessary. If the inflammation is prolonged the 
 mineral acids^ quinine, iron, and change of climate may 
 hasten the subsidence of the disease. 
 
 2. In Children. — The catarrhal laryngitis of children 
 is often called catarrhal croup. It is one of the most 
 common diseases of childhood. 
 
 It occurs often without discoverable cause, sometimes 
 after exposure to cold and wet, from the inhalation of 
 steam and smoke, and as a complication of measles and 
 scarlatina. 
 
 The disease is most common in children between the 
 ages of one and five years, less frequent in older children. 
 There is a well-marked predisposition to the disease in 
 some children and in some families. 
 
 The changes in the mucous membrane of the larynx 
 are the same as those observed in adults, but the smaller 
 size of the larynx in children causes the swollen mucous 
 membrane to be a still greater obstruction to the act of 
 breathing. 
 
 Symptoms. — The local symptoms are : Dyspnoea, which 
 is continuous, but with exacerbations ; in some cases, 
 attacks of laryngismus stridulus ; stridulous voice, or loss 
 of voice ; and stridulous cough. 
 
 The general symptom is a rise of temperature with its 
 accompanying disturbances. The fever may precede, 
 
8 THE LARYNX. 
 
 or follow, or be simultaneous with, the local symp- 
 toms. 
 
 The invasion of the disease is often sudden, and then 
 usually occurs in the night, with the continuous dyspnoea, 
 or an attack of laryngismus stridulus as the first symp- 
 tom. 
 
 In other cases the invasion of the disease is gradual, 
 with a croupy cough as the first symptom. 
 
 The ordinary cases last for three days and nights, the 
 symptoms worse during the night and better during the 
 day. 
 
 The patients vary as to the height of the temperature 
 and the degree of the dyspnoea. Most of the patients 
 are decidedly better by the fourth day, the improvement 
 beginning with the production of mucus from the in- 
 flamed membranes. Occasionally, however, the laryn- 
 gitis is protracted for one or two weeks, or it may be 
 succeeded by a bronchitis. 
 
 The Prognosis is good, even the severe cases are sel- 
 dom fatal. 
 
 Treatment. — For the laryngitis we apply moist heat to 
 the neck, and give internally five- or ten-drop doses of the 
 wine of antimony, every one or two hours. For the at- 
 tacks of laryngismus stridulus we give emetics. For_ the 
 fever it may be proper to use small doses of antifebrin or 
 tincture of aconite ; for the restlessness, small doses of 
 opium. In the protracted cases small doses of calomel 
 may be of service. 
 
THE LARYNX. 9 
 
 Croupous Laryngitis. 
 
 Membranous Croup. Lesions. — The mucous mem- 
 brane of the larynx is congested, swollen, and infiltrated 
 with fibrine and pus. Its free surface is coated with a 
 false membrane composed of fibrine, pus, and necrotic 
 epithelium. 
 
 Causes. — Croupous laryngitis is most frequently seen 
 as one of the lesions of diphtheria, but it may also be 
 caused by inhalations of steam and smoke, by the 
 poisons of the infectious diseases, and by exposure to 
 cold and wet. It is much more common in children than 
 in adults. 
 
 The Symptoms are the same as those of a catarrhal 
 laryngitis, but are more severe, more continuous, and 
 last for a longer time. The temperature is higher, the 
 dyspnoea is more severe, and the evidences of imperfect 
 aeration of the blood are more marked. In the favor- 
 able cases, after from four to seven days, the inflamma- 
 tion subsides, the false membrane becomes loosened, is 
 coughed up, and the dyspnoea is relieved. In the un- 
 favorable cases the dyspnoea continues, and causes the 
 death of the patient. 
 
 The Prognosis is unfavorable, especially in children 
 under three years of age. 
 
 The Treatment is the same as that for a catarrhal laryn- 
 gitis, but in addition it is often necessary to employ in- 
 tubation or tracheotomy to relieve the dyspnoea. 
 
lO THE PHYSICAL SIGNS. 
 
 The Physical Signs of the Pleura and of the 
 Lungs. 
 Percussion. — When we percuss the wall of the chest 
 we obtain certain sounds, and of these sounds we note 
 the quality, the pitch, the intensity, and the duration. 
 
 1. Pulmonary Resonance. — This is characterized by 
 pulmonary quality, low pitch, considerable duration, and 
 variable intensity. It is heard over the healthy lung. 
 
 2. Dulness. — Of this the quality is imperfectly pul- 
 monary, the pitch is higher, the duration is short, the 
 intensity is small. It is heard over the normal lung 
 where the chest-wall is thickened by bone or muscle, and 
 where the liver and heart are in contact with the lung. 
 It is heard over pleuritic adhesions, over small quantities 
 of fluid in the pleural cavities, over consolidations of the 
 lung, emphysema, enlargements of the heart, liver, and 
 spleen, aneurisms of the aorta, abscesses, and tumors. 
 
 3. Flatness.— i:\ie quality is flat, the pitch is high, the 
 duration is short, the intensity is small. It is heard over 
 the liver, where it is uncovered by the lung, over thick 
 pleuritic adhesions, fluid in the pleural cavities, com- 
 plete consolidation of the lung, aneurisms, abscesses, 
 tumors, and rarely over a lung which is not consolidated, 
 but of which the bronchi are completely obstructed. 
 
 4. Tympanitic Resonance, — The quality is tympanitic, 
 the pitch is high or low, the duration is considerable, 
 the intensity is marked. It is heard over the stomach 
 and intestines, over air in the pleural cavities, over cavi- 
 ties in the lungs, over solidified and compressed lung, 
 and with emphysema. 
 
THE PHYSICAL SIGNS. II 
 
 5. The Cracked Poi Sound. — The quality is metallic, 
 the pitch is high, the duration and intensity are not very 
 great. It is heard over cavities, and over consolidated 
 and compressed lung. 
 
 6. Amphoric Resonance. — The quality is amphoric, the 
 pitch is low, the duration and intensity are considerable. 
 It is heard over air in the pleural cavity, over large cavi- 
 ties in the lung, and occasionally over consolidations of 
 the lower lobe of the left lung. 
 
 Thk Breathing. — In listening to the breathing we 
 distinguish the sound of inspiration and that of expira- 
 tion, and of each we note the quality, the pitch, the in- 
 tensity, and the duration. 
 
 1. Pulmonary, or Vesicular Breathing. — Of inspiration, 
 the quality is pulmonary, the pitch is low, the duration 
 is considerable, the intensity is variable. Of expiration, 
 the pitch is low and the duration is shorter. 
 
 2. Bronchial Breathing. — Of inspiration, the quality is 
 bronchial, the pitch is high, the intensity and dura- 
 tion are variable. Of expiration, the pitch is higher 
 and the duration is longer than those of inspiration. It 
 is heard over consolidated and compressed lung, and over 
 cavities. 
 
 3. Broncho-vesicular Breathing. — This is of a charac- 
 ter intermediate between that of vesicular and that of 
 bronchial breathing. It is heard over the normal lung 
 in the interscapular region, and over the lesser degrees 
 of consolidation and compression of the lung. 
 
 4. Cavernous Breathing. — Of the inspiration, the qual- 
 ity is cavernous, the pitch is low. The expiration is 
 longer and lower pitched than the inspiration. It is 
 
12 THE PHYSICAL SIGNS. 
 
 heard over cavities and over consolidated or compressed 
 lung. 
 
 5. Amphoric Breathing. — The quality is amphoric, the 
 pitch is low, the expiration is prolonged. It is heard 
 over large cavities in the lungs, and over pleural cavities 
 which contain air, with perforation of the lung. 
 
 6. Sibilant Breathing. — The quality is sibilant, the 
 pitch is high, the intensity is great, the expiration is 
 prolonged. 
 
 Sonorous Breathing. — The quality is sonorous, the 
 pitch is low, the intensity is great, the expiration is pro- 
 longed. Both these forms of breathing are produced 
 by a contraction of the calibre of the larger and 
 medium sized bronchi. The ordinary causes of such a 
 contraction are bronchitis and spasmodic asthma. 
 
 A special form of sibilant and sonorous breathing is 
 produced by narrowing of the lumen of the trachea, or of 
 the large bronchi. 
 
 RAles. — These are abnormal sounds which accom- 
 pany the breathing and are not heard over the healthy 
 
 lung. 
 
 1. The Crepitant Rale. — This is a very fine, dry, crack- 
 ling sound. It is heard at the end of inspiration, is pro- 
 duced in puffs, and saems to be close to the ear. It is 
 heard with dry pleurisy, with pneumonia, and with 
 phthisis. 
 
 2. The Subcrepitant Rdle. — This is a fine, moist sound ; 
 heard with inspiration, or with expiration, or with both. 
 It accompanies dry pleurisy, bronchitis, pneumonia, 
 phthisis, and cedema of the lungs. 
 
 3. The Coarse, or Mucous, RAles. — These are loud. 
 
THE PHYSICAL SIGNS. 1 3 
 
 moist sounds, heard both with inspiration and expira- 
 tion. They are heard with pleurisy, with bronchitis, 
 with pneumonia, and with phthisis. 
 
 4. The Gurgling Rdles. — These are loud, coarse, 
 moist sounds, of gurgling quality. They are heard over 
 small cavities, over compressed lung, and occasionally 
 over pleuritic adhesions. 
 
 Friction Sounds. — These are produced by the rub- 
 bing of opposed surfaces of pleura coated with fibrine, or 
 by the movement of pleuritic adhesions. 
 
 They have the characters of the crepitant, the sub- 
 crepitant, the mucous, or the gurgling rMe ; the, sound is 
 a grazing, or rubbing, or creaking one. 
 
 The Voice, The Pulmonary Voice. — ^The quality is 
 pulmonary, the pitch is low, the intensity and the thrill 
 differ with the individual. 
 
 Increased Vocal Resonance. — The quality is pulmonary, 
 the pitch is higher, the intensity and the thrill are greater. 
 It is heard over the normal lung in the right infra-clavi- 
 cular and in both the interscapular regions. It is also 
 heard over consolidated or compressed lung, over cavi- 
 ties, and over lung which is adherent to the wall of the 
 chest. 
 
 Diminished Vocal Resonance. — The intensity and the 
 thrill are diminished, the quality and the pitch are the 
 same as with the pulmonary voice. It is heard over 
 small effusions in the pleural cavities, over thick pleuritic 
 adhesions, over consolidated lung, and over lungs of 
 which the bronchi are occluded. 
 
 Suppressed Vocal Resonance. — There is absence of the 
 voice-sound with fluid in the pleural cavities, with intra- 
 
14 THE PHYSICAL SIGNS. 
 
 thoracic tumors, with consolidation of the lung, and with 
 obstructions of the bronchi. 
 
 Bronchophony. — The quality is bronchial, the pitch is 
 high, the intensity and the thrill are variable. It is 
 heard over consolidated and compressed lung, and over 
 cavities. 
 
 ^gophony. — This is a form of bronchophony charac- 
 terized by its peculiar, shrill quality. It is heard over 
 lung compressed by fluid in the pleural cavity, at the 
 level of the fluid. 
 
 Pectorilogy. — Not only the sound of the voice is heard, 
 but the articulation of words can be distinguished. It is 
 heard over large cavities, and sometimes over consoli- 
 dated lung. 
 
THE PLEURA. 
 
 The pleura is a connective-tissue membrane composed 
 of fibrillated connective tissue, with its basement sub- 
 stance and cells, and. covered over its free surface by a 
 layer of endothelial cells. Imbedded in it are nerves, 
 blood-vessels, and lymphatics. According to its distribu- 
 tion, we speak of the pulmonary, costal, mediastinal, and 
 diaphragmatic pleura. 
 
 The pleura may become inflamed in several different 
 ways, and we describe : 
 
 Pleurisy with the production of fibrine. 
 
 Pleurisy with the production of fibrine and serum. 
 
 Pleurisy with the production of fibrine, serum, and 
 pus. 
 
 Pleurisy with adhesions. 
 
 Tubercular pleurisy. 
 
 In pleurisy with the production of fibrine alone, or .of 
 both fibrine and serum, the morbid changes in the pleura 
 are essentially the same, differing only in the presence or 
 absence of the serum. 
 
 The first change in the pleura is simply a congestion 
 and a falling off of the endothelial cells. Then the 
 
2 THE PLEURA. 
 
 pleura loses its smooth, shining appearance and looks 
 dull and rough, this change being due to the presence 
 of small knobs and threads of coagulated fibrine on its 
 surface. At the same time, if serum is to be present, it 
 begins to collect in the pleural cavity. 
 
 Next there is a swelling of, and a new-growth from, the 
 connective-tissue cells of the pleura, and an emigration 
 of white blood-cells from the vessels. Then we find the 
 pleura coated with a layer of fibrine in which are en- 
 tangled pus-cells and new connective-tissue cells. After 
 this the new connective-tissue cells entangled in the 
 fibrine become more numerous, a basement substance 
 and new blood-vessels are formed. 
 
 Finally, the fibrine and the serum are absorbed and 
 disappear, and the pleura is left thickened and with con- 
 nective-tissue adhesions binding together its opposed 
 surfaces. 
 
 Pleurisy with the Exudation of Fibrine. Dry 
 Pleurisy. 
 
 Lesions. — The inflammation begins in the costal or 
 pulmonary pleura, according to the cause producing it. 
 It extends regularly to the portion of pleura opposite to 
 it. Usually only a circumscribed portion of the costal, 
 pulmonary, mediastinal, or diaphragmatic pleura is in- 
 volved, but sometimes the entire pleura of one side of the 
 chest is inflamed. The inflamed pleura is coated with 
 fibrine, and bands of fibrine form adhesions between the 
 opposed pleural surfaces. 
 
 In rare cases the quantity of fibrine is so great as to 
 compress the lung. 
 
THE PLEURA. 3 
 
 When the inflammation has subsided, the fibrine is ab- 
 sorbed, but permanent connective-tissue thickening and 
 adhesions are left. 
 
 Causes. — Exposure to cold and wet, wounds of the 
 chest-walls, inflammations of the lung, peritonitis, the in- 
 fectious diseases, and Bright's disease are regular causes 
 of pleurisy. In some cases there seems to be an indi- 
 vidual predisposition to pleurisy, and the same person 
 suffers from several attacks. 
 
 Symptoms. — The most constant physical sign is a fric- 
 tion sound — a crepitant, subcrepitant, or mucous rAle, 
 or a rubbing sound. This is heard over the inflamed por- 
 tion of the pleura. It cannot be heard if only the med- 
 iastinal or diaphragmatic pleura are inflamed. It is heard 
 only with inspiration, or with expiration also. It is usu- 
 ally not continuous, but requires a forced inspiration to 
 develop it. 
 
 In some cases there is also dulness over the inflamed 
 portion of the pleura. 
 
 In the mild cases the only constitutional symptom is 
 pain over the inflamed pleura. 
 
 In the more severe cases there is a febrile movement 
 attended with prostration and headache, shallow breath- 
 ing, and a dry cough. These symptoms only last for a 
 few days. 
 
 The exceptionally severe cases, with very large exuda- 
 tions of fibrine, resemble cases of lobar pneumonia. 
 
 The ordinary cases recover after a short time, but the 
 patient is left with permanent thickenings and adhesions 
 of the pleura. Such adhesions may give no further trou- 
 ble, except for occasional pain ; or they may form the 
 
4. THE PLEURA. 
 
 starting-point for a chronic pleurisy with adhesions, fol- 
 lowed by interstitial pneumonia and chronic bronchitis. 
 
 Treatment. — For the pleurisy we employ wet, or dry, 
 cups, or blisters over the inflamed pleura. For the pain 
 we use opium. While the febrile movement is present 
 the patients should be kept in bed. So long as the 
 friction sound persists the patient must be kept in the 
 house if the weather is cold, but in warm weather this 
 is not necessary. 
 
 Pleurisy with the Exudation of Fibrine and Se- 
 rum. Pleurisy with Effusion. 
 
 The inflammation involves the greater part of the 
 pleura on one side of .the chest. Occasionally both 
 sides of the chest are inflamed, and when this , is the 
 case the pericardium is apt also to be inflamed. The 
 pleural cavity contains more or less clear, or turbid, 
 serum. The surface of the pleura is coated with fibrine, 
 and bands of fibrine join together its opposed surfaces. 
 The lung is more or less compressed, according to the 
 quantity of fluid. 
 
 After the inflammation has subsided the serum and fib- 
 rine are absorbed, and thickenings and adhesions of con- 
 nective tissue are left. 
 
 The compressed lung expands partially or com- 
 pletely. According to the expansion of the lung, there 
 is left more or less retraction of the affected side of the 
 chest. 
 
 The Causes are the same as those which produce dry 
 pleurisy. 
 
THE PLEURA. 5 
 
 Symptoms. — The disease may run an acute, or a sub- 
 acute course. 
 
 1. The acute form. The symptoms begin abruptly 
 with chills, fever, full and frequent pulse, pains in the 
 head and limbs, vomiting, and prostration. The breath- 
 ing is frequent and shallow, there may be a dry cough, 
 there is severe pain. The pain is referred to the in- 
 flamed pleura, or to some point in the back, or in the 
 abdomen, or even to the opposite side of the chest. It 
 usually becomes less severe with the accumulation of 
 serum in the pleural cavity. 
 
 After a few days the acute symptoms subside. The 
 inflammatory products remain in the chest for some 
 time longer. They may then be absorbed, or the 
 pleurisy may take on the subacute form and last for a 
 long time. 
 
 2. The subacute form. — The symptoms are developed 
 gradually and slowly. The patients complain of pain in 
 the side, of dyspnoea on exertion, of a dry cough, of 
 loss of appetite, flesh, and strength, and they become 
 ansemic. They are, for a time, not confined to bed, 
 an'd often continue at their work. They have a little 
 fever, the temperature normal in the morning, but run- 
 ning up to 1 00° in the afternoon. 
 
 In some cases, however, the temperature runs higher : 
 100° in the morning and loi" to 103" in the afternoon. 
 With these higher temperatures the patients lose flesh 
 and strength more rapidly, and may sweat at night. 
 
 The physical signs. — At the beginning of the inflam- 
 mation, when the pleura is coated with fibrine and but 
 little serum has been exuded, there is a friction sound. 
 
O THE PLEURA. 
 
 which is a rubbing sound, or a crepitant or subcrepitant 
 rale. After the fluid has been absorbed there is again 
 a friction sound — a subcrepitant or coarse rale, or a 
 creaking sound. 
 
 When a considerable quantity of fluid has accumu- 
 lated in the pleural cavity there are physical signs due 
 to the presence of the fluid and the compression of the 
 lung. 
 
 Below the level of the fluid there is flatness on per- 
 cussion, absence of voice, of breathing, and of vocal 
 fremitus. The fluid accumulates in the lower part of 
 the pleural cavity, compressing the lung upward and 
 against the vertebral column ; or in the posterior part of 
 the pleural cavity, compressing the lung against the an- 
 terior wall of the chest ; or it may be shut in by adhesions. 
 The compression of the lung is in proportion to the 
 quantity of the fluid. 
 
 At the level of the fluid there is dulness on percussion 
 and cegophony. 
 
 Above the level of the fluid, over the compressed 
 lung, the percussion resonance is pulmonary, or exagger- 
 ated and high-pitched, or tympanitic. The breathing is 
 pulmonary, or exaggerated, or broncho-vesicular, or 
 bronchial. 
 
 The affected side measures more than the opposite 
 side of the- chest, the diaphragm is pushed down, the 
 intercostal spaces may be forced outward, the heart 
 may be displaced toward the opposite side of the 
 chest. 
 
 As the fluid is absorbed the voice and breathing can 
 be heard lower and lower down, the flatness disappears. 
 
THE PLEURA. 7 
 
 but dulness on percussion remains for some time after 
 all the fluid has been absorbed. 
 
 Exceptional physical signs. — The vocal fremitus may 
 not be lost below the level of the fluid. Bronchophony 
 alone, or both bronchial voice and breathing, may be 
 heard below the level of the fluid, especially if the quan- 
 tity of fluid is large and the lung much compressed. 
 
 Above the level of the fluid, over the compressed 
 lung, there may be cavernous breathing and gurgling 
 rales. 
 
 The sacculated effusions give very irregular physical 
 signs, varying with the position of the fluid. 
 
 The acute cases of pleurisy with effusion may last for 
 only a few weeks, but more frequently, whether acute or 
 subacute, they last for weeks or months. 
 
 In a few cases the disease terminates fatally. Death 
 is then often sudden, and seems to be due to congestion 
 and cedema of the other lung, or to interference with 
 the action of the heart. 
 
 In a moderate number of cases the inflammation 
 changes its character, pus is added to the other inflam- 
 matory products, and the patients have empyema. 
 
 Most of the patients recover, but with a damaged 
 pleura, and with a lung which expands more or less in- 
 completely. In many of them the only subsequent in- 
 convenience is some pain on the affected side of the 
 chest ; but in others there is marked retraction of the 
 wall of the chest, chronic pleurisy with adhesions, inter- 
 stitial pneumonia, or chronic bronchitis. It may also 
 happen that such a pleurisy will be succeeded by chronic 
 phthisis. 
 
» THE PLEURA. 
 
 The displaced heart may return to its natural position, 
 or it may remain fastened in its new place by adhesions, 
 or it may be drawn over to the retracted side of the 
 chest. 
 
 Diagnosis. — Pleurisy with effusion may be mistaken 
 for empyema, tubercular pleuiisy, pneumonia, phthisis, 
 abscess of the liver, or tumors of the pleura. In many 
 cases we are warranted in drawing off fluid from the 
 pleural cavity with a fine needle, in order to establish 
 the diagnosis. 
 
 Treatment. — Of the acute form of pleurisy with effu-. 
 sion, the treatment is that of an acute exudative inflam- 
 mation. Wet or dry cups, or blisters over the affected 
 side of the chest, calomel, and the sulphate of magnesia 
 given internally, are the most efficient remedies. The 
 patients are to be kept in bed and on a fluid diet. The 
 pain and restlessness may be relieved by opium com- 
 bined with aconite or veratrum viride, or by chloral 
 hydrate with one of the bromides. 
 
 In subacute pleurisy with effusion we have to treat 
 the inflammation and the accumulation of fluid within 
 the pleural cavity. The only direct means of treating 
 the inflammation is the use of counter-irritation over 
 the affected side of the chest. The indirect means are : 
 keeping the patients in bed, or getting them out of doors 
 in a suitable climate, according to the case ; the use of 
 iron, quinine, and the mineral acids ; and the regulation 
 of the diet. 
 
 If the quantity of fluid in the pleural cavity is mod- 
 erate it can be removed by diuretics : the iodide or 
 acetate of potash, the diuretic pill, chloride of sodium, 
 
THE PLEURA. 9 
 
 caflfein, convallaria, digitalis. At the same time the 
 urine is to be measured every day, and the ingestion of 
 fluids somewhat restricted. 
 
 If the chest is distended with fluid this must be re- 
 moved by the aspirator. In doing this the strictest 
 cleanliness^nust be observed, and only a moderate quan- 
 tity of the serum withdrawn. Immediately after the as- 
 piration the use of diuretics should be begun. 
 
 Pleurisy with the Production of Serum, Fibrine, 
 AND Pus. Empyema. 
 Lesions. — The inflammation regularly involves the 
 whole of the pleura on one side of the chest, less fre- 
 quently a circumscribed portion of the pleura. The in- 
 flammation follows two different forms : 
 
 1. The pleura is coated with fibrine and pus, and its 
 cavity contains purulent serum, but the pleura itself is 
 but little changed. This form is most common in chil- 
 dren. 
 
 2. The pleura is coated with fibrine and pus, its cavity 
 contains purulent serum, and in addition the pleura itself 
 is much changed. It is split up by great numbers of new 
 cells, so that it resembles granulation tissue. 
 
 In either case the fluid accumulates in the lower part 
 of the pleural cavity, pushing the lung upward and tow- 
 ard the vertebral column ; or in the posterior part of the 
 pleural cavity, pushing the lung forward ; or it is saccu- 
 lated in any part of the pleural cavity. The lung is 
 usually much compressed. In old cases the pleura be- 
 comes much thickened, and may be infiltrated with the 
 salts of lime. 
 
10 THE PLEURA. 
 
 The suppurative process may extend from the pulmon- 
 ary pleura to the lung, and the pus then escape at inter- 
 vals from the bronchi ; or it may extend from the costal 
 pleura to the wall of the chest, and the pus escape ex- 
 ternally. 
 
 In a few cases the inflammatory products and the super- 
 ficial layers of the pleura become gangrenous. 
 
 Symptoms. — i. -The inflammation may be primary, 
 after exposure to cold, or without discoverable cause. 
 The patients are suddenly attacked with chills, a high 
 temperature, marked prostration, headache, pains in the 
 back and limbs, pain over the inflamed pleura, shallow 
 and painful breathing, sometimes cough. The symptoms 
 may continue acutely and the patients die in a short time, 
 or they may subside and the inflammation pass into the 
 chronic condition. 
 
 2. The inflammation may be secondary to a pleurisy 
 with effusion, or to a lobar pneumonia. A pleurisy 
 with effusion may change suddenly or slowly into an em- 
 pyema. The patients lose flesh and strength more rap- 
 idly, and have higher temperatures. A lobar pneumonia 
 may run its course, convalescence be established and con- 
 tinue for several days, and then the temperature goes up 
 and there are the physical signs of fluid in the pleural cavity. 
 
 3. An empyema, after running its course for a shorter 
 or longer time, will suddenly change, the inflammatory 
 products become gangrenous, the patients pass into the 
 pysemic condition and die in a few days. 
 
 4. Abscesses in the wall of the thorax, in the liver, in 
 the abdominal cavity, or in the lung may rupture into the 
 pleural cavity and set up a purulent inflammation. 
 
THE PLEURA. II 
 
 The physical signs of empyema are the same as those 
 of pleurisy with effusion, but sacculation of the fluid and 
 irregular physical signs are more common. 
 
 The course of the disease. — Some of the acute cases 
 continue without any abatement of the symptoms, and 
 terminate fatally within a short time. More frequently 
 the course of the disease is chronic. The patients go on 
 for months or years with fever, gradual loss of flesh and 
 strength, and dyspncea and cough. In some the lung 
 is perforated and the pus from time to time coughed up 
 through the bronchi ; in some the wall of the chest is 
 perforated and the pus imperfectly evacuated ; in some 
 there is septic poisoning. 
 
 Very rarely does spontaneous recovery take place ; 
 somewhat more frequently there is partial recovery, with 
 absorption of some of the pus and sacculation of the re- 
 mainder. Most of the patients, if not cured by proper 
 treatment, die exhausted by the disease, or with pulmon- 
 ary phthisis, or with waxy viscera. 
 
 Tlie prognosis is more favorable in children than in 
 adults, in those operated on early than in those operated 
 on late. It is unfavorable after septic poisoning has 
 begun, and when the empyema is caused by' the rupture 
 of an abscess into the pleural cavity. 
 
 The diagnosis is between empyema, pleurisy with ef- 
 fusion, lobar pneumonia, pulmonary phthisis, and abscess 
 of the liver. 
 
 The treatment. — In a very few cases, especially in 
 children, empyema can be cured by repeated aspirations, 
 but as a rule it is necessary to make an opening in the 
 wall of the chest. The opening is usually to be made as 
 
12 THE PLEURA. 
 
 low down as possible, just in front of the axillary line, 
 and in many cases portions of one or more ribs must be 
 resected. It is often wise to draw off part of the fluid 
 with the aspirator one or two days before the operation 
 is performed. It may be proper to introduce the hand 
 into the pleural cavity, break up the adhesions between 
 the lung and the wall of the chest, and sweep away the 
 masses of fibrine which coat the pleura. The operation 
 is to be done with the strictest antiseptic precautions. 
 After the operation the antiseptic dressings should be 
 changed as seldom as possible, no attempt should be 
 made to wash out the tube or the chest, and, if the case 
 is to do well, the drainage-tube should be removed by the 
 end of the fourth week. It is better to operate a second 
 time and to remove more of the ribs, than to leave the 
 drainage-tube in the chest for too long a time. 
 
 Chronic Pleurisy with Adhesions. 
 
 Lesions. — There is a chronic inflammation of the 
 pleura with the production of new connective tissue, but 
 without fibrine, serum, or pus. The inflammation be- 
 gins at some part of the pleura, and then extends until 
 first one lung and then both are completely covered with 
 adhesions and fastened to the walls of the chest. It is 
 not to be confounded with the old adhesions found over 
 so many lungs after death, but is a chronic inflammatory 
 process with the progressive formation of more and more 
 adhesions. 
 
 Causes. — The disease usually originates in adhesions 
 which have bee/i left behind by previous attacks of dry 
 pleurisy, pleurisy with effusion, or pneumonia ; but in 
 
THE PLEURA. 1 3 
 
 some cases no history of such previous acute attacks can 
 be obtained. 
 
 The symptoms vary with the extent of the lesions. 
 
 In the early stages the only symptoms are occasional 
 pain over the affected part of the chest, dulness on per- 
 cussion, and friction sounds. 
 
 When the disease is farther advanced the pain contin- 
 ues, there is a dry cough, the breathing is imperfect, 
 there is dyspnoea on exertion, and the area of dulness on 
 percussion and of the friction sounds is larger. 
 
 In the advanced cases the difficulty in breathing be- 
 comes very marked, the cough is more troublesome, the 
 heart is diminished in size and sometimes displaced, the 
 circulation is feeble, the patients lose flesh and strength. 
 They usually die from some intercurrent disease, but oc- 
 casionally the pleurisy is the only discoverable cause of 
 death. 
 
 Treatment. — The patients should live as much as pos- 
 sible in the open air. They may be benefited by the 
 use of cod-liver oil, iron, quinine, or the mineral acids. 
 They should practise daily the filling and emptying of 
 the lungs with air in as complete a manner as is pos- 
 sible. 
 
 Tubercular Pleurisy. 
 
 Apart from the tubercular inflammation of the pleura, 
 which accompanies general tuberculosis and chronic 
 phthisis, we find tubercular pleurisy occurring as a local- 
 ized tubercular inflammation. 
 
 Lesions. — The inflammation involves regularly the 
 whole of the pleura on one side of the chest, the costal 
 
14 THE PLEURA. 
 
 pleura being principally involved. The pleura is of a 
 bright-red color mottled with small white points, or is 
 only thickened and coated with fibrine. The tissue of 
 the pleura is split up by the growth of new connective- 
 tissue cells, and contains numerous tubercle granula. 
 There is a large quantity of fluid in the pleural cavity, 
 which is blood-stained, or purulent, or clear. 
 
 Symptoms. — The clinical history is that of pleurisy 
 with effusion, or of empyema, but the patients do badly. 
 They lose flesh and strength, the fluid accumulates rap- 
 idly after it has been drawn off, the inflammation of the 
 pleura persists, and the patients die, either suddenly or 
 exhausted by the disease, within a few weeks or months. 
 
 Hydro-Pneumothorax. 
 
 This name is used to designate the presence of both 
 air and fluid in the pleural cavity. Such a condition 
 may be established in several different ways. 
 
 There may be a gangrenous empyema with the forma- 
 tion of gas in the pleural cavity. 
 
 There may be an empyema with an opening through 
 the wall of the chest or into the lung. 
 
 There may be abscess, or gangrene of the lung per- 
 forating the pulmonary pleura. 
 
 There may be pulmonary phthisis with softening of 
 cheesy nodules and perforation of the pleura. 
 
 Symptoms. — The only cases of hydro-pneumothorax 
 which have a special clinical history are those due to 
 the rupture of abscesses or phthisical nodules in the 
 lung. There is first the history of the previous lung 
 disease. Then, suddenly, at the time of the perforation, 
 
THE PLEURA. I 5 
 
 there is severe pain, a feeling as if something had given 
 way within the chest, urgent dyspnoea, a rapid and feeble 
 heart action, and great prostration. The patients may 
 die in collapse within a few hours of the commencement 
 of the attack ; or the urgent symptoms may subside and 
 the patients continue to live for some time with the 
 symptoms of empyema and phthisis. 
 
 Physical signs. — The affected side of the chest is 
 larger than the other, and moves but little with respira- 
 tion. The heart and the diaphragm are displaced. 
 Vocal fremitus is absent. Percussion gives, above the 
 level of the fluid, exaggerated pulmonary or tympanitic 
 resonance, or flatness; below the level of the fluid, 
 flatness. Auscultation gives, above the fluid amphoric 
 breathing, or absence of breathing ; below the level of 
 the fluid, absence of breathing. If the patient is shaken 
 we get the splashing sound of the fluid in the chest 
 called " succussion." We may also get the sound re- 
 sembling drops of liquid falling into liquid, called " the 
 metallic tinkle." 
 
THE LUNGS. 
 
 The lungs first appear as two small protrusions on 
 the front of the oesophagus. They are diverticula of the 
 hypoblast surrounded by mesoblast. The formative pro- 
 cess consists in the budding of hypoblastic into meso- 
 blastic substance ; the hypoblast furnishing the lining 
 epithelium and the mesoblast the stroma. As the lungs 
 continue to develop' they look like glands with acini and 
 ducts. 
 
 Just before birth the lungs are fully formed, but the 
 air-spaces are not dilated and are completely lined with 
 cuboidal epithelium. After birth the air-vesicles ,are 
 dilated and their epithelium is flattened. 
 
 As the child becomes older the air-spaces occupy a 
 larger, and the bronchi and the stroma a smaller, part of 
 the lung. 
 
 In the adult lung the stroma is arranged so as to divide 
 the lung up into lobules, six- or seven-sided blocks, each 
 side 5 to 15 mm. long. But few of the lobules are en- 
 tirely separated from each other by the stroma. The 
 small bronchi enter the lobules irregularly and break up 
 into terminal bronchioles. The bronchioles terminate 
 in the air-passages. The air-vesicles are given off from 
 the air-passages or directly from the bronchioles. The 
 
2 THE LUNGS. 
 
 walls of the air-passages and vesicles are thin, connective- 
 tissue membranes with scattered flat cells on their sur- 
 faces. 
 
 Bronchitis. 
 
 Causes. — Inflammation of the bronchi occurs at all 
 ages ; but its acute form is most common in children, 
 and its chronic form most common in old persons. 
 
 Persons living in cities, those who are much confined 
 to the house, and those whose health has been enfeebled, 
 are liable to the disease. There is in some persons an 
 individual predisposition to inflammations of the bronchi. 
 The disease is especially prevalent in cold and damp 
 climates and during the cold and wet months of the 
 year. As exciting causes of bronchitis we recognize 
 exposure to cold, the inhalation of irritating gases and 
 substances, and (probably) pathogenic bacteria. Measles, 
 whooping-cough, and many of the infectious diseases are 
 often complicated by bronchitis. 
 
 I. The acute catarrhal bronchitis of adults. 
 
 Lesions. — The inflammation involves the trachea, the 
 large bronchi, and the medium-sized bronchi, not often 
 the smaller ones. As a rule, the bronchi of both lungs 
 are equally inflamed. The mucous membrane of the 
 bronchi becomes congested and swollen, at first dry, 
 afterward coated by an increased production of mucus. 
 There are also desquamation of the epithelial cells, a 
 moderate emigration of white blood-cells, sometimes 
 diapedesis of the red blood-cells. The lumen of the 
 bronchi may be narrowed, either by the congestion and 
 swelling of the mucous membrane or the contraction of 
 the muscular coat. • 
 
THE lungs; 3 
 
 Symptoms. — The mild cases of acute bronchitis are at- 
 tended with cough accompanied by scanty mucous sputa, 
 by pain over the sternum, and a moderate feeling of in- 
 disposition. There may be no physical signs, or a few 
 coarse r41es, or sibilant and sonorous breathing. The 
 natural period of the inflammation seems to be about one 
 week, but it is often prolonged for a much longer time. 
 
 In the more savere cases there is cough with mucous, 
 or blood-streaked, or muco-purulent sputa. There is a 
 febrile movement which precedes and accompanies the 
 local symptoms. There may be a good deal of bronchial 
 dyspnoea. There are coarse rSles heard usually over both 
 lungs, sometimes only over one, and in some cases sibi- 
 lant and sonorous breathing. Tiie cases vary a good 
 deal as to their severity, but their natural termination is 
 in recovery after one or two weeks. In some of the 
 cases a localized broncho-pneumonia is developed, with 
 dulness and increased vocal resonance over the con- 
 solidated portion of lung. 
 
 There are cases in which the bronchitis, instead of 
 running its natural course, continues. The patients 
 have cough with muco-purulent sputa, an irregular fever, 
 higher in the evening, night-sweats, loss of flesh and 
 strength. These symptoms may continue for weeks or 
 months. 
 
 Treatment. — The milder cases are not confined to 
 bed, but are to be cautioned against undue exposure. 
 Many of them recover without any treatment, but in 
 some it is necessary to use counter-irritation over the 
 chest, and to give combinations of ipecac, belladonna, 
 opium, and quinine in small doses frequently repeated. 
 
4 THE LUNGS. 
 
 In the more severe cases the patients are in bed. 
 The counter-irritation over the chest must be employed 
 more energetically. It may be necessary to give calomel 
 or sulphate of magnesia ; or the use of ipecac, aconite, 
 veratrum viride, or opium may be indicated. If the 
 dyspnoea is a marked feature, we should endeavor to 
 make out whether it is due to the congestion of the 
 bronchi or to the contraction of their muscular coats. 
 If it is due to congestion, the drugs which increase the 
 production of mucus are indicated : pilocarpine, que- 
 bracho, grindelia robusta, ipecac. If it is due to con- 
 traction of the muscular coat, we employ the drugs which 
 relax muscular spasm : nitrite of amyl, nitro-glycerine, 
 chloral hydrate, opium. 
 
 In the protracted cases the most efficient treatment is 
 to send the patients to a different climate. If this can- 
 not be done we employ quinine, iron, the mineral acids, 
 turpentine, strychnia, oxygen. 
 
 2. TTie acute catarrhal bronchitis of old persons. 
 
 The lesions are the same as in the bronchitis of 
 adults. 
 
 The symptoms are more severe in proportion to the 
 extent of the bronchitis, and the disease is not as well 
 borne as it is in adults. There are, from the first, much 
 prostration ; an irregular febrile movement ; a rapid and 
 feeble pulse ; difficult and oppressed breathing ; cough 
 with mucous expectoration ; restlessness, sleeplessness, 
 sometimes delirium ; loss of appetite, nausea, vomiting. 
 There are coarse and subcrepitant rS,les over both lungs, 
 or only over a portion of one lung. In some cases no 
 rales can be heard. 
 
THE LUNGS.' 5 
 
 An acute bronchitis in old persons is often alarming 
 and sometimes fatal. 
 
 The treatment is the same as in adults ; but the nurs- 
 ing is even more important, the difficulty in feeding the 
 patients is greater, and stimulants are more likely to be 
 necessary. 
 
 3. The acute catarrhal bronchitis of children. 
 
 The lesions are the same as in adults : congestion and 
 swelling of the mucous membrane, after a time an in- 
 creased production of mucus with some subsidence of 
 the swelling. But as the lungs of children are smaller, 
 as the bronchi constitute a relatively larger portion of 
 the lung, as the bronchi are smaller and more easily 
 occluded, as such an OQclusion may even be complete 
 with uuaeration of portions of the lung, so we find bron- 
 chitis in children to interfere seriously with the function 
 of breathing and to constitute a serious disease. 
 
 Symptoms. — An acute bronchitis may be preceded by 
 coryza, pharyngitis, tonsillitis, or laryngitis ; it may 
 occnr as a primary inflammation ; or it may complicate 
 measles, whooping-cough, or one of the infectious dis- 
 eases. 
 
 In the mild cases there is no fever, the children hardly 
 feel sick ; but they cough, and coarse rales can be heard 
 over both lungs. The inflammation regularly runs its 
 course and subsides within one or two weeks. 
 
 In the majority of these rhild cases no treatment 
 is necessary, not even for the cough. It is wise, how- 
 ever, to keep these patients in the house until the 
 bronchitis has subsided, unless the weather is warm and 
 good. J 
 
6 THE LUNGS. 
 
 In the more severe cases the invasion of the inflam- 
 mation is marked in some cases by general convulsions. 
 There is a well marked febrile movement, the temper- 
 ature higher in the afternoon, sometimes falling even to 
 the normal in the morning. The pulse is rapid, but usu- 
 ally not feeble. The breathing is rapid, sometimes in- . 
 sufficient ; it may be made worse for a time by disten- 
 tion of the stomach with food. There may be alternating 
 restlessness and drowsiness. There are subcrepitant and 
 coarse rslles heard over both lungs, sometimes early, 
 sometimes late in the disease. 
 
 The inflammation regularly runs its course within two 
 weeks, and the patients recover. But they are often 
 alarmingly ill for several days, and may die from the dis- 
 ease. . 
 
 In infants only a few weeks old, rapid breathing, 
 fever, and prostration are the only symptoms, and the 
 disease proves fatal within a few days. 
 
 Treatment. — During the first days of the inflamma- 
 tion we employ counter-irritation over the chest by 
 turpentine, croton-oil, or poultices, and give small doses 
 of calomel or sulphate of magnesia. Later ipecac, 
 aconite, and opium may be of service. But it is to 
 be remembered that in young children all drugs may 
 do harm, and that too little treatment is better than too 
 nmch. 
 
 4. Chronic Catarrhal Bronchitis. 
 
 Chronic catarrhal bronchitis may from the first have 
 the character of a chronic inflanmiation ; it may follow 
 one or more attacks of acute bronchitis ; it may compli- 
 cate gout, emphysema, chronic endocarditis, interstitial 
 
THE LUNGS. 7 
 
 pneumonia, pleuritic adhesions, phthisis ; it may be pro- 
 duced by the inhalation of irritating substances. 
 
 Lesions. — The mucous glands produce too much 
 mucus, they may be hypertrophied ; the walls of the 
 bronchi are thickened or thinned ; the lumen of the 
 bronchi may be narrowed or dilated. 
 
 Symptoms. — In the mild cases the patients are only 
 troubled by the cough and expectoration, while their 
 general health remains good. 
 
 In the severe cases the cough is more troublesome, 
 the expectoration more profuse ; there may be constant 
 or spasmodic' dyspnoea ; there is an irregular fever and 
 loss of flesh and strength. There are coarse and subcrepi- 
 tant rSles, sometimes sibilant and sonorous breathing. 
 
 The disease runs a protracted course, better in the 
 summer and worse in the winteh The patients are more 
 likely to die from some intercurrent disease than from 
 the bronchitis. 
 
 Treatment. — The most efficient treatment is the selec- 
 tion of a proper climate — preferably a dry, inland, ele- 
 vated region, either warm or cold. 
 
 As regards drugs, the mineral acids, iodide of potash, 
 the preparations of turpentine, ipecac, and belladonna 
 are sometimes of service. 
 
 5. Acute Croupous Bronchitis. 
 
 Lesions. — The inflammation involves the trachea and 
 bronchi. The mucous membrane is congested, swollen, 
 and coated with a layer of coagulated fibrine in which 
 are entangled pus and epithelial cells. The smaller 
 bronchi are not merely coated, but filled with the inflam- 
 matory products. 
 
8 THE LUNGS. 
 
 Causes. — Croupous bronchitis occurs with lobar pneu- 
 monia and diphtheria, from the inhalation of hot steam 
 and smoke, and as a primary inflammation. It is pos- 
 sible that in some of the primary cases the patients really 
 have diphtheria, but without inflammation of the throat 
 or larynx. 
 
 Symptoms. — In the primary cases the disease may be 
 preceded by a catarrhal tracheo-bronchitis. 
 
 The patients have chills,, well-marked fever, prostra- 
 tion, very urgent dyspnoea, and cough. The sputa are 
 at first mucous ; later, mixed with fragments of false mem- 
 brane. The patients develop the evidences of imperfect 
 aeration of the blood— ^cyanosis, delirium, stupor. Over 
 the lungs there are coarse rales, or absence of breathing. 
 About half the patients die with dyspnoea within from 
 three to fourteen days. 
 
 TTie treatment is the same as for a severe catarrhal 
 bronchitis, but it is to be energetically used, and the 
 constant inhalation of oxygen gas is of service. 
 
 6. Chronic Croupous Bronchitis. 
 
 There are patients who give the history and the symp- 
 toms of a chronic bronchitis, or of chronic phthisis, but 
 who from time to time cough up casts of the bronchi, 
 often of considerable size. 
 
 These casts represent bronchi of some size, with their 
 branches. They are of white color and are composed 
 of an albuminoid substance allied to fibrine or mucus. 
 
 Except for the occasional production of these casts 
 there seems to be nothing to distinguish these cases from 
 the ordinary cases of chronic bronchitis, or phthisis. 
 
THE LUNGS. 
 
 Pneumonia. 
 
 The inflammations of the lung, as distinguished from 
 those of the -bronchi and pleura, are called " pneumonia." 
 
 It is convenient, in describing the different varieties of 
 pneumonia, to classify them in a somewhat arbitrary way, 
 as follows : 
 
 Primary Lobar Pneumonia. 
 
 Secondary and Complicating Lobar Pneumonia. 
 
 Pneumonia of Heart Disease. 
 
 Broncho-pneumonia. 
 
 Interstitial Pneumonia. 
 
 Tubercular Pneumonia. 
 
 Syphilitic Pneumonia, 
 
 I, Primary Lobar Pneumonia. 
 
 Ths inflammation regularly involves the whole of one 
 lobe, or the whole of one lung, or portions of both lungs. 
 
 Juergensen, from a study of 6,666 cases, gives the fol- 
 lowing table to show the relative frequency of the situa- 
 tion of the lesion : 
 
 Per cent. 
 
 Right Lung. 53.70 
 
 " " upper lobe 12.15 
 
 " " middle lobe 1.77 
 
 " " lower lobe 22.14 
 
 " " wliole lung g.35 
 
 I^eft Lung .'.... 38.23 
 
 " " upper lobe 6.96 
 
 " " lowcT lobe 22.73 
 
 " " whole lung 8.54 
 
10 THE LUNGS. 
 
 Percent/ 
 
 Both Lungs 8.07 
 
 " " both upper lobes 1.09 
 
 " " both lower lobes 3.34 
 
 The inflammation in acute lobar pneumonia is of pure 
 exudative type, characterized by congestion, emigration 
 of white blood-cells, diapedesis of red blood-cells, and 
 exudation of blood-plasma, while the tissue of the lung 
 remains unchanged. For clinical purposes it is impor- 
 tant to have as distinct an idea as possible of the condi- 
 tion of the lung while it is the seat of such an exudative 
 inflammation, so that we describe the condition in which 
 the lung is found while the inflammation is going through 
 its regular stages of congestion, exudation, and resolu- 
 tion. 
 
 During the first hours of the inflammation only irreg- 
 ular portions of the lobe which is to be inflamed are in- 
 volved ; later, the entire lobe. The lung is congested, 
 oedematous, tough, but not consolidated. The air-spaces 
 contain granular matter, nbrine, pus-cells, red blood- 
 cells, and epithelial cells. The epithelium remaining on 
 the walls of the air-spaces is swollen ; there are large 
 numbers of white blood-cells in the capillaries. The 
 larger bronchi are congested, dry, or coated with mucus ; 
 the small bronchi contain the same inflammatory prod- 
 ucts as do the air-spaces. The pulmonary pleura, as a 
 rule, is not coated with fibrine. This is called the stage 
 of " congestion." The stage of congestion regularly only 
 lasts a few hours, but it may be protracted for several 
 days. 
 
 When the, exudation of the inflammatory products has 
 
THE LUNGS. II 
 
 reached its full development, the presence of these prod- 
 ucts within the air-spaces and bronchi causes the lung 
 to be solid, and at this time the lung is said to be in the 
 condition of " red hepatization.'' The lung is now con- 
 solidated, red, its cut section looks granular, the granules 
 corresponding to the plugs of inflammatory matter within 
 the air-spaces. For some time after death the inflam- 
 matory products remain solid, and the cut section of the 
 lung dry, but later, with the commencement of post- 
 mortem changes, these products soften and the cut sec- 
 tion is covered with a grumous fluid. The air-vesicles, 
 the air-passages, the small bronchi, and sometimes the 
 large bronchi, are filled and distended with fibrine, pus- 
 cells, red blood-cells, and epithelium. In spite of the 
 pressure on the walls of the air-spaces, the blood-vessels 
 in their walls remain pervious. The pulmonary pleura 
 is coated with fibrine and the interstitial connective tis- 
 sue of the lung is infiltrated with fibrine. The hepatized 
 lobe is increased in size, sometimes so much so as to com- 
 press the rest of the lung. About one-fourth of the fatal 
 cases die in the stage of red hepatization, at any time 
 from twenty-four hours to eleven days after the initial 
 chill. 
 
 After the air-spaces have become completely filled 
 with the exudation, if the patient continues to live, there 
 follows a period during which the exudate becomes first 
 decolorized, and then degenerated. This is the period 
 of "gray hepatization." The lung remains solid, its 
 color changes, first to a mottled red and gray, then to 
 a uniform gray. The coloring matter is discharged 
 from the red blood-cells and the exudate begins to de- 
 
12 THE LUNGS. 
 
 generate and soften. The lung is found passing from 
 red to gray hepatization at any time between the second 
 and the eighteenth day of the disease. It is found 
 completely gray at any time from the fourth to the 
 twenty-fifth day. About one-half of the cases die in the 
 condition of mottled red and gray hepatization ; about 
 one-fourth in the condition of gray hepatization. 
 
 If the patients recover the exudate undergoes still fur- 
 ther degeneration and softening and is removed by the 
 lymphatics. This is the stage of " resolution." It should 
 commence immediately after defervescence and be com- 
 pleted within a few days. But it may not begin until a 
 number of days after defervescence, or it may be unusu- 
 ally protracted. 
 
 Modifications of the inflammation. — The lung, instead 
 of being freed from the exudate at the regular time, may 
 remain in the condition of gray hepatization for weeks. 
 
 The quantity of inflammatory products may be so 
 great that the blood-vessels are compressed and portions 
 of the lung become necrotic. 
 
 There may be an excessive production of pus-cells, 
 with infiltration of the walls of the air-spaces and of the 
 stroma of the lung. 
 
 The inflammatory product within the air-spaces, instead 
 of consisting only of fibrine, pus, and epithelium, may 
 consist also of organized connective tissue. 
 
 The bronchitis may be developed in an unusual degree, 
 and involve not only the bronchi of the inflamed lung 
 but also those of the other lung. 
 
 The pleurisy may be unduly developed at any time in 
 the course of the pneumonia, or after it has subsided. 
 
THE LUNGS. 1 3 
 
 There may be an excessive production of fibrine, or of 
 fibrine and serum, or of fibrine, serum, and pus. 
 
 There may be gangrene of part of the inflamed lung. 
 
 Causes. — Lobar pneumonia occurs in nearly all cli- 
 mates, warm as well as cold. In the- United States it is 
 said to be more common in the South than in the North. 
 
 In New York it prevails in the winter and spring, and 
 the colder the weather the more numerous are the cases 
 of pneumonia. In some cases there is a distinct history 
 of exposure to cold. There are occasionally local epi- 
 demics of the disease, and rarely it seems to be con- 
 tagious. 
 
 The disease seems to have the characters of an infec- 
 tious inflammation which requires for its production an 
 exciting cause of inflammation and the presence and 
 growth of the diplococcus pneumoniae. It may retain 
 throughout the characters of a local inflammation, or it 
 may be accompanied by a general infection. 
 
 Children under five years of age usually have broncho- 
 pneumonia ; children between the ages of five and fifteen 
 may have either broncho-pneumonia or lobar pneumonia ; 
 adults usually have lobar pneumonia. 
 
 Symptoms. — Physical signs. During the stage of con- 
 gestion there is commencing dulness on percussion. The 
 respiration is rude, or feeble. There may be a sub- 
 crepitant r^le. If the bronchitis is excessive, there are 
 coarse and subcrepitant rMes, and sibilant and sonorous 
 breathing. 
 
 During the stage of red hepatization there is, on per- 
 cussion, more or less dulness, or flatness, or tympanitic 
 resonance, or crackedrpot sound. The vocal fremitus is 
 
14 THE LUNGS. 
 
 regularly increased, but may be diminished. Bronchial 
 voice and breathing are often, but not always, present. 
 The normal breathing sounds are lost. There is often a 
 crepitant ik\e. In the stage of gray hepatization the 
 physical signs are the same as during red hepatization, 
 the crepitant i&le may persist, or may disappear. 
 
 During the stage of resolution the dulness diminishes, 
 the normal respiratory murmur begins to return, there 
 are crepitant and subcrepitant rales. 
 
 In old persons the physical signs are often imperfectly 
 developed, and sometimes absent altogether. 
 
 Rational symptoms. In from one-sixth to one-third of 
 the cases there are prodromic symptoms. Chilliness, 
 moderate fever, general malaise, oppression of the chest 
 are present and continue for from one to four days. 
 These symptoms probably correspond to a protracted 
 period of congestion. 
 
 In about ninety per cent, of the cases there are, during 
 the first twenty-four hours, one or more decided chills, 
 and it is from the chill that we usually reckon the days 
 of the disease. 
 
 The temperature rises at once, and often reaches its 
 maximum on the first or second day. It continues, with 
 morning remissions and evening exacerbations, until de& 
 ervescence. Sometimes the temperature is the highest 
 on the day before defervescence. The ordinary temper- 
 ature of lobar pneumonia is about 104° F. 
 
 Defervescence may take place at any time from the 
 second to the eighteenth day. It is most common on 
 the seventh day ; next on the fifth, eighth, sixth, and 
 ninth days in order. It usually begins in the evening. 
 
; THE LUNGS. Ig 
 
 and the temperature falls to or below the normal in from 
 six to forty-eight hours. 
 
 The height of the temperature is usually in propor- 
 tion to the severity of the disease. But some cases do 
 well in spite of very high temperatures ; some cases get 
 worse with a falling temperature ; some cases die with a 
 temperature below the normal ; there are rare cases 
 without any rise of temperature. The fever may be pro- 
 longed by the extension of the inflammation to fresh 
 portions of the lung. 
 
 There is often pain over the inflamed lung, referred to 
 the region below the nipple, and developed within twelve 
 hours after the chill. There is much difference in the 
 patients as to the severity of the pain. In some cases 
 there is no pain until the patients begin to cough. 
 
 The character of the heart's action and of the pulse 
 is of great imp ortance. The pulses hould be about loo, 
 and full. It may be too rapid, or too slow, or too full. 
 On the day before defervescence there is danger of 
 failure of the heart's action, with venous congestion, 
 cerebral symptoms, or sudden death. 
 
 The breathing, at the invasion of the disease, is op- 
 pressed and rapid ; later, rapid, more or less labored, and 
 insuflficient. The badness of the breathing is in propor- 
 tion to the extent of lung involved, or to the severity 
 of the comphcating bronchitis. 
 
 The cough is developed early in the disease, or later. 
 It is often most troublesome as resolution begins. In 
 some cases the cough is trifling, or absent. 
 
 The characteristic sputa are little rounded, viscid pel- 
 lets of red, yellow, or brownish color, mixed with thin 
 
1.6 THE LUNGS. 
 
 fluid mucus. In bad cases there is expectoration of a 
 diffluent, dark-colored fluid. The sputa may be nothing 
 but ordinary mucus, or there may be no sputa. In rare 
 cases the patients cough up pure blood at the beginning 
 of the disease. 
 
 The cheeks are usually flushed. The tongue is coated, 
 sometimes dry. There is loss of appetite, nausea, some- 
 times vomiting. 
 
 The urine is diminished in quantity, high colored, some- 
 times contains a little albumen and a few casts. 
 
 Headache, restlessness, and sleeplessness are present 
 in many of the cases ; delirium, stupor, and coma in a 
 smaller numbir. 
 
 The degree of prostration varies with the severity of 
 the disease. There are rare cases in which patients con- 
 tinue to be up and about after the lung is consolidated. 
 
 Complications. — At any time in the course of the pneu- 
 monia, or after it has subsided, there may be developed 
 pleurisy with efiusion, or empyema, on the same side as 
 the pneumonia. 
 
 If an excessive general bronchitis accompanies the 
 pneumonia it changes the physical signs, adds to the 
 dyspnoea, and raises the temperature. 
 
 Acute pericarditis is always a serious complication. 
 The only evidence of it may be the greater illness of 
 the patient ; or there may be cyanosis, rapid breathing, 
 a rapid and feeble pulse, pain over the heart, and the 
 characteristic friction sound. 
 
 A previously existing chronic endocarditis adds much 
 to the dangers of the pneumonia. If it is an aortic or 
 mitral stenosis the characteristic murmur is often absent. 
 
THE LUNGS. 1/ 
 
 Acute meningitis is an infrequent complication. It 
 may, or may not, be attended with characteristic symp- 
 toms. 
 
 Jaundice may occur, either with mild or with severe 
 cases. 
 
 If the kidneys have been previously normal the pneu- 
 monia only produces a mild degeneration, or an exuda- 
 tive nephritis. But if a chronic nephritis already exists 
 the pneumonia is apt to bring on an exacerbation of the 
 nephritis, with serious renal symptoms. 
 
 The course of the disease. — i. The simple cases. 
 The patients have one or more chills, a temperature of 
 ioo°-io4° F, vomiting, pain in the side, prostration, 
 breathing from 25 to 40, cough, the characteristic 
 sputa, a pulse of 90 to no and full, sleeplessness, rest- 
 lessness, and the characteristic physical signs. Defer- 
 vescence and resolution take place at the regular times. 
 Or, on the day before defervescence, there is heart fail- 
 ure and death. 
 
 2. The cases run the regular course, but the physical 
 signs are not developed until after several days. 
 
 3. The inflammation, instead of remaining confined 
 to the lobe where it began, may extend to other por- 
 tions of the lung. Each extension of the inflammation 
 is attended with an exacerbation of the symptoms. 
 
 4. The inflammation from the outset involves the 
 larger part of both lungs, and the patients die within a 
 few days. 
 
 5. Resolution, instead of beginning within one or two 
 days, may be delayed for one, two, or three weeks. 
 
 6. There are cases in which the patients behave as 
 
18 THE LUNGS. 
 
 if poisoned by an extension of the infection from the 
 lung, and this without reference to the extent of lung 
 inflamed. They have marked cerebral symptoms, a dry 
 tongue, high temperature, a rapid and feeble pulse, 
 rapid emaciation. This form of the disease is usually 
 fatal. 
 
 7. There are cases, otherwise normal, but with exces- 
 sive delirium, which may continue even after deferves- 
 cence. Sometimes the patients remain insane after re- 
 covering from the pneumonia. 
 
 8. The course of the disease is altered by the compli- 
 cating lesions — meningitis, bronchitis, pleurisy, peri- 
 carditis, endocarditis, and nephritis. 
 
 9. In old persons the physical signs are obscure, the 
 cough is slight or absent, the disease is badly borne. 
 
 Modes of death. — The patients die with heart failure 
 just before defervescence ; from the extent of the inflam- 
 mation ; from general poisoning ; from one of the com- 
 plications ; from thrombosis of the coronary arteries. 
 
 Duration. — In the cases which recover, defervescence 
 takes place at any time from the second to the eighteenth 
 day, most frequently on the seventh or fifth. Resolution 
 is accomplished within a few days after this, but may be 
 delayed up to three weeks. 
 
 In the fatal cases death may take place at any time 
 from five hours to thirty days — most frequently on the 
 seventh, eighth, and tenth days. 
 
 In persons over seventy death is most common on the 
 fifth, sixth, and seventh days. 
 
 Treatment — Attempts to check the pneumonia at its 
 beginning are occasionally made and are sometimes sue- 
 
■THE LUNGS. 19 
 
 cessful. For this purpose venesection and large doses 
 of calomel are employed. 
 
 For the most part, however, we are content to treat 
 the symptoms. In a considerable number of cases, 
 •which run a regular course, nothing is necessary but care- 
 ful nursing. 
 
 Bid breathing may be relieved by cupping the entire 
 chest, or by giving small doses of calomel and opium. 
 Excessive restlessness, sleeplessness, and pain can be 
 mitigated by opium, the bromides, or assafoetida. 
 
 The temperature is best left alone, even if it is high. 
 
 An excessively full pulse can be relieved by small 
 doses of aconite or veratrum viride. 
 
 Failure of the heart's actioi> requires the use of alco- 
 holic stimulants, or of combinations of digitalis, conval- 
 laria, and the iodide of potash. 
 
 II. Secondary Lobar Pneumonia. 
 
 Lesions. — The inflammation does not involve an en- 
 tire lobe, but portions of one or more lobes, so that we 
 find scattered areas of hepatization with the rest of the 
 lung congested. The air-spaces and small bronchi are 
 filled with fibrine, pus, and epithelium. 
 
 Causes. — This form of pneumonia is common with in- 
 juries and inflammation of the brain and spinal cord, after 
 surgical operations, with any disease or injury which con- 
 fines a patient to bed, and with the infectious diseases. 
 
 Symptoms. — In some cases the pneumonia gives neither 
 rational symptoms nor physical signs. In others there are 
 chills, fever, rapid breathing, pain, cough, and expectora- 
 tion, and the physical signs of consolidation of the lung. 
 
20 THE LUNGS. 
 
 III. The Pneumonia of Heart Disease. 
 
 This is a chronic inflammation of both lungs, produced 
 by valvular lesions of the heart, by dilatations of the ven- 
 tricles, and by aneurisms of the arch of the aorta. It is 
 most common with mitral stenosis. 
 
 Lesions. — The lungs are small, there are often old 
 pleuritic adhesions, there may be serum in the pleural 
 cavities. The texture of the lungs is leathery and dense ; 
 they are dry and not congested ; they are of a pink or 
 salmon color, mottled with brown or black. They may 
 be partly consolidated. There may be one or more 
 hemorrhagic infarctions. The capillaries are large and 
 tortuous, the walls of the air-spaces are thickened, the 
 air-spaces are partly or completely filled with epithelial 
 cells. 
 
 Symptoms. — The patients have dyspnoea, cough, mu- 
 cous and bloody sputa, sometimes continued expectora- 
 tion of large quantities of pure blood. The only physical 
 signs are dulness on percussion and imperfect breathing, 
 with sometimes a few rMes. 
 
 IV. Broncho-pneumonia. 
 
 Synonymes : Capillary Bronchitis ; Lobular Pneumo- 
 nia ; Catarrhal Pneumonia. 
 
 Lesions. — The essential and constant lesion of broncho- 
 pneumonia is an inflammation of the walls (not the mu- 
 cous membrane) of the bronchi, and of the air-spaces 
 immediately surrounding the inflamed bronchi. The 
 walls of the bronchi are thickened and infiltrated by a 
 growth of new cells. The walls of the air-spaces are 
 thickened, their cavities are filled with fibrine, pus, and 
 
THE LUNGS. 2t 
 
 epithelium, or with new connective tissue. The inflam- 
 mation involves the medium-sized and smaller bronchi 
 of both lungs, but is not everywhere equally severe ; in 
 some parts of the lungs the lesions are much more marked 
 than in others. In some of the cases there are no other 
 changes, except some general congestion of the lungs. 
 In other cases there may be added : A catarrhal inflam- 
 mation of the mucous membrane of the bronchi, diffuse 
 consolidation of parts of the lung, pleurisy, dilatation of 
 the inflamed bronchi, areas of atalectasis, simple or tuber- 
 cular inflammation of the bronchial glands. 
 
 The character of the inflammation is such that resolu- 
 tion is slow, and the acute inflammation may be followed 
 by a chronic one. 
 
 If the broncho-pneumonia becomes chronic the walls 
 of the bronchi remain thickened, the bronchi remain di- 
 lated, the peribronchitic zones of pneumonia persist. If a 
 larger part of the lung has been consolidated, this consol- 
 idation persists, with a diffuse growth of connective tissue, 
 and sometimes with thickening of the pulmonary pleura. 
 
 Causes. — Broncho-pneumonia is the ordinary pneumo- 
 nia of children ; it is frequent in young persons and occa- 
 sionally seen in adults. 
 
 It occurs as a primary inflammation, is often secondary 
 to measles and whooping-cough, less frequently to the 
 other infectious diseases. It is most frequent during 
 the, cold and wet months of the year; in some cases 
 there is a history of exposure to cold, in others no excit- 
 ing cause is discoverable. 
 
 The same patient may suffer from several attacks of 
 the disease. 
 
22 THE LUNGS^. 
 
 Symptoms. — In very young infants the only symptoms 
 are fever, prostration, and rapid breathing. The disease 
 is almost certainly fatal. 
 
 In older children there may be first the measles or 
 whooping-cough, or a coryza, or pharyngitis, or catarrhal 
 bronchitis, and then the broncho-pneumonia. Or the dis- 
 ease may begin without any preceding morbid conditions. 
 In some of the cases the invasion is marked by general 
 convulsions. There is a rapid rise of temperature, the 
 patients are sleepless, restless, or delirious, the pulse is 
 rapid, the breathing is rapid and insufficient, the face is 
 flushed, the tongue is coated and sometimes dry, there 
 may be vomiting, sometimes there is pain over the chest. 
 There may be no cough, or cough with mucous sputa. 
 The urine may contain a little albumin and a few casts. 
 The disease varies in its sevysrity, but most of the pa- 
 tients are seriously ill. 
 
 The physical signs vary with the condition of the lung. 
 If the inflammation is limited to the walls of the bronchi 
 and to the air-spaces immediately surrounding them, 
 there are no physical signs. If a catarrhal bronchitis is 
 added, there are coarse and subcrepitant rMes. If there 
 is a diffuse pneumonia, with consolidation of a consider- 
 able part of the lung, there are dulness on percussion 
 and bronchial voice and breathing ; if there is fibrine on 
 the pleura, there are crepitant and subcrepitant r^les. 
 The signs of consolidation are usually developed be- 
 tween the second and fifth days. The constitutional 
 symptoms continue for from seven to fourteen days, and 
 then gradually or quickly subside. Resolution follows, 
 and is'aecomplished in from seven to fourteen days more. 
 
THE tUNGS. 3J 
 
 This is the course of the disease in the regular cases 
 which recover. 
 
 The bad cases die at any time from the second to the 
 fourteenth day. 
 
 In the cases which recover, resolution is sometimes 
 delayed for several weeks, and the children then con- 
 tinue to be pale, irritable, prostrated, without appetite, 
 sometimes with a little afternoon fever. 
 
 In some cases the inflammation extends and involves 
 successively different portions of the lungs. 
 
 The cerebral cases. — In many of the cases of broncho- 
 pneumonia there are cerebral symptoms — convulsions, 
 restlessness, and delirium — but in some patients these 
 symptoms are developed to such a degree, and are so 
 out of proportion to the pulmonary symptoms, that the 
 cases require a separate description. 
 
 The symptoms resemble those of an acute or a tuber- 
 cular meningitis. They may begin and go on acutely 
 with high fever, prostration, one or more convulsions, 
 alternating delirium and stupor. Or the course is more 
 subacute, loss of 'appetite, vomiting, moderate prostra- 
 tion, not very high fever, alternating stupor and delirium. 
 These "symptoms may continue for from two to ten days 
 before there are any pulmonary symptoms. Then, as 
 the pulmonary symptoms are developed, the cerebral 
 symptoms subside. 
 
 If, after the subsidence of the acute broncho-pneu- 
 monia a chronic inflammation persists, the children begin 
 to improve, but yet do not get well. 
 
 In some the cough and the physical signs continue, 
 the appetite is poor, the children do not gain flesh and 
 
24 THE LUNGS. 
 
 Strength, but yet they are not sick in bed — often not con- 
 fined to the house. 
 
 In others the same symptoms exist, there is also an 
 irregular fever, and the patients are sick in bed. 
 
 Of these protracted cases some recover entirely ; 
 some recover with permanent consolidation of a portion 
 of the lungs ; some die exhausted by the disease ; some 
 go on to have a chronic interstitial pneumonia which 
 lasts for many years. 
 
 In some cases of acute broncho-pneumonia, the ac- 
 companying inflammation of the bronchial glands may be 
 of tubercular character, and this may later serve as the 
 starting-point of a general tuberculosis. 
 
 Treatment. — If the inflammation is confined to the 
 walls of the bronchi and the air-spaces around them, 
 counter-irritation of the wall of -the chest and anti- 
 phlogistic remedies are not likely to be of service. If,,, 
 on the othei hand, catarrhal bronchitis and general copr 
 gestion of the lungs are present, with rapid and labeled 
 breathing, it may be well, to use cups, or irritating lini- 
 ments, or poultices over the chest, and to (give repeated 
 small doses of calomel or the sulphate of magnesia. 
 Throughout the disease good results may be obtained 
 from the continued use of ipecac in small doses. 
 
 The sleeplessness, restlessness, and delirium are best 
 relieved by opium ; in children who cannot take opium, 
 we may use the bromides or assafcetida. The disposition 
 to convulsions seems to be lessened by the use of the 
 bromides. If the pulse is too full, with high tempera- 
 tures, the children are made more comfortable by the 
 tincture of aconite. Alcoholic stimulants are not to be 
 
THE LUNGS. 2$ 
 
 used unless there is decided failure of the heart's action. 
 The feeding and nursing of the child are of the greatest 
 importance. 
 
 If resolution is delayed, or if the broncho-pneumonia 
 persists, we employ iron, quiniiie, mineral acids, oxygen, 
 cod-liver oil, and, above all, change of air. 
 
 In adolescence the clinical picture of broncho-pneu- 
 monia is the same as it is in children, but the cerebral 
 symptoms are not developed to the same extent, and 
 they are more likely to cough up blood. 
 
 In adults the disease presents itself to us under several 
 different forms : 
 
 1. The patient has an ordinary attack of catarrhal 
 bronchitis lasting for several days. Instead of getting 
 well promptly, however, the patients continue to cough 
 and to feel sick, and, on examining the chest, we find a 
 circumscribed area where there is dulness on percussion 
 and loud, high-pitched voice. This consolidation of the 
 lung does not, however, last very long, and the patients 
 make a good recovery. 
 
 2. The patients are suddenly attacked with a very 
 severe and general broncho-pneumonia. There are 
 chills, a rapid rise of temperature, headache, pains in the 
 back and chest, vomiting, great prostration, a rapid pulse 
 which soon becomes feeble, very bad breathing — rapid, 
 labored, and insufficient — venous congestion of the skin 
 and of the viscera, cough at first dry, then with profuse 
 mucous and blood-stained sputa, sleeplessness, restless- 
 ness and delirium, and albumin in the urine. There are 
 coarse subcrepitant and crepitant rMes over both lungs, 
 sibilant and sonorous breathing ; the percussion-note is 
 
26 THE LUNGS 
 
 normal, or exaggerated, or dull. The disease lasts for 
 from seven to fourteen days ; it is very apt to prove fatal. 
 Treatment. — The most efficient remedies are the en- 
 ergetic use of wet or dry cups over the entire chest, the 
 administration of calomel or the sulphate of magnesia in 
 small and repeated doses, ipecac, the inhalation of oxy- 
 
 * gen-gas, and stimulants. 
 
 '' 3. There is a form of broncho-pneumonia in adults 
 which resembles lobar pneumonia. There is a general 
 catarrhal bronchitis, with broncho-pneumonia and consol- 
 idation of one or more lobes. The symptoms and phys- 
 ical signs are like those of lobar pneumonia, but with ' 
 some difference. The invasion of the disease is not as 
 sudden, the pulse is more rapid, the cerebral symptoms 
 are more constant, the expectoration is like that of bron- 
 chitis, the physical signs are more slowly developed, the 
 duration of the disease is rather longer and resolution is 
 slower. 
 
 4. There is a form of broncho-pneumonia which re- 
 sembles acute phthisis. 
 
 The patients have a cough with expectoration, at first 
 mucous, afterward muco-purulent. There is a moderate 
 fever, with evening exacerbations and sweating at night. 
 The patients steadily lose flesh and strength. The phys- 
 ical signs are those of bronchitis and of consolidation of 
 parts of the lung. The disease is protracted, continuing 
 as long as ten weeks, and is apt to prove fatal. 
 
 5. Broncho-pneumonia, especially of the lower lobes, 
 is secondary to the infectious diseases, to injuries, to sur- 
 gical operations, and to any conditions which confine pa- 
 tients to bed. 
 
THE LUNGS. 
 
 Interstitial Pneumonia. 
 
 Moderate degrees of inflammation of the lung, with 
 the production of interstitial connective tissue, are com- 
 mon. Such a development of interstitial pneumonia as 
 to constitute a disease by itself is comparatively rare. 
 
 Causes, — Well-marked interstitial pneumonia follows 
 attacks of broncho-pneumonia ; severe attacks of pleurisy 
 which leave behind extensive adhesions ; chronic bron- 
 chitis ; and the inhalation of the dust of coal or stone. 
 
 Lesions. — The inflammatory changes are regularly con- 
 fined to one lung, except in the cases of inhalation pneu- 
 monia. This lung is thickly covered with old adhesions, 
 its pulmonary pleiira is thickened, the lung itself is small. 
 Bands of dense fibrous tissue extend from the pleura 
 into the lung. There is a growth of connective tissue 
 in the septa between the lobules, around the bronchi 
 and the blood-vessels, and in the walls of the air-spaces. 
 The cavities of the air-spaces are compressed and ob- 
 literated. The mucous membrane of the bronchi is the 
 seat of chronic catarrhal inflammation. The walls of' 
 the bronchi may be thickened and their lumen nar- 
 rowed ; or their walls rriay be thinned with the formation 
 of btionchi-ectasise. 
 
 The other lung is large and emphysematous. 
 
2 THE LUNGS. 
 
 Symptoms. — The patients have a cough with mucous 
 expectoration. The cough becomes more constant and 
 troublesome as the disease progresses. The expectora- 
 tion becomes muco-purulent, sometimes fetid. If the 
 bronchi become dilated, the muco-pus accumulates in 
 them and is coughed up at intervals in large quan- 
 tities. There may be occasional hasmoptyses. There is 
 dyspnoea on exertion, at first slight, later more marked. 
 There may be uncomfortable feelings or actual pain over 
 the affected side of the chest. There is gradual loss of 
 -flesh and of strength. Neither laryngitis nor diarrhoea be- 
 long to the disease. There is no fever except with ex- 
 acerbations of the bronchitis. 
 
 The affected side of the chest is retracted, the other 
 side is enlarged, the heart is displaced, the vertebral 
 column is curved laterally. There is, on percussion, 
 dulness, or flatness, or tympanitic resonance. The 
 vocal fremitus is increased. The breathing is sonorous,'' 
 sibilant, ^Iffnchial, cavernous, or amphoric, according 
 to the condition of the bronchi and the degree of con- 
 solidation of the lung. There are pleuritic creaking 
 sounds, subcrepitant, coarse, or gurgling r^les. 
 . The disease is one which lasts for many years, and the 
 patients usually die with some acute inflammation of the 
 previously healthy lung. 
 
 Treatment. — The most efficient treatment is that the 
 patient should reside permanently in a climate where he 
 is able to live out of doors, and where his bronchitis does 
 well. 
 
 If this cannot be done, we attend to the bronchitis 
 and the nutrition of the patient as well as we can. 
 
THE LUNGS. 3 
 
 SvPHiLiTic Pneumonia. 
 
 Constitutional syphilis may give rise to inflammation 
 of the lung. 
 
 The most ordinary form of syphilitic pneumonia is 
 that of a chronic interstitial inflammation with the pro- 
 duction of new connective tissue. The distribution of 
 the inflammation varies : 
 
 1. There is an interstitial pneumonia beginning around 
 the large bronchi and blood-vessels at the root of the 
 lungs, extending to the interlobular septa and the walls of 
 the air-spaces, and resulting in the conversion of the cen- 
 tral portions of one or both lungs into dense fibrous tissue. 
 
 2. The inflammation follows the type of a broncho- 
 pneumonia, with thickening of the walls of the bronchi 
 and small zones of peri-bronchitic pneumonia. 
 
 3. With more or less interstitial pneumonia, there is a 
 syphilitic inflammation of the walls of the trachea and 
 large bronchi. These walls are thickened in some 
 places, ulcerated in others, so that either the condition 
 of stenosis or dilatation may be established. 
 
 4. With the interstitial pneumonia there may be asso- 
 ciated the production of gummy tumors, or an obliterat- 
 ing endarteritis with areas of coagulation necrosis. 
 
 We also occasionally meet with pneumonias of the 
 type of lobar pneumonia or broncho-pneumonia, which 
 run an acute but irregular course, and which seem to be 
 caused by syphilis. 
 
 Tuberculosis. 
 
 Persons are said to suffer from tuberculosis if there 
 are going on, in one or more parts of their bodies, tuber- 
 
4 THE LUNGS. 
 
 cular inflammations. To such tubercular inflammations 
 may, or may not, be added evidences of systemic infection. 
 
 Tubercular inflammation is an inflammation accom- 
 panied with the growth of the tubercle bacillus. The 
 inflammation itself is of the exudative, or productive 
 type, or of both combined. 
 
 The tubercle bacilli are little beaded rods, 2 to S 
 mikrom. in length. They are found in the inflamed tis- 
 sues, the inflammatory products, the lymphatics, and the 
 blood-vessels. 
 
 The exudative form of inflammation is accompanied 
 with the production of serum, fibrin, and pus. 
 
 The productive form is accompanied with the produc- 
 tion of round-celled tissue, of fibrous tissue, or of tubercle 
 tissue. Tubercle tissue is composed of a basement sub- 
 stance forming a meshwork enclosing large polygonal 
 cells, and of giant cells. It is arranged in the form of 
 little spherical bodies — tubercle granula — or of diffuse 
 infiltrations. 
 
 With tubercular inflammations there is often associated 
 obliterating endarteritis, the new tissue produced is of 
 low vitality, so we find that tubercular inflammations are 
 regularly attended with necrosis and cheesy degeneration. 
 
 There is also a well-marked disposition on the part 
 of tubercular inflammation to continue and to become 
 chronic. 
 
 Tubercular inflammation may be diffuse, involving 
 large areas of tissue ; or it may be circumscribed, involv- 
 ing a number of small areas. In the latter case the little 
 foci composed of products of inflammation are called 
 miliary tubercles. 
 
THE LUNGS. • 5 
 
 Causes. — There is a well-marked predisposition in 
 some individuals to tuberculosis. This disposition may- 
 be either hereditary or acquired. 
 
 The most direct exciting cause is inoculation with the 
 tubercle bacilli. This is the way in which the disease 
 is experimentally produced in animals ,; but in human 
 beings it is an exceptional method of production. 
 
 In the human being there are usually required for the 
 production of tuberculosis : a predisposition on the part 
 of the individual, one of the ordinary causes of inflamma- 
 tion, and the growth of the tubercle bacillus. 
 
 The tubercular inflammation acquired in this way may 
 remain confined to some one part of the body and re- 
 tain throughout the characters of a local inflammation. 
 It may, after a time, be followed by the development of 
 successive tubercular inflammations in other parts of the 
 body. It may be accompanied with the evidences of 
 systemic infection. It may be followed by a sudden de- 
 velopment of tubercular inflammation in many parts of 
 the body at the same time. There may be a sudden de- 
 velopment of tubercular inflammation in many parts of 
 the body, at about the same time, not preceded by a local 
 tuberculosis. 
 
 Acute General Miliary Tuberculosis. 
 
 Lesions. — There is a formation of miliary tubercles in 
 many different parts of the body, at about the same 
 time, with more or less diffuse exudative inflammation of 
 the same parts of the body. The tubercles are found 
 most constantly and in the largest numbers in the lungs, 
 liver, spleen, and serous membranes. 
 
6 • THE LUNGS. 
 
 In the lungs the bronchi are congested and coated with 
 mucus ; the walls of the air-spaces are congested, the 
 epithelial cells which line them are increased in size and 
 number, some of the air-spaces are filled with epithelium, 
 fibrin, and pus ; there may be fibrin on the pulmonary 
 pleura. 
 
 The miliary tubercles are present in large numbers 
 and distributed through both lungs. They are small, or 
 large ; gray, white, or yellow ; single or aggregated. 
 They are composed of: 
 
 1. Groups of air-vesicles filled with granular matter, 
 pus-cells, and epithelium. 
 
 2. Groups of air-spaces of which the walls are infil- 
 trated with tubercle tissue, and the cavities filled with tu- 
 bercle tissue, or other inflammatory products. 
 
 3. Infiltrations of the walls of small bronchi with tu- 
 bercle tissue, or round-celled tissue, the infiltration often 
 extending to the walls of the adjacent air-spaces. 
 
 There are also miliary tubercles in the pulmonary 
 pleura, in the septa between the lobules, in the walls of 
 the bronchi, and in the walls of the veins. 
 
 Causes. — Acute general tuberculosis may be due to in- 
 fection from a pre-existing local tuberculosis, or it may 
 be a primary general infection. 
 
 Symptoms. — There are local symptoms due to the in- 
 flammations of the pia mater, the lungs, and the perito- 
 neum ; and general symptoms due to the systemic in- 
 fection. The cases vary as to the predominance of the 
 local or the general symptoms. 
 
 The invasion of the disease may be acute, the patient 
 at once confined to bed with a high temperature ; or 
 
THE LUNGS. 7 
 
 subacute, the patient able to be up, and with but little 
 fever. The subsequent course of the disease may be acute 
 and short, with high temperatures ; or subacute and pro- 
 longed, with lower temperatures. 
 
 The fever may follow the continued, or remittent, or 
 intermittent types. The temperature may be high or 
 low, or not above the normal. 
 
 The prostration may be marked from the first, or it 
 may be days or weeks before the patient is confined to 
 bed. The pulse and the heart action are rapid and 
 feeble throughout the disease. 
 
 The tongue is coated, late in the disease brown and 
 dry. The breathing is rapid. 
 
 There is loss of appetite* nausea, and sometimes vomit- 
 ing. The bowels may be normal, or constipated, or loose. 
 
 There may be complicating acute degeneration of the 
 kidneys, or exudative nephritis. 
 
 Sooner or later alternating stupor and delirium, ex- 
 treme emaciation, and the typhoid state are developed. 
 
 There are often miliary tubercles in the choroid coat 
 of the eye, which can be seen with the ophthalmoscope. 
 
 The disease continues only for a few days, or for weeks 
 or months. It always terminates fatally. 
 
 Varieties. — In children the most common form of the 
 disease is that which follows the type of a tubercular 
 meningitis. I>ess frequently the disease is not attended 
 with cerebral symptoms, but with rapid aud insufRc^ent 
 breathing, with or without the physical signs of bronchitis. 
 
 In adults the disease may take the form of a tuber- 
 cular meningitis. 
 
 Or there may be marked pulmonary symptoms : cough 
 
8 THE LUNGS. 
 
 with mucous sputa ; rapid and oppressed breathing ; 
 pain over the chest ; a crepitant rMe if there is pleurisy ; 
 coarse and subcrepitant relies with the bronchitis ; dul- 
 ness on percussion if there is consolidation. If there has 
 been a pre-existing chronic phthisis, the physical signs 
 of this will persist. Occasionally the symptoms are those 
 of a tubercular peritonitis.. 
 
 Rarely the tubercles are confined to the lymphatic 
 glands, and the disease resembles pseudo-leukaemia. 
 The patients lose flesh and strength, they become an- 
 aemic, they have an irregular fever, and the lymphatic 
 glands throughout the body become enlarged. 
 
 Not infrequently there are no local symptoms, and the 
 disease resembles a typhoid ot malarial fever. The pa- 
 tients lose flesh and strength ; they have fever of con- 
 tinued, remittent, intermittent, or irregular type, and 
 finally pass into the typhoid state. 
 
 In some of the cases of this type the symptoms of the 
 tuberculosis are masked by those of some severe com- 
 plicating disease. 
 
 Tubercular Pneumonia. 
 Independently of general tuberculosis, the lungs may 
 become the seat of localized tubercular inflammations. 
 These inflammations may conveniently be described 
 under the names of Sub-acute MiHary Tuberculosis, 
 Chronic Miliary Tuberculosis, Acute Phthisis, and 
 Chronic Phthisis. 
 
 I. Sub-acute Miliary Tuberculosis. 
 Lesions. — There are miliary tubercles of the char- 
 acters already described in the lungs. These tubercles 
 
THE LUNGS. 9 
 
 may occupy only a part of one upper lobe, or the larger 
 part of both lungs. There may be also a general or 
 localized catarrhal bronchitis ; but usually no pleurisy 
 or diffuse pneumonia are present. 
 
 Causes. — Subacute miliary tuberculosis may be de- 
 veloped without discoverable cause in persons who have 
 the tubercular predisposition, or it may be secondary to 
 a chronic miliary tuberculosis. 
 
 Symptoms. — These are in proportion to the extent of 
 lung involved. 
 
 If only one upper lobe is involved, the patients have 
 afternoon fever with night-sweats, a rapid pulse, more or 
 less dyspnoea, cough with mucous expectoration, some- 
 times haemoptyses, and gradual loss of flesh and strength. 
 Although they are evidently seriously ill, they are often 
 not confined to bed. 
 
 If both lungs are involved, the patients lose flesh 
 and strength more rapidly, they develop alternating 
 delirium and stupor, and pass into the typhoid condi- 
 tion. 
 
 As there is no pleurisy, nor consolidation, the phy- 
 sical signs are limited to the coarse and subcrepitant 
 rales of the bronchitis, and the altered quality of the 
 breathing due to the miliary tubercles. 
 
 N If both lungs are involved, the symptoms continue and 
 the patients die after a few weeks. If only one upper 
 lobe is involved the disease may last for a few months 
 and the patients then recover, or it may be succeeded 
 by chronic miliary tuberculosis. 
 
 Treatment. — The most eflicient plans of treatment are : 
 to send the patients to a proper climate, and to cause 
 
lO THE LUNGS. 
 
 them to take the largest possible quantity of food, espe- 
 cially of fats. 
 
 II. Chronic Miliary Tuberculosis. 
 
 Lesions. — The morbid process begins at the apex of 
 one lung and then slowly extends, either progressively 
 or in attacks, until a larger part of the lungs is involved. 
 
 In the simplest form of the disease the only change in 
 the lungs is the formation of miliary tubercles. These 
 tubercles are harder and denser than those found with 
 general tuberculosis, or with subacute pulmonary tuber- 
 culosis. They are composed of tubercle tissue, or round- 
 celled tissue, or connective tissue, or are in the condition 
 of cheesy degeneration. 
 
 Usually, however, in addition to the miliary tubercles 
 there are other changes in the lungs. These additional 
 lesions begin in the same part of the lung where the 
 tubercles are formed, and accompany the development 
 of the tubercles in fresh parts of the lungs. 
 
 There may be a localized catarrhal bronchitis. 
 
 There may be an inflammation of the walls of the 
 bronchi with partial destruction of these walls, and the 
 formation of cylindrical or sacculated bronchi-ectasise. 
 The walls of the cavities thus formed may be converted 
 into connective tissue, or they may remain suppurating 
 and necrotic. 
 
 There may be an interstitial pneumonia with the pro- 
 duction of new connective tissue, the obliteration of the 
 air-spaces, and the consolidation of portions of the lung. 
 
 There may be dilatation of the air-spaces of the por- 
 tions of the lungs which are not consolidated. 
 
THE LUNGS. II 
 
 There may be thickening of the pulmonary and costal 
 pleura, with connective-tissue adhesions. 
 
 While the morbid process begins as a localized tuber- 
 cular inflammation of the lung, and often retains through- 
 out this local character, yet it may also happen that 
 from this local lesion other parts of the body-may be in- 
 fected. Tubercular laryngitis, and tubercular inflamma- 
 tion of the solitary and agminated glands of the small in- 
 testine, often complicate the pulmonary lesion, and some- 
 times even acute general tuberculosis is produced. 
 
 Symptoms. — The disease may follow z. subacute tuber- 
 culosis, or it may be chronic from the outset. If it is 
 chronic from the outset it gives at first no symptoms. 
 Indeed, there seems to be reason to believe that a chron- 
 ic miliary tuberculosis of small extent may run its entire 
 course and get well without giving any symptoms at all. 
 Usually, however, sooner or later, symptoms are devel- 
 oped. 
 
 The first symptom may be one or more small hsemop- 
 tyses, less frequently a large hemoptysis, the patient 
 otherwise feeling very well. Or the first symptom may 
 be a cough whith continues for weeks or months, and 
 does not get better. Or the patient may simply lose flesh 
 and strength, with afternoon fever, and a rapid pulse. 
 
 At this early stage of the disease there may be no 
 physical signs. If any such signs are present they are 
 due to thickening of the pleura, to miliary tubercles alone 
 or combined with fibrous tissue, and to localized bron- 
 chitis, all confined to the apex of the lung. We may find, 
 therefore, at one apex : retraction of the chest above and 
 below the clavicle, dulness on percussion, subcrepitant 
 
12 THE LUNGS, 
 
 rSles, a high-pitched and louder voice, the breathing 
 diminished, or of altered quality, or with prolonged ex- 
 piration. 
 
 When the disease is established it may run a mild 
 course. The inflammation remains confined to one 
 apex. The patients have cough, with or without mucous 
 sputa ; loss of appetite, flesh, and strength ; pain over 
 the inflamed lung ; an irrregular fever ; a rapid pulse ; 
 hsemoptyses ; the physical signs due to the pleurisy, the 
 localized bronchitis, the miliary tubercles, and the inter- 
 stitial pneumonia. In some of the cases the symptoms 
 are not at any time severe ; in others the symptoms are 
 so out of proportion to the lesion as to indicate a sys- 
 temic infection. The symptoms continue for months, 
 or for one or two years. Then they subside, the patients 
 recover, but the inflamed portion of the lung is perman- 
 ently changed, and they are liable to fresh attacks of the 
 disease. 
 
 Or the disease may run a severe course. The inflam- 
 mation extends and involves more and more of the lungs. 
 The pleuritic adhesions are more extensive, the bron- 
 chitis, the interstitial pneumonia, and the tubercles in- 
 volve more of the lungs, cavities are formed by the 
 dilatation of the bronchi, and the walls of these cavities 
 may suppurate. 
 
 The patients get worse from year to year, but with in- 
 tervals of improvement. The physical signs correspond 
 to the extent of the pleurisy, the bronchitis, the consoli- 
 dation, and the cavities. 
 
 The hsemoptyses may be repeated, either from the 
 bronchi, or from eroded vessels in the walls of bronchi. 
 
THE LUNGS. 1 3 
 
 The Cough may dep&nd upon the pleurisy, the bron- 
 chitis, or the cavities. There is no expectoration, or the 
 sputa are mucous, or muco-purulent. They usually con- 
 tain tubercle bacilli. 
 
 There is dyspnoea according to the extent of lung in- 
 flamed and the complicating emphysema. 
 
 An irregular fever, higher in the afternoon and with 
 sweating at night, conies and goes throughout the disease. 
 The pulse is habitually rapid. There is more or less 
 pain over the inflamed lung. In women menstruation is 
 apt to cease altogether. There is loss of appetite, some- 
 times vomiting g,nd marked emaciation. 
 
 There may be evidences of tubercular infection from 
 the lungs, or of pyaemic infection from the suppurating 
 walls of the cavities. 
 
 Complicating laryngitis, or enteritis, may add their 
 symptoms. 
 
 . The disease, when once established, goes on continu- 
 ously, or with intermissions for years. 
 
 The best marked cases are those with cavities and 
 considerable consolidation of the lung. The obscure 
 cases are those in which the miliary tubercles constitute 
 the only lesion, or in which the cavities are small. 
 
 There are cases in which the laryngitis, with its char- 
 acteristic symptoms, is the marked feature of the disease, 
 while the pulmonary lesions and symptoms are but little 
 developed. 
 
 There are rare cases in which, in the same way, the 
 intestinal lesion is disproportionately developed. 
 
 The Prognosis in the early periods of the disease, with 
 little evidence of systemic infection, is good. As more 
 
14 THE LUNGS. 
 
 of the lungs is involved, as cavities are formed, as the 
 complicating laryngitis and enteritis are developed, and 
 the evidences of systemic infection become manifest, the 
 prognosis is worse and worse. 
 
 Treatment. — The curative treatment of chronic miliary 
 tuberculosis is embraced in two principal things — climate 
 and feeding. 
 
 The selection of climate is to be made with reference 
 to the individual, and not with reference to his lungs. It 
 should be a climate where he feels well, eats well, sleeps 
 well, and gains flesh and strength. If no one climate 
 answers this purpose, the patient should travel from 
 place to place. The climatic treatment should be con- 
 tinued, if possible, for two full years. 
 
 The feeding consists in enabling the patient to eat and 
 digest considerable quantities of wholesome food and of 
 fats. To do this, the most minute attention is necessary to 
 the functions of the stomach, the intestines, and the liver. 
 Great care should be taken to avoid all medicines which 
 interfere with the patient's ability to eat and digest food. 
 
 It may also be necessary to alleviate symptoms. 
 
 The cough may be due to pharyngitis, laryngitis, 
 pleurisy, bronchitis, or cavities. 
 
 The pharyngitis and laryngitis are to be treated by 
 local applications ; the pleurisy by counter-irritation 
 over the chest ; the bronchitis and cavities by inhalations 
 of compressed air, the mineral acids, the preparations of 
 turpentine and strychnia. It may be necessary to use 
 opium, but this should be avoided as long as possible. 
 
 If the patients are anasmic, they require the administra- 
 tion of iron and the inhalation of oxygen. 
 
THE LUNGS. IS 
 
 The smaller hsemoptyses require no treatment. The 
 larger Ones may be restricted by the use of ergot, ipecac, 
 or gallic acid. 
 
 The fever and night-sweats may be mside less severe 
 by the use of antifebrin alone, or combined with quinine, 
 or arsenic ; by the mineral acids, belladonna, and the 
 oxide of zinc ; by sponging off the body with hot water 
 at night. 
 
 For the diarrhoea we employ a restricted diet, the 
 bichloride of mercury, ipecac, iron, and arsenic, opium 
 by itself, or combined with castor-oil, bismuth, the ace- 
 tate of lead, or camphor. 
 
 Acute Pulmonary Phthisis. 
 
 Acute consumption. Acute catarrhal phthisis. This 
 name is used to designate an acute tubercular inflamma- 
 tion of the lungs combined with other non-tubercular in- 
 flammatory changes. 
 
 Lesions. — r. In one or more lobes there may be miliary 
 tubercles and a diffuse consolidatioii, due to the filling 
 of the air-spaces with fibrin, pus, and epithelium. 
 
 2. There is a tubercular broncho-pneumonia involving 
 the smaller bronchi of one or more lobes, and zones of 
 air-spaces surrounding these bronchi. The walls of the 
 bronchi and of the surrounding air-vesicles are infiltrated 
 with tubercle tissue. 
 
 3. Besides the tubercular inflammation of the walls of 
 the bronchi and of the air-spaces surrounding them, there 
 are a general catarrhal bronchitis, diffuse consolidation 
 of the lung by the filling of the air-spaces with fibrin, 
 pus, and epithelium, and fibrin on the pulmonary pleura. 
 
1 6 THE LUNGS. 
 
 4. Besides the tubercular broncho-pneumonia, the 
 diffuse consolidation, and the pleurisy, there are small 
 or large portions of dead lung-tissue in the condition of 
 coagulation necrosis. These areas pass into the con- 
 dition of cheesy degeneration, and are surrounded by 
 zones of tubercle tissue, or of round-celled tissue j or 
 they soften and form cavities which are in communica- 
 tion with the bronchi. 
 
 5. In addition to the lesions just mentioned, the walls 
 of the bronchi are so changed by the tubercular inflam- 
 mation that cylindrical or sacculated bronchi-ectasise are 
 formed. 
 
 Causes. — An attack of acute phthisis may follow some 
 previous tubercular inflammation of the lung, or it may be 
 a primary disease. A person who has the tubercular 
 predisposition, when exposed to the ordinary causes of 
 inflammation of the lung, instead of having a lobar or 
 broncho-pneumonia, has a tubercular pneumonia. 
 
 Symptoms. — The invasion may be acute or subacute. 
 
 I. The Acute Cases. — The patients are suddenly at- 
 tacked with chills, fever, pain in the side, cough with 
 mucous expectoration, and marked prostration. The 
 whole appearance of the patient is that of a person at- 
 tacked with lobar or broncho-pneumonia. In addition 
 to the other symptoms there is often a profuse haemop- 
 tysis continued for several days. Within one or two 
 days the physical signs of the bronchitis, the pleurisy, 
 and the consolidation of the lung are developed : 
 Coarse, subcrepitant and crepitant r41es, dulness on per- 
 cussion, increased vocal fremitus, bronchial voice and 
 breathing. 
 
THE LUNGS. \^ 
 
 All these symptoms are continued for one or two 
 weeks. Then there is a partial subsidence of the symp- 
 toms. After this the patients may : 
 
 (a) Continue to get worse. The fever persists, the 
 cough is worse and accompanied with muco-purulent ex- 
 pectoration, there is rapid loss of flesh and strength, the 
 patients pass into the typhoid state, with alternating de- 
 lirium and stupor. The physical signs of the consolida- 
 tion of the lung continue, and there are added those of 
 the formation of cavities. The patients die at the end 
 of a few weeks or months. 
 
 (b) The improvement is greater. The appetite re- 
 turns, the patients have less fever, gain strength, are 
 able to get out of bed, and then go on to the condition 
 of chronic phthisis. 
 
 {e) If the inflammation is limited to the lower lobe, 
 the quantity of the tubercular inflammation small, with 
 no areas of coagulation necrosis, or bronchi-ectasiae, 
 then the inflammatory products may be absorbed, the 
 lung return nearly to its natural condition, and the pa- 
 tients recover. 
 
 2. The Subacute Cases. — The patients have cough with 
 mucous expectoration, dyspnoea, afternoon fever, loss of 
 appetite, flesh, and strength, often large haemoptyses. 
 They are not sick enough to remain in bed all the time. 
 The physical signs are those of consolidation of part of 
 one of the upper lobes, or of localized or general bron- 
 chitis without consolidation. 
 
 If there is consolidation of part of one of the upper 
 lobes, after a time one or more cavities are formed. The 
 patients then go on to have chronic phthisis ; or they may 
 
1 8 THE LUNGS. 
 
 have successive attacks of acute phthisis involving fresh 
 portions of the lung. 
 
 If there is only a tubercular broncho-pneumonia with- 
 out consolidation, this may continue for one, two, or 
 three years, and then subside, and the patients get per- 
 manently well. Or the broncho-pneumonia may con- 
 tinue, bronchi-ectasise are formed, the lung between the 
 inflamed bronchi becomes the seat of chronic inflamma- 
 tion, and the patients go on to have chronic phthisis. 
 
 The Prognosis of acute phthisis is unfavorable. The 
 only cases which recover are those in which there is 
 tubercular broncho-pneumonia without diffuse consolida- 
 tion of the lung ; and those in which there is consolida- 
 tion of one lower lobe with but little tubercular inflam- 
 mation. 
 
 Treatment. — While the inflammation of the lungs is 
 active the patients are to be kept in bed, on a fluid 
 diet, the haemoptyses controlled by ergot or ipecac, the 
 patients made more comfortable by opium or bromides. 
 
 As the acuteness of the inflammation subsides, the pa- 
 tients return to solid food, they get out of bed, and the 
 question of a suitable climate for them has to be deter- 
 mined. In selecting a proper climate, we are guided by 
 the condition of the lungs and the character of the patient. 
 
 In some cases it is evident that the lesions of the lung 
 are so extensive and profound that no real improvement 
 can be expected ; these patients are best kept at home. 
 
 In some cases the amount of lung involved is compara- 
 tively small, and although no permanent recovery can 
 be expected, yet life may be prolonged. The proper 
 climate for these patients is a dry, inland one, where they 
 
THE LUNGS. 1 9 
 
 are not likely to have fresh attacks of inflammation of the 
 lung. Whether this climate should be a warm or a cold 
 one, must be determined by the character of the indi- 
 vidual. In the cases of tubercular broncho-pneumonia 
 without consolidation, a cold, dry, inland climate is usu- 
 ally the best. 
 
 Chronic Phthisis. 
 
 Lesions. — The changes in the lungs are of the same 
 nature as those found in chronic phthisis, but modified 
 by the long duration of the inflammation. The pleura is 
 thickened, the lung is consolidated, the bronchi are in- 
 flamed, there are cavities with suppurating walls formed 
 by the dilatation of the bronchi, or the softening of areas 
 of coagulation necrosis. Softening of portions of dead 
 lung close to the pleura may produce perforation, escape 
 of air into the pleural cavity, and inflammation of the 
 pleura. There may be secondary tubercular inflamma- 
 tion of the larynx, and of the lymphatic glands in the 
 wall of the large intestine. 
 
 The inflammation, although chronic, is more active at 
 some times than at others, and there may at any time be 
 fresh attacks of acute inflammation. 
 
 Causes. — Chronic phthisis regularly succeeds acute or 
 subacute phthisis. 
 
 Symftoms.^-The physical signs are those due to the 
 pleurisy, the consolidation of the lung, the bronchitis, 
 the cavities, and the perforation of the pulmonary pleura. 
 Hsemoptyses from the bronchi are apt to mark the inva- 
 sion of fresh portions of the lung; haemorrhage from erod- 
 ed vessels in the walls of cavities may occur at any time. 
 
20 THE LUNGS. 
 
 The cough depends principally upon the bronchitis 
 and the suppuration of the walls of cavities. The sputa 
 are muco-purulent and abundant. 
 
 Dyspncea on exertion increases with the extent of lung 
 rendered unavailable for breathing. 
 
 The fever and sweating at night seem to depend on 
 the bronchitis and the suppuration of the cavities, rather 
 than on the pneumonia. The functions of the stomach 
 are often disturbed, and there may be catarrhal gastritis. 
 
 Toward the close of the disease an uncontrollable 
 diarrhcea often sets in, either with or without ulceration 
 of the intestine. In women menstruation is apt to cease 
 during the continuance of the phthisis. 
 
 The laryngitis gives its characteristic symptoms. 
 
 The disease goes on nearly continuously, or with inter- 
 vals of improvement. 
 
 Treatment. — The most efficient treatment is the per- 
 manent residence of the patient in a dry, inland climate, 
 where he can lead an out-of-door life. All other treat- 
 ment merely palliates the symptoms. 
 
 Pulmonary Emphysema. 
 
 I. Interlobular, or Interstitial, Emphysema. — This name 
 is given to the condition of the lung produced by the 
 escape of air into the interstitial connective tissue. This 
 condition is most frequently a complication of broncho- 
 pneumonia. It does not cause any recognizable clinical 
 symptoms. 
 
 II. Vesicular Emphysema. — This name is given to cer- 
 tain chronic changes in the lungs, of which dilatation of 
 the air-spaces forms a part. 
 
THE LUNGS. 21 
 
 1. CompensatingEmphysema. — If one lung is so changed 
 by disease that it can only partially perform its functions, 
 the other lung becomes increased in size, and its air- 
 spaces are dilated. This change in the lung is a healthy, 
 rather than a morbid, one, and gives no symptoms of 
 disease. 
 
 2. Senile and Substantive Emphysema. — This change in 
 the lungs occurs as a senile change, or as a chronic in- 
 flammation ; in the same way that we see similar changes 
 developed in the endoca,rdium, the arteries, and the kid- 
 neys. 
 
 As a chronic inflammation it begins usually in adults, 
 in gouty persons, and in those who are disposed to 
 chronic inflammation of the heart, arteries, and kidneys. 
 
 Lesions. — There is a chronic interstitial inflammation 
 of the lungs, with thickening of the walls of some air-spaces, 
 thinning of the walls of others ; an increase of the epi- 
 thelial cells on the walls of the vesicles ; a dilatation of 
 the air-spaces, and the formation of holes in the walls of 
 some of the air-spaces. The dilatation of the air-spaces 
 which has given the name to the disease does not seem 
 to be the important part of the lesion. 
 
 The changes in the lung are sometimes attended with 
 an obstruction to the passage of the blood through them, 
 probably due to contraction of the branches of the pul- 
 monary artery, or to chronic endarteritis. This obstruc- 
 tion to the passage of the blood through the lungs gives 
 rise to venous congestion of the skin, stomach, small in- 
 testines, liver, and kidneys, and to dropsical effusions. 
 After a time the right ventricle of the heart may become 
 dilated and hypertrophied. 
 
22 THE LUNGS. 
 
 Acute or chronic bronchitis, pleurisy with adhesions, 
 endocarditis, endarteritis, and chronic nephritis are often 
 associated with emphysema. 
 
 Symptoms. — Physical Signs. 
 
 The thorax may remain of its natural shape, or there 
 is a prominence of the costal cartilages, or the thorax 
 assumes the barrel shape. 
 
 The percussion resonance is unchanged ; or of shorter 
 duration, higher pitch, and altered quality ; or exagger- 
 ated, with pulmonary, or vesiculo-tympanitic quality. 
 
 The respiratory murmur is feeble, or the expiration is 
 prolonged, or both inspiration and expiration are exag- 
 gerated. The bronchitis gives coarse and subcrepital 
 r&les, and sibilant and sonorous breathing. 
 ■ The asthmatic attacks give sibilant and sonorous 
 breathing. 
 
 The pleuritic adhesions give dulness on percussion. 
 
 Rational Symptoms. There is often difficulty in 
 breathing, either on exertion, or constant, or spasmodic. 
 The dyspnoea on exertion may be moderate, or so 
 severe as to interfere seriously with the activity of the 
 patient. The constant dyspnoea belongs to the ad- 
 vanced forms of the disease. It is most distressing, and 
 is accompanied with exaggerated action and hypertrophy 
 of the muscles of the thorax. The spasmodic dyspncea 
 takes the form of asthmatic attacks, or of a dyspncea 
 like that of Bright's disease. 
 
 Bronchitis is often a prominent feature of the disease, 
 — either repeated attacks of acute bronchitis, or pro- 
 tracted chronic bronchitis. 
 
 In the advanced cases there is established a difficulty , 
 
THE LUNGS. 23 
 
 in the passage of the blood through the lungs, which in 
 turn is followed by venous congestion of many portions 
 of the body, and eventually by dilatation and hypertrophy 
 of the right ventricle of the heart. The skin is dusky- 
 colored or livid, the ends of the fingers are swollen, 
 there is dropsy ; the liver, the spleen, the stomach and 
 small intestines, and the kidneys are the seat of chronic 
 congestion. The congestion of the viscera is followed 
 by a loss of nutrition. The patients lose flesh and 
 strength, and become anasmic. 
 
 There is a liability to short or long attacks of contrac- 
 tion of the smaller arteries, with increased arterial ten- 
 sion, headache, sleeplessness, stupor, delirium, muscular 
 twitchings, irregular heart action, and dyspnoea. 
 
 Course of the Disease. — i. In many patients emphy- 
 sema gives no symptoms at all, or only a very moderate 
 dyspnoea on exertion. 
 
 2. In many patients the emphysema does give symp- 
 toms, but in a variety of ways. 
 
 (a) The attacks of acute bronchitis, or the chronic 
 bronchitis, may always be the prominent symptoms. 
 
 {h) The attacks of "spasmodic asthma may constitute 
 the principal feature of the disease. 
 
 (c) The difficulty in the passage of the blood through 
 the lungs, with the attendant dyspnoea, venous conges- 
 tion, dropsy, and loss of nutrition, may render the patient 
 very seriously ill. 
 
 (rf) The complicating endocarditis, or endarteritis, or 
 nephritis, may give their additional symptoms. 
 
 (<?) There are rare and fatal cases without any pul- 
 monary symptoms. Loss of flesh and strength, anaemia, 
 
24 THE LUNGS. 
 
 contraction of the arteries, with increased arterial tension 
 and its accompanying symptoms, are developed and con- 
 tinue up to the time of the patients' death. 
 
 Treatment. — The chronic inflammation of the lungs is 
 favorably affected by an out-of-door life in a suitable 
 climate ; by abstinence from alcohol, tobacco, sugars, 
 and starches ; by the use of fats ; and by methodical 
 inhalations of compressed air. 
 
 The constant dyspnoea is due to the changes in the 
 lung, and is then to be treated by the same means which 
 are used for the chronic inflammation ; or it is due to 
 the complicating contraction of the arteries, and is then 
 to be treated by the drugs which dilate the arteries. 
 
 The asthmatic attacks are due to : 
 
 («) Spasmodic contraction of the muscular coat of 
 the bronchi. This can be relieved by inhalation of the 
 fumes of stramonium, nitrate of potash, chloroform, and 
 ether ; by the administration of emetics, belladonna, 
 compound spirits of ether, and opium. 
 
 (b) Congestion of the walls of the bronchi. This can 
 be relieved by the drugs which increase the production 
 of mucus, such as lobelia and grindelia robusta ; by 
 drugs which stimulate the heart, such as caffein, conval- 
 laria, and digitalis ; and by the application of dry cups 
 to the wall of the chest. 
 
 (c) Contraction of the smaller arteries. This can be 
 relieved by the drugs which dilate the arteries, such as 
 nitrite of amyl, nitro-glycerine, chloral hydrate, iodide 
 of potash, and opium. 
 
 ((/) To inflammation of the nasal passages. This is 
 to be treated by local applications. 
 
THE HEART. 
 
 In examining any case of suspected disease of the 
 heart we follow a certain routine in the physical examina- 
 tion. We determine the size, the impulse, the rhythm, 
 the character of the heart-sounds and the murmurs. 
 The size of the heart is made out by simple or aus- 
 fcultatory percussion. We map out the upper, the left, 
 and the right edges and the position of the apex-beat. 
 Increase in the size of the heart is readily made out ; 
 diminution in its size is much more difficult to determine. 
 Of the ihipulse we notice the strength, the distinct- 
 ness, the difTuseness, and the force in relation to the 
 pulse. 
 
 Of the rhythm we notice the regularity and the rapidity. 
 Of the heart-sounds we notice the loudness, the dis- 
 tinctness, and the quality. 
 
 Murmurs are pericardial or endocardial. Pericardial 
 murmurs are produced by the rubbing together of op- 
 posed surfaces of pericardium coated with fibrine. They 
 are heard with the first sound, or with the second sound, 
 or during the second silence ; the murmur may be single 
 or double. Although the murmur accompanies the 
 heart-sounds it is not always exactly synchronous with 
 them. There is no fixed point of maximum intensity. 
 The quality of the murmur is superficial, rubbing oi 
 
2 THE HEART. 
 
 grazing ; or it is deep, soft and blowing. The murmur is 
 not always present, but comes and goes. 
 
 Endocardial murmurs are produced by : 
 
 (a) Changes in the valves by which the valves are 
 rendered insufficient, or stenosed, or roughened. 
 
 (5) Ventricular lesions. Inflammation of the endo- 
 cardium or of the chordae tendineae, abnormal tendinous 
 cords extending across the ventricle, or thrombi in the 
 ventricles. Ventricular murmurs are systolic ; their point 
 of maximum intensity is at the apex ; they are not trans- 
 mitted. 
 
 [c) Unknown causes not involving any anatomical 
 change in the heart. These murmurs are systolic, their ^ 
 point of maximum intensity is at the second left intercostal 
 space or at the apex. They can be heard, in some per- 
 sons, at all times ; in others, only after muscular exer- 
 tion ; in others, only when they are anaemic. They do 
 not indicate any disease of the heart. 
 
 Pericarditis. 
 
 Lesions. — The pericardium is a connective-tissue 
 membrane like the pleura. It may be inflamed with : 
 
 The production of fibrine. 
 
 The production of fibrine and much serum. 
 
 The production of fibrine, serum, and pus. 
 
 The production of tubercle tissue. 
 
 After a pericarditis has run its course the inflamma- 
 tory products may be completely absorbed ; or connec- 
 tive-tissue adhesions are left, of small or large extent ; or 
 the inflammation becomes chronic, the purulent serum 
 remains, and the pericardium is split up by a cell-growth ; or 
 calcific plates may be formed in the thickened pericardium. 
 
THE HEART 3 
 
 The wall of the heart may remain unchanged, or the 
 muscular fibres may undergo fatty degeneration, or there 
 may be an interstitial myocarditis. 
 
 The inflammation seems usually to begin over the 
 base of the heart. 
 
 The serum accumulates in the lower and posterior 
 portions of the pericardial sac. As the sac is distended 
 by the fluid the heart is pushed upward and forward, the 
 lungs are pushed to one side, and the diaphragm is 
 pushed down. The size of the sac may be so great that 
 the trachea, the left bronchus, the oesophagus, or the 
 aorta is compressed by it. 
 
 Causes, — Pericarditis is very rarely a primary inflam- 
 mation. It is seen most frequently with rheumatism, 
 pneumonia, pleurisy, and Bright's disease ; less often 
 with the infectious diseases and from injuries. 
 
 Symptoms. — The physical signs. With fibrine alone, 
 the only physical sign is the pericardial murmur. 
 
 With distention of the pericardial sac by serum the 
 area of precordial dulness is enlarged in all directions. 
 The anterior wall of the chest may be bulged out. The 
 apex-beat is carried upward. The physical signs due 
 to the pericarditis may be complicated by murmurs due 
 to a pre-existing endocarditis. 
 
 The rational symptoms of pericarditis are pain, 
 rapid, feeble, and irregular heart-action, rapid and op- 
 pressed breathing, venous congestion of the skin and 
 viscera, dysphagia, a febrile movement, and prostra- 
 tion. 
 
 The cases with exudation of fibrine alone give the 
 fewest and least severe symptoms ; those with large 
 
4 THE HEART. 
 
 exudations of serum give very marked symptoms ; those 
 with serum, fibrine, and pus are the worst of all. 
 
 The prognosis in the milder cases depends more upon 
 the primary disease than upon the pericarditis. With 
 the large serous and purulent effusions, however, the 
 pericarditis becomes in itself a dangerous lesion. 
 
 Trea/meni.— There is first the treatment of the primary 
 disease to which the pericarditis is secondary. For the 
 pericarditis we employ counter-irritation over the pre- 
 cordial region, cardiac stimulants, calomel or sulphate 
 of magnesia as they are used for exudative inflamma- 
 tions. To remove excessive quantities of fluid in the 
 pericardial sac we use cathartics, diuretics, or draw off 
 the fluid with the aspirator. 
 
 Endocarditis. 
 
 The endocardium is a connective-tissue membrane 
 which lines the cavities of the heart and forms the 
 larger part of the valves. It is a thin, dense, and elas- 
 tic membrane, containing but few blood-vessels. It be- 
 comes the seat of productive rather than of exudative 
 inflammation. During foetal life the endocardium of the 
 right heart is inflamed; after birth, usually the endo- 
 cardium of the left heart. The valves are the portion of 
 the endocardium most frequently affected, but that which 
 lines the auricles and ventricles and covers the papillary 
 muscles may be inflamed independently. 
 
 We distinguish : 
 
 Acute endocarditis. 
 
 Malignant endocarditis. 
 
 Chronic endocarditis. 
 
THE HEART. 5 
 
 Acute Endocarditis. 
 
 Lesions. — i. The valves are swollen and succulent; 
 the basement-substance and cells are swollen ; the sur- 
 face of the valves remains smooth. As the valves are 
 swollen they are also shortened and insufficient. 
 
 2. The valves are not only swollen but there is an 
 extensiire growth of their connective-tissue cells, result- 
 ing in the formation of ulcers and of vegetations. On 
 the roughened surfaces of the valves fibrine from the 
 blood coagulates in considerable masses. Portions of 
 the vegetations may become detached, pass into the 
 aorta, and become lodged in the smaller arteries as em- 
 boli. 
 
 Causes. — Acute endocarditis is usually a complication 
 of rheumatism, or of scarlatina. 
 
 Symptoms. — The physical signs are due to the insuf- 
 ficiency and roughening of the valves. So we have a 
 mitral systolic, or aortic diastolic, or double aortic murmur. 
 
 The rational symptoms are : 
 
 Fever, prostration, disturbed action of the heart with 
 consequent changes in the circulation, and symptoms 
 due to embolism. The disturbed heart-action follows 
 one of two types : 
 
 I. The heart's action is violent, tumulutous, and irreg- 
 ular; there is very marked venous congestion of different 
 parts of the body. 
 
 The congestion of the pia mater produces delirium 
 and stupor. 
 
 The congestion of the lungs gives labored breathing, 
 and may go on to inflammation and consolidation of 
 parts of the lungs. 
 
6 THE HEART. 
 
 The congestion of the pleura produces hydrothorax ; 
 that of the stomach, vomiting; that of the liver, en- 
 largement of that organ ; that of the peritoneun), ascites ; 
 that of the subcutaneous connective tissue, dropsy. 
 
 The congestion of the kidneys is attended with a 
 diminished quantity of urine, which contains a little 
 albumen and a few casts. If the urine is scanty for a 
 long time the patients become anaemic and develop the 
 symptoms of chronic uraemia. 
 
 2. The heart's action is feeble and rapid. There is 
 not as much disposition to venous congestion, but the 
 patients suffer from dyspnoea, they are very feeble, they 
 are liable to attacks of syncope. 
 
 The emboli which give the most marked symptoms 
 are those which become lodged in the cerebral arteries. 
 
 A large number of cases of acute endocarditis recover, 
 but very few without permanent changes in the valves. 
 
 In some the valves, although rendered insufficient, 
 undergo no further changes, and the patients do 
 well. 
 
 In some the valves, after remaining unchanged for 
 years, finally become the seat of chronic endocarditis. 
 
 In some the acute endocarditis passes into the chronic 
 form, and the patients grow worse with but little inter- 
 ruption. 
 
 Treatment. — The principal objects of treatment are 
 the cure of the rheumatism and the relief of the bad 
 heart-action with the consequent disturbances of circu- 
 lation. For the rheumatism the most efficient remedies 
 are the salicylate of soda, the oil of wintergreen, the 
 alkalies^ antipyrine, and phenacetine. 
 
THE HEART. ^ 
 
 If the heart's action is exaggerated, tumultuous, and 
 irregular, with excessive venous congestion, we employ- 
 venesection, wet cups or leeches, purging or sweating. 
 Chloral hydrate, amyl nitrite, opium, and potassium 
 iodide are often of much service. 
 
 If the heart's action is feeble and rapid we need the 
 cardiac stimulants — digitalis, convallaria, caffeine, and 
 £^cohol. 
 
 Malignant Endocarditis. 
 
 Lesions. — Either the mitral, the aortic, or the tricus- 
 pid valve, the endocardium of the left auricle, or of the 
 right ventricle may be inflamed. The inflamed endocar- 
 dium is covered with a thin or thick layer of soft ma- 
 terial, composed of fibrine and micrococci. The endocar- 
 dium beneath is swollen, infiltrated with cells, often 
 ulcerated. If the malignant endocarditis affects a heart 
 already the seat of chronic endocarditis, the old lesions 
 persist. 
 
 Portions of the soft matter on the inflamed endocar- 
 dium often become detached and are lodged as emboli 
 in the arteries of the brain, lungs, heart, spleen, and kid- 
 neys. These emboli are infectious and set up an in- 
 flammation of the surrounding tissues. So there may be 
 complicating meningitis, pericarditis, bronchitis, pneu- 
 monia, or synovitis. The liver, spleen, and kidneys are 
 swollen and their cells degenerated. 
 
 Causes. — Malignant endocarditis occurs with rheuma- 
 tism, after childbirth, and from unknown causes. 
 
 Symptoms. — The disease begins with chills and a 
 febrile movement. There is loss of appetite and some- 
 
8 THE HEART, 
 
 times vomiting ; the breathing is rapid. The heart's 
 action may not be very much disturbed ; or it may be 
 feeble, rapid, and irregular. The temperature continues 
 high — 103° to 107° F. — but with occasional rapid falls. 
 Cerebral symptoms are soon developed — restlessness, 
 sleeplessness, delirium, and stupor. There is a heart- 
 murmur if the endocarditis is sufficient to produce insuf- 
 ficiency, or roughening of the valves. The urine contains 
 some albumen ; the joints may be inflamed ; there may 
 be convulsions or paralyses from embolism of the larger 
 cerebral arteries. There may. be bleeding from the mu- 
 cous membranes and into the skin. 
 
 The patients pass into the typhoid condition and die, 
 most at the end of seven to ten days, a few within three 
 days, some not until after three to five weeks. 
 
 The whole picture is that of an infectious disease, with 
 more or less pronounced evidence of the cardiac lesion. 
 
 Chronic Endocarditis. 
 
 Lesions. — The inflammation involves most frequently 
 the mitral and aortic valves, less often the tricuspid and 
 pulmonary valves and the endocardium of the ventricles 
 and auricles. There are two forms of chronic endocar- 
 ditis. 
 
 1. The endocardium is thick, dense ; there may be 
 little beaded vegetations on its surface ; it may be infil- 
 trated with the salts of lime. But its surface remains 
 smooth, and thrombi are not formed on it. Such an 
 endocarditis renders the valves rigid, insufficient, or 
 stenosed. 
 
 2. The endocardium is thickened, there is a growth of 
 
THE HEART. 9 
 
 cells producing vegetations and ulcer?, the surface of the 
 endocardium is roughened, and thrombi are formed on 
 it. In such an inflamed endocardium there may also be 
 a deposition of the salts of lime. 
 
 When the valves are affected by either of these fomrs 
 of endocarditis, they are rendered insufficient, or stenosed. 
 These changes are followed by dilatation of the ventri- 
 cles, by hypertrophy of their walls, and by disturbances 
 of the circulation of the blood throughout the body. 
 
 With chronic endocarditis are often associated myo- 
 carditis, endarteritis, contraction of the arteries, emphy- 
 sema, and chronic nephritis. 
 
 Causes. — Chronic endocarditis may succeed acute 
 endocarditis, either immediately or after a long interval. 
 It may be caused by rheumatism, gout, or syphilis. It 
 very often is a primary lesion. It is rarely due to the 
 rupture of a valve by external violence. 
 
 The symptoms depend on : 
 
 The endocarditis. 
 
 The dilatation and hypertrophy. 
 
 The character of the heart's action. 
 
 The presence of thrombi on the endocardium. 
 
 The myocarditis. 
 
 The endarteritis. 
 
 The contraction of- the arteries. 
 
 The emphysema. 
 
 The chronic nephritis. 
 
 The general venous congestion. 
 - I. The Endocarditis. The inflammation may last for 
 months or years, cease to be active, and no further 
 changes be produced in the valves ; or it may continue 
 slowly and with intermissions up to the time of the pa- 
 
lO THE HEART. 
 
 tient's death, the valves becoming more and more dam- 
 aged, and the inflammation extending to other valves ; 
 or the inflammation may be more active, the endocardium 
 more rapidly and profoundly changed, with a febrile 
 movement and loss of nutrition. 
 
 The changes in the endocardium, due to the inflam- 
 mation, may produce cardiac murmurs. 
 
 Aortic stenosis gives a murmur with the first sound, 
 and during the first silence. The murmur is loudest at 
 mid-sternum, opposite the third interspace. It is trans- 
 mitted upward and to the right. It may be heard be- 
 hind on the left side of the second, third, and fourth 
 dorsal vertebrae. It may be loudest at the lower end of 
 the sternum, or in the second interspace, on the right or 
 left side. There may be well-marked aortic stenosis 
 with no murmur. 
 
 Aortic insufficiency gives a murmur with the second 
 sound, loudest at mid-sternum opposite the third inter- 
 space. It is transmitted down the sternum, and upward 
 to the right. It may be loudest at the lower end of the 
 sternum, in the left fourth interspace, or at the apex. It 
 is a very constant murmur. 
 
 Mitral stenosis gives a presystolic; or systolic mur- 
 mur, or both. The presystolic murmur is heard just be- 
 fore the first sound. It is loudest at the apex and is 
 usually circumscribed. The systolic murmur is loudest 
 at the apex and is transmitted to the left. The murmurs 
 of mitral stenosis are very inconstant, and often absent 
 altogether. 
 
 Mitral insufficiency gives a systolic murmur, loudest 
 at the apex, and transmitted to the left. This murmur is 
 nearly always a constant one. 
 
THE HEART, II 
 
 Ventricular murmurs are produced by roughening of 
 the ventricular endocardium, or thrombi in the ventricles. 
 They are systolic, loudest at the apex, and circumscribed. 
 They are not constant. 
 
 2. Dilatation and hypertrophy of the ventricles. Dil- 
 atation alone of the ventricles adds to the dangers of the 
 endocarditis. Hypertrophy alone seems often, to be of 
 benefit. Hypertrophy and dilatation together, if not ex- 
 cessively developed, may also be of benefit. A heart 
 which remains of normal size, or which becomes small, 
 when associated with advanced valvular changes is apt 
 to act badly. 
 
 Aortic stenosis is regularly followed by dilatation and 
 hypertrophy, first of the left ventricle, then of the right. 
 
 Aortic insufficiency is followed by dilatation and hy- 
 pertrophy of the left ventricle. 
 
 I Mitral stenosis should be followed by dilatation and 
 hypertrophy of the left auricle and the right ventricle. 
 But there may be dilatation alone of either or of both 
 ventricles ; or dilatation and hypertrophy of the left ven- 
 tricle ; or the entire heart may be small. 
 
 Mitral insufficiency is followed by dilatation alone, or 
 dilatation and hypertrophy of the left ventricle. 
 
 3. The characters of the heart's action. Disturbances 
 of the heart's action seem to depend upon the changes 
 in the valves and walls of the heart ; upon contractipn 
 of the arteries ; and upon unknown causes. 
 
 The heart's action may be rapid, slow, feeble, forcible, 
 intermittent, irregular, or tumultuous. The contractions 
 of the heart may be so feeble that there are more apex, 
 beats than arterial pulsations. 
 
 Aortic and mitral stenosis, without contraction of the 
 
12 THE HEART. 
 
 arteries, gives a feeble and irregular pulse ; with contrac- 
 tion of the arteries, the pulse is tense and the heart-ac- 
 tion often laboring. Aortic stenosis may give more 
 ventricular contractions than heart-beats. 
 
 Aortic insufficiency gives an exaggerated heart-action 
 with dilated arteries, full of blood, but soft. 
 
 Abnormal sensations referred to the heart. seem to de- 
 pend upon its disturbed action. 
 
 There maybe actual pain, referred to the heart and the 
 left shoulder ; the pain constant, produced by exertion, 
 or paroxysmal. Or there are feelings of constriction, or 
 of displacement of the heart. 
 
 4. Thrombi attached to the endocardium. These in- 
 terfere with the heart's action. They may obstruct the 
 orifices of the heart ; fragments of them lodged in the cere- 
 bral arteries produce convulsions, paralyses, and aphasia. 
 
 5. Myocarditis. — Interstitial myocarditis, degeneration 
 of the heart-muscle, and disease of the coronary arteries 
 are each one capable of rendering the heart's action fee- 
 ble and irregular ; of producing attacks of angina pecto- 
 ris ; and of causing sudden death. 
 
 6. Chronic endarteritis affecting many of the arteries 
 adds to the difficulties of the circulation. If it involves 
 the cerebral arteries the characteristic symptoms of cere- 
 bral endarteritis may be developed. 
 
 7. Pulmonary emphysema is a frequent complication, 
 and adds much to the dangers of the endocarditis. 
 
 8. Venous congestion takes a very large share in pro- 
 ducing the symptoms of chronic endocarditis. It is due 
 to the valvular lesions, the dilatation of the ventricles, 
 the disturbed heart-action, the contracted arteries, and 
 the complicating emphysema or endarteritis. 
 
THE HEART, 1 3 
 
 Congestion of the pia mater produces delirium, stupor, 
 and convulsions. 
 
 Congestion of the lungs produces chronic bronchitis, 
 hsemoptyses, the pneumonia of heart disease, oedema of 
 the lungs, and hydrothorax. 
 
 Congestion of the stomach produces pain, gastric dys- 
 pepsia, vomiting, and vomiting of blood. 
 
 Congestion of the small intestine produces loss of 
 flesh and strength. 
 
 The general congestion of the body gives subcutane- 
 ous dropsy and dropsy of the serous cavities. 
 
 The kidneys may be the seat of chronic congestion, 
 of chronic degeneration, or of chronic nephritis. 
 
 With chronic congestion of the kidney the quantity 
 of urine is diminished, its specific gravity is high, there is 
 little or no albumen, the quantity of urea to the ounce 
 of urine is sufficient. This change in the kidney seems 
 to add but little to the symptoms. 
 
 The chronic congestion, if protracted, is succeeded by 
 a chronic nephritis. The specific gravity of the urine 
 falls, the quantity of urea is diminished, and albumen and 
 casts make their appearance. 
 
 With chronic degeneration of the kidney the quantity 
 of the urine is diminished, the specific gravity and the 
 proportion of urea are unchanged, there is a moderate 
 quantity of albumen and a few casts. If the excretion of 
 urine is scanty for a long time the patients may pass into 
 the condition of chronic uraemia. 
 
 The chronic nephritis is diffuse and most frequently 
 follows one of two types. 
 
 I. There is an abundant exudation of serum from the 
 vessels of the kidneys. The urine is of low specific 
 
14 THE HEART. 
 
 gravity and contains large quantities of albumen. The 
 patients are ansemic, dropsical, and suffer from chronic 
 ursemia. 
 
 2. There is little or no exudation from the blood- 
 vessels of the kidneys, but there is an extensive growth 
 of interstitial connective tissue. The urine is of low 
 specific gravity, contains little urea, and little or no al- 
 bumen. The patients are liable to attacks of acute urae- 
 mia, with contracted arteries. 
 
 Course of the Disease. — The disease may succeed one 
 or more attacks of acute endocarditis, or it may be 
 chronic from the outset. 
 
 In the chronic cases the symptoms are usually not de- 
 veloped until the disease has existed for some time. 
 Then first one or two symptoms appear and others are 
 added later. 
 
 The first symptom may be : 
 
 Dyspnoea on exertion. 
 
 Anaemia and emaciation. 
 
 Cough and expectoration. 
 
 Cardiac palpitation and pain. 
 
 Stomach symptoms. 
 
 Dropsy. 
 
 Contraction of the arteries. 
 
 It sometimes happens that the patients go on for a 
 long time with an endocarditis, but without symptoms. 
 Then suddenly, with a pericarditis, a pleurisy, a bronchi- 
 tis, or without discoverable cause, they develop a most 
 distressing and urgent dyspnoea with contracted arteries. 
 This dyspnoea continues and the patients die within a 
 few days or weeks. 
 
 The endocarditis may stop at any time. It may go 
 
THE HEART. IS 
 
 on slowly, or quickly ; it may be complicated by the dis- 
 eases already mentioned. v 
 
 The bad cases die with dyspnoea ; or feeble and ema- 
 ciated ; or with dropsy ; or with cerebral symptoms ; or 
 they die suddenly. 
 
 T^e prognosis depends upon : 
 
 The extent and activity of the endocarditis. 
 
 The condition of the ventricles. 
 
 The character of the heart's action. 
 
 The presence or absence of contraction of the ar- 
 teries. 
 
 Treatment. — The principal indications for treatment 
 are to check the progress of the endocarditis, to regulate 
 the action of the heart and the condition of the arteries, 
 and to alleviate symptoms. 
 
 To check the progress of the endocarditis we' put the 
 patient on a diet of fats, meat, fruits, and vegetables ; 
 we prohibit the use of alcohol and tobacco, and we in- 
 sist on a life passed in the open air. 
 
 To regulate the action of the heart and the condition 
 of the arteries. If the arteries are contracted we em- 
 ploy nitrite of amyl, nitro-glycerine, potassium iodide, 
 chloral hydrate, or opium. 
 
 If the heart's action is feeble we use digitalis, stroph- 
 anthus, caffeine, or convallaria. If the heart's action is 
 too forcible we use continuous cold over the heart, a nitric- 
 acid issue, aconite, veratrum viride, or barium chloride. 
 
 With aortic, or mitral, stenosis and a feeble heart it 
 may be necessary to confine the patients to bed. 
 
 With many forms of endocarditis the patients do best 
 if they are allowed to follow their ordinary mode of life, 
 avoiding sudden and violent exertion. 
 
1 6 THE HEART. 
 
 In a certain number of cases very excellent results are 
 obtained by regulated hill-climbing. 
 
 Hypertrophy and Dilatation of the Heart with- 
 out Endocarditis. 
 
 I. From excessive and prolonged muscular exertion. 
 The left ventricle alone, or both ventricles, are hyper- 
 
 trophied or dilated, or both dilated and hypertrophied. 
 
 To produce these changes in the heart the muscular 
 exertion must be excessive and prolonged, so we find 
 them most frequently in soldiers, athletes, and la- 
 borers. 
 
 In the milder cases there is only hypertrophy of the 
 left ventricle. The patient has the feelings of pain, or 
 constriction, or displacement of the heart, with rapid 
 heart-action. 
 
 These patients usually do well. It is only necessary 
 to make them lead a regular life and sometimes to take 
 digitalis. 
 
 In the more severe cases there is dilatation alone, or 
 dilatation with hypertrophy. There are pain over the 
 heart, rapid and feeble heart-action, dyspnoea on exer- 
 tion, and loss of flesh and strength. These cases are 
 always serious, and not all of them recover. 
 
 It is necessary to keep the patients in bed, and to use 
 cardiac stimulants. 
 
 II. From disease of the lungs. 
 
 Emphysema, chronic phthisis, interstitial pneumonia, 
 pleurisy, and deformities of the chest may produce dilata- 
 tion, first of the right ventricle, and afterward of the 
 left. 
 
 III. Exophthalmic goitre, or prolonged palpitation of 
 
THE HEART. 1 7 
 
 the heart, may be followed by hypertrophy of the left 
 ventricle, 
 
 IV. Acute or chronic nephritis, chronic inflammation 
 of the aorta, and congenital narrowing of the aorta may 
 produce hypertrophy of the left ventricle. 
 
 V. Simple ancemia may be attended with temporary 
 dilatation and hypertrophy of the left ventricle. 
 
 VI. There is an important group of cases of dilatation 
 of the ventricles without hypertrophy, of which the causa- 
 tion is very obscure. 
 
 Usually both ventricles are dilated, but sometimes 
 only the left. The valves are normal, but their orifices 
 may be so large that they are insufficient. The walls of 
 the ventricles are normal, or the muscular fibres are de- 
 generated, or there is a growth of cells between the 
 fibres. Thrombi may be formed in the cavities of the 
 ventricles. Venous congestion of the viscera is soon 
 established, dropsy somewhat later. 
 
 Of the causes of this heart-lesion we are ignorant. It 
 is often enough developed in young and healthy adults. 
 In some cases there is a distinct history of sudden muscular 
 exertion ; in others, no exciting cause can be discovered. 
 
 In the more acute cases the invasion of the symptoms 
 is sudden. 
 
 The patients complain of pain in the epigastrium, they 
 become unconscious, and th'ey vomit ; or the first symp- 
 tom is urgent cardiac dyspnoea. After this the heart's 
 action is rapid, irregular, and feeble. The physical signs 
 are those of dilatation of the heart. There is constant 
 and distressing dyspnoea, there may be cough and 
 hsemoptyses, the patients lose flesh and strength, and 
 die at the end of a few weeks. 
 
1 8 THE HEART. 
 
 In the more chronic cases the invasion is less sudden 
 and decided. The patients suffer from rapid, feeble, and 
 irregular heart-action, dyspncea, cough, and hsemoptyses, 
 marked dropsy, and loss of flesh and strength. They 
 may live for several months. 
 
 The treatment of these cases is eminently unsatisfac- 
 tory. We are unable to improve the action of the heart, 
 and the best that we can do is to palliate the patient's 
 sufferings with opium. 
 
 The Fatty Heart. 
 
 1. There is an accumulation of fat beneath the peri- 
 cardium. This occurs in persons who also have accu- 
 mulations of fat in other parts of the body. 
 
 The heart's action is often feeble, and there is dyspnoea 
 on exertion. It is difficult to tell whether the cardiac 
 symptoms are due to the fat on the heart or to the gen- 
 eral condition of the patient. 
 
 The indications for treatment are by a regulated diet 
 and systematic exercise to remove the fat. 
 
 2. There is a fatty degeneration of the muscular fibres 
 of the wall of the heart. 
 
 The heart remains of its normal size, or becomes 
 somewhat smaller. Its walls are soft and lighter colored. 
 The degeneration may involve the walls of both ventri- 
 cles, or of one, or of part of one. The degeneration may 
 advance so far at some one point that the wall of the ven- 
 tricle will be ruptured. 
 
 Causes. — This change in the heart may be secondary 
 to profound anaemia, to long and wasting diseases, to the 
 severe infectious diseases, and to poisoning by phospho- 
 rus. It occurs also as a primary disease, and is then es- 
 
THE HEART. 1 9 
 
 pedially common in males between the ages of forty and 
 seventy. 
 
 Symj>toms. — Physical signs : The heart is of normal 
 size, or diminished. The impulse is feeble ; the first 
 sound is short and feeble ; the action may be regular, 
 irregular, fast or slow. The systolic murmur at the 
 apex, or at the second left interspace, which occurs with- 
 out valvular lesions, may be present. 
 
 There may be pain, referred to the heart, either con- 
 tinuous or spasmodic ; or attacks of angina pectoris. 
 
 There may be attacks of syncope, dyspnoea on exer- 
 tion, or constant dyspnoea. Cerebral symptoms : Ver- 
 tigo, convulsions, loss of' consciousness, or coma may 
 be developed. There may be gradual loss of flesh and 
 strength. Dropsy is not a frequent symptom. 
 
 Some of the patients never give any symptoms of 
 their cardiac lesion, and die of some other disease. 
 
 Some give no symptoms until they have a fatal attack 
 of angina, of syncope, of coma, or of rupture of the 
 heart. 
 
 Some give the characteristic symptoms of the disease 
 for months or years. 
 
 Treatment. — The best that can be done is the regula- 
 tion of the diet and mode of life, and the use of cardiac 
 stimulants. 
 
 Rupture of the Heart. 
 
 Lesions. — Ruptures of the heart are most common in 
 the anterior wall of the left ventricle near the apex. 
 They also occur in the wall of the right ventricle, the 
 right auricle, the septum between the ventricles and the 
 papillary muscles. The rupture is small, direct, or indi- 
 
20 THE HEART. 
 
 rect. The rupture is due to fatty degeneration of the 
 muscle, or to occlusion of one of the branches of the cor- 
 onary artery. 
 
 Symptoms. — The rupture may occur during exertion, 
 or while the patient is perfectly quiet. 
 
 If the rupture is direct death is almost instantaneous. 
 If it is indirect the patients may live for hours or days. 
 They have sudden pain in the heart, vomiting, dyspnoea, 
 prostration, irregular and feeble heart-action. 
 
 The Neuroses of the Heart, 
 palpitation. 
 
 There is no structural change in the heart, except that 
 in the long-continued cases the left ventricle may be 
 hypertrophied. 
 
 The heart's action is too frequent, and may be irreg- 
 ular. There may be an apparent exaggeration of the 
 heart's action, but yet it is a feeble heart. 
 
 The patients suffer from the consciousness of the 
 heart's action, from abnormal cardiac sensations, from 
 vertigo, headache, fulness of the head, syncope, sleep- 
 lessness, loss of flesh and strength, and a variety of 
 nervous phenomena. 
 
 Many of the cases are mild and easily relieved, but 
 some are very serious. 
 
 Causes. — In some of the cases there is apparently a 
 cause for the palpitation — gastric and hepatic dyspepsia, 
 an abnormal mode of life, the abuse of tobacco and of 
 tea, and ansemia. In other cases no cause can be dis- 
 covered. 
 
 Treatment. — The indications for treatment are to ob- 
 
THE HEART. 21 
 
 tain control over the patient, to remove the causes of 
 the disease, to regulate the mode of life, and to use car- 
 diac stimulants. 
 
 Angina Pectoris. 
 
 The disease is characterized by pain, oppression, a 
 sense of impending death, abnormal action of the heart, 
 or contraction of the arteries. 
 
 Lesions. — There may be inflammation of the coronary 
 arteries, fatty degeneration of the heart, inflammation of 
 the aorta, chronic endocarditis, changes in the cardiac 
 plexus of nerves, or no discoverable lesions. 
 
 Causes. — The disease is especially common in males, 
 among the better classes, and in persons over fifty years 
 of age. 
 
 Symptoms. — The symptoms occur in attacks. Be- 
 tween the attacks the patients are perfectly well, or they 
 suffer from the symptoms of the disease of the coronary 
 arteries ; of the fatty heart ; of the diseased aorta ; or of 
 the chronic. endocarditis. 
 
 During the attack the patients have : Pain and ten- 
 derness, referred to the precordial part of the lower 
 sternal region,or to the middle or upper sternal region. 
 The pain radiates to the mid-dorsal spine ; to the 
 left, or to both sides of the neck and the occiput; 
 to the left shoulder and arm, to both arms, to the right 
 arm alone, to the left leg, or to both arms and the left 
 leg. With the pain there may be feelings of numbness 
 and tingling. 
 
 A feeling of cardiac oppression and of impending 
 death, which they describe very vividly. 
 
 A pulse of high tension, or a feeble and irregular pulse. 
 
22 THE HEART. 
 
 Dyspnoea in some of the cases, but not in all. 
 
 Vomiting, flatulence, eructations of gas. An unim- 
 paired intelligence, or slight convulsive movements, or 
 general convulsions, or loss of consciousness. 
 
 An anxious face, with a skin cold and bathed in per- 
 spiration. 
 
 The attacks usually come on suddenly and without 
 warning. They may, however, be preceded by abnor- 
 mal cardiac sensations, or be excited by certain muscular 
 movements, or occur at regular intervals. 
 
 Each attack may last for a few minutes, or for several 
 hours. A patient may have only a single attack, from 
 which he recovers, or during which he dies. He may 
 have a number of attacks any one of which may prove 
 fatal ; or after a number of attacks there may be no fur- 
 ther recurrence. 
 
 The prognosis of the disease is very serious, but yet 
 there is a considerable number of persons who suffer from 
 one or more attacks and entirely recover. 
 
 Treatment. — For purposes of treatment we divide the 
 cases into two classes : Those in which, during the at- 
 tack, the arteries are contracted, with a pulse of high 
 tension ; and those in which, without any such contraction 
 of the arteries the heart's action is feeble and irregular. 
 
 The attacks with contraction of the arteries can usually 
 be relieved by inhalations of nitrite of amy], hypodermic 
 injections of morphine, and the internal use of nitro- 
 glycerine. The attacks without contraction of the 
 arteries are very much more difficult to manage. 
 
 During the intervals between the attacks we try to 
 improve the general health of the patient in every pos- 
 sible way. 
 
. THE HEART. 23 
 
 Pseudo-Angina Pectoris, 
 
 We use this name to designate a somewhat irregular 
 group of cases, which present the common feature of 
 attacks of disturbance of the action of the heart. 
 
 Lesions. — There may be chronic inflammation of the 
 coronary arteries, fatty degeneration of the heart, inflam- 
 mation of the arch of the aorta, or no discoverable 
 lesion. 
 
 Symptoms, — Pain may be absent altogether. When 
 present it is not as severe as the pain of true angina, but 
 is referred to the same regions. 
 
 The patients may be much alarmed about themselves, 
 but do not have the feeling of impending death. 
 
 The heart's action is feeble and irregular, although 
 sometimes it may seem to be exaggerated. 
 
 The breathing may be hurried and labored. There 
 may be vomiting and pain in the stomach. 
 
 The. attacks come on suddenly, they last for minutes, 
 days, or weeks. In the longer attacks the symptoms 
 are not continuous. 
 
 The patient may die in any of the attacks ; or after 
 one or more such attacks there may be no further recur- 
 rence. 
 
 Treatment. — During the attacks we use cardiac stim- 
 ulants ; between the attacks we try to improve the gen- 
 eral health. 
 
 Exophthalmic Goitres. 
 
 Basedow's disease. Graves' disease. 
 
 The cases are characterized by rapid heart-action, en- 
 largement of the thyroid gland, and protrusion of the 
 eyeballs. 
 
24 THE HEART. 
 
 Lesions. — After death the thyroid gland is found sim- 
 ply hypertrophied, there is nothing in the orbits, the left 
 ventricle of the heart may be hypertrophied. In a few 
 cases in the ganglia of the cervical sympathetic there 
 have been found degeneration of the nerve-cells and a 
 new growth of connective tissue. 
 
 Causes. — The disease is much more common in women 
 than in men, and especially during early adult life. 
 
 Symptoms. — The symptoms are usually developed 
 slowly, but exceptionally within a few days. The first 
 symptom is regularly the increased frequency of the 
 heart's action, but without irregularity or feebleness. 
 Then comes the moderate and symmetrical enlargement 
 of the thyroid, sometimes with dilatation of its veins. 
 
 The enlargement of the thyroid may precede the pal- 
 pitation ; it may be absent altogether. 
 
 Next comes the exophthalmos. It may, however, 
 precede the goitre ; it may be the first symptom ; it may 
 be absent altogether. 
 
 After a time there may be developed hypertrophy of 
 the left ventricle of the heart. 
 
 Besides the characteristic symptoms of the disease, 
 there may be added a variety of nervous phenomena, 
 dyspnoea, ansemia, and loss of flesh and strength. 
 
 The disease is apt to last for years ; it is not of itself 
 fatal. Some of the patients recover altogether, some 
 only in part. 
 
 Treatment. — The indications are to improve the gen- 
 eral health of the patient in every way ; to relieve the 
 anaemia ; to give the cardiac stimulants and the iodides 
 of potassium and sodium ; and to use the galvanic cur- 
 rent over the cervical sympathetic. 
 
ANEURISM OF THE AORTA. 
 
 Lesions. — There is a chronic inflammation of the 
 wall of the aorta ; by this the wall of the aorta is thick- 
 ened, or thinned, or ulcerated. The thickened portions 
 may undergo fatty degeneration, or become calcified. 
 As a result of these changes there may be rupture of the 
 aorta, diffuse dilatations, or sacculated dilatations. So 
 there are formed dissecting, fusiform, and sacculated 
 aneurisms. 
 
 Dissecting Aneurisms. 
 
 Peacock describes 19 cases. They occurred in per- 
 sons between the ages of twenty-four and eighty-four 
 years. Crisp describes 21 cases. They occurred be- 
 tween the ages of twenty-four and ninety years. Seven 
 were in males, fourteen in females. Sibson describes 52 
 cases. 
 
 The rupture of the inner coat is usually in the as- 
 cending portion of the arch, near the valves. The blood 
 finds its way between the coats of the aorta, and then 
 ruptures through the outer coat within the pericardium, 
 or lower down. 
 
 The patients usually have no symptoms until the rupt- 
 ure of the aorta. Then they die suddenly, or they live 
 for hours or days with great prostration and feeble heart 
 action. 
 
2 ANEURISM OF THE AORTA. 
 
 Fusiform and Sacculated Aneurisms. 
 
 Fusiform and sacculated aneurisms occur either sepa- 
 rately or together. 
 
 The fusiform dilatations may involve the arch alone, 
 or the whole aorta. 
 
 The sacculated aneurisms have a small or large 
 opening. The sacs are small or large ; they are single 
 or multiple. 
 
 Causes. — These aneurisms are especially common in 
 males between the ages of thirty and fifty years ; in 
 persons who have constitutional syphilis ; in persons who 
 have chronic inflammation of the aorta, and whose occu- 
 pation involves severe muscular exertion. 
 
 Situation. — Sibson gives the situation of 860 cases of 
 aneurism of the aorta as follows : 
 
 Of the arch of the aorta, 480. 
 
 At the sinuses of Valsalva, 8 7. 
 
 Of the ascending portion of the arch, 141. 
 
 Of the transverse portion of the arch, 120. 
 
 Of the ascending and transverse portions of the arch 
 together, 112. 
 
 Of the descending portion of the arch, 72. 
 
 Of the transverse and descending portions of the arch 
 together, 20. 
 
 Of the whole arch, 28. 
 
 Of the thoracic aorta, 71. 
 
 Of the abdominal aorta at the cceliac axis, 131 
 
 Of the lower part of the abdominal aorta, 26. 
 
 Symptoms. — These are due to the presence of the 
 aneurismal tumor, its pressure on the surrounding parts, 
 and its effect on the circulation of the blood. 
 
ANEURISM OF THE AORTA. 3 
 
 The tumor, if situated within the thorax, gives dul- 
 ness on percussion, the feeling of a pulsating tumor, a 
 double murmur, and a thrill. If it is situated within 
 the abdomen, it gives the feeling of a pulsating tumor, 
 a murmur, and a thrill. 
 
 The pressure of the tumor is on : 
 
 The descending vena cava, with venous congestion of 
 the head and neck. 
 
 The trachea and large bronchi, with cough, dyspnoea, 
 stridulous cough, voice, and breathing, and tubular breath- 
 ing over the lungs. 
 
 The pulmonary artery, the right auricle, and the upper 
 part of the ventricles, with disturbances of the circulation. 
 
 The oesophagus, with difficulty in swallowing. 
 
 The recurrent laryngeal nerve, with paralysis of one 
 of the vocal chords. 
 
 The brachial plexus of nerves, with pain. 
 
 The vertebrae, with pain. 
 
 Any sacculated aneurism is liable to rupture. 
 
 Aneurisms at the Sinuses of Valsalva. 
 
 These aneurisms are sacculated, and are most fre- 
 quently given off from the right coronary sinus. 
 
 Small aneurisms in this situation give no symptoms, 
 unless they rupture within the pericardium and cause 
 sudden death. 
 
 Larger aneurisms may compress and erode the pul- 
 monary artery, the right auricle, or the right ventricle. 
 
 There is an area of dulness, or a pulsating tumor, 
 either to the right or left of the sternum, at about the 
 third interspace. 
 
4 ANEURISM OF THE AORTA. 
 
 There is a murmur in 34 per cent, of the cases. 
 Dyspnoea in 38 per cent. 
 Cough in 24 per cent. 
 Pain in 21 per cent. 
 An enlarged heart in 29 per cent. 
 Rupture of the aneurism within the pericardium in 
 48 per cent. 
 
 In the pulmonary artery in 13.5 per cent. 
 In the right auricle in 8.5 per cent. 
 In the right ventricle in 5 per cent. 
 In the left ventricle in 5 per cent. 
 
 Aneurisms of the Ascending Portion of the Arch. 
 
 These aneurisms are sacculated in 51 per cent., fusi- 
 form in 37 per cent, of the cases. 
 
 The sacs are given off from the anterior wall, the 
 right wall, the left wall, and the posterior wall. 
 
 They compress the right lung, the left lung, the right 
 bronchus, the left bronchus, the pulmonary artery, the 
 descending vena cava, the trachea, or the oesophagus. 
 There is an area of dulness, or a pulsating tumor, be- 
 neath and to the right of the sternum, at about the sec- 
 ond interspace. 
 
 A murmur is present in 23 per cent, of the cases ; 
 dyspnoea in 51 per cent. ; cough in 36 per cent. ; stri- 
 dor in 4 per cent. ; pain in the chest in 29 per cent. ; 
 in the neck and shoulders in 10 per cent, j in the right 
 arm in 2 per cent. 
 
 About 1 1 per cent, of the patients are in good health 
 up to the time of their death. 
 
 The aneurisms rupture in 57 per cent, of the cases : 
 
ANEURISM OF THE AORTA. 5 
 
 within the pericardium, externally, into the descending 
 vena cava, into the right lung, the pulmonary artery, the 
 left pleura, the right bronchus, the left lung, the right 
 pleura, the trachea, or the right auricle. 
 
 Aneurisms of the Transverse Portion of the Arch 
 OF THE Aorta. 
 
 These aneurisms are most frequently sacculated. 
 The larger number are given off from the posterior wall 
 of the aorta ; a smaller number from the anterior, or 
 upper wall. 
 
 Those given off from the posterior wall soon com- 
 press the trachea or bronchi, the oesophagus, and the 
 recurrent laryngeal nerve. The patients very soon have 
 dyspnoea, cough, stridor, paralysis of one of'the vocal 
 chords, tubular breathing over one or both lungs. But 
 the physical signs of the tumor are absent or obscure 
 until it reaches a large size. These aneurisms are apt 
 to rupture into a bronchus, the trachea, or the oesopha- 
 gus. 
 
 The aneurisms given off from the anterior and upper 
 wall soon give the physical signs of a tumor ; they 
 make a difference in the pulsation of the carotid and 
 radial arteries. They must attain some size before 
 they exert much pressure. 
 
 Aneurisms of both the Ascending and Transverse 
 Portions of the Arch of the Aorta. 
 These are very often fusiform aneurisms. The physi- 
 cal signs of the tumor are soon evident. The pressure 
 is on the anterior wall of the chest, the large vessels, the 
 
6 ANEURISM OF THE AORTA. 
 
 bronchi or trachea, the recurrent laryngeal nerve, and 
 the oesophagus. 
 
 Aneurisms of the Descending Portion of the Arch 
 OF the Aorta. 
 
 These aneurisms are most frequently sacculated. 
 They are given off from the posterior and left wall of 
 the aorta. The vertebrse are eroded in 42 per cent, of 
 the cases. The aneurism may compress the left bron- 
 chus, the oesophagus, the left lung, the trachea, the right 
 lung, or the ribs in front. 
 
 The principal symptoms are the pain from the erosion 
 of the vertebrse, and the cough and dyspnoea from the 
 pressure on the bronchi, the trachea, and the lungs. 
 
 Aneurisms of the Thoracic Aorta. 
 
 These are sacculated or fusiform in the proportion of 
 thirty-five to twenty-eight. 
 
 They are given off from the posterior wall of the 
 aorta. Most of them erode the vertebras. They may 
 compress the oesophagus and the left lung, and may form 
 a tumor in the back. 
 
 The most marked symptom is the pain due to the 
 erosion of the vertebrae. 
 
 Aneurisms of the Abdominal Aorta. 
 
 These are usually sacculated. The larger number are 
 situated near the coeliac axis. They are given off with 
 about equal frequency from the anterior and the pos- 
 terior walls of the aorta. 
 
ANEURISM OF THE AORTA. 7 
 
 Those on the posterior wall very early erode the ver- 
 tebrse. 
 
 The anterior aneurisms give pain referred to the epi- 
 gastrium and the anterior portion of the abdomen. The 
 tumor is easily made out by palpation. 
 
 The posterior aneurisms give pain referred to the ver- 
 tebrae, and radiating downward. The tumor is often 
 obscure. 
 
 These aneurisms rupture into the peritoneal cavity, 
 behind the peritoneum, into the mesentery, and into the 
 right or left pleural cavity. 
 
 There may be incomplete or complete obstruction of 
 the aorta by thrombi extending from the aneurisnial sac. 
 
 Treatment. — The medical treatment of aneurism of 
 the aorta consists in determining for each patient, ex- 
 perimentally, whether he is better for rest, or for regu- 
 lated exercise ; and in the administration of the iodide 
 of potash. The iodide is given in doses of from five to 
 twenty grains, three or four times a day. In favorable 
 cases the aneurism is diminished in size, the symptoms 
 are alleviated, and life is prolonged. 
 
THE CESOPHAGUS. 
 
 Stenosis. 
 
 1. Congenital stenosis of the oesophagus is rare. It 
 is most frequently seen in children, who die early. Ex- 
 ceptionally, the patients survive to adult life, but with 
 constantly increasing difficulty in swallowing. 
 
 2. Stenosis by compression is due to the pressure of 
 aneurisms, of tumors of the thyroid, and of tumors of the 
 neck and the thorax. The only symptom is incomplete 
 difficulty in swallowing. 
 
 3. Stenosis from tumors of the posterior wall of the 
 pharynx, either polypoid or diffuse. 
 
 4. Cicatricial stenosis from the contraction following 
 the lesions inflicted by irritant poisons. These require 
 surgical treatment. 
 
 5. Stenosis due to syphilitic inflammation of the wall 
 of the oesophagus. 
 
 6. Carcinoma of the oesophagus. 
 
 The new growth, of flat-celled epithelial type, begins 
 at some part of the wall of the oesophagus, and soon sur- 
 rounds it. There are masses of new growth, and deep 
 ulcers ; either may be the predominant feature. The 
 new growth involves only one or two inches of the 
 oesophagus, or a much larger portion. The lower half 
 of the oesophagus is the portion most frequently in- 
 
THE CESOPHAGUS. 9 
 
 volved. The growth may remain confined to the wall 
 of the cesophagus, or may extend to the trachea, bronchi, 
 lungs, pleura, pericardium, and vertebrae. Metastatic 
 tumors may be formed in the lymphatic glands, lungs, 
 and liver. A cancer of the stomach may be developed 
 at the same time with a cancer of the cesophagus. 
 
 The disease occurs most frequently in males over forty 
 years of age. 
 
 The first symptom is difficulty in swallowing. This 
 begins with difficulty in swallowing large pieces of solid 
 food, then smaller pieces cannot be swallowed, and, 
 finally, not even liquids. The progress of the dysphagia 
 is gradual, and often intermittent. 
 
 The next symptom is pain, referred to the upper end 
 of the sternum. 
 
 It is not until the tumor has existed for some time, 
 and the difficulty in swallowing is considerable, that there 
 is much change in the nutrition of the patients. But 
 after they have once begun to emaciate they get worse 
 very rapidly. 
 
 Life may be prolonged for a few weeks by passing 
 tubes through the oesophagus into the stomach, and by 
 the use of rectal alimentation. 
 
 7. Spasmodic stricture occurs in young and old per- 
 sons, in both males and females. There is sometimes a 
 history of hysteria, sometimes one of sudden choking. 
 
 The one symptom is difficulty in swallowing, some- 
 times attended with pain. 
 
 The dysphagia may be complete, or partial. It occurs 
 in attacks which last for minutes, days, weeks, or months ; 
 and which are repeated at short or long intervals. 
 
lO THE OESOPHAGUS. 
 
 The best treatment is the passage of large tubes 
 through the oesophagus, at regular intervals. 
 
 Dilatation. 
 
 1. Fusiform dilatations of the oesophagus are secondary 
 to stenosis, or occur without discoverable cause. They 
 involve a part, or the entire length, of the oesophagus. 
 The wall of the dilated oesophagus is often thickened. 
 
 The symptoms are difficulty in swallowing, vomiting, 
 regurgitation of food, and rumination. 
 
 The treatment consists in the dilatation of the stenosis 
 and the feeding the patients with the stomach-tube. 
 
 2. Sacculated dilatations are of two kinds. 
 
 (a) Small sacs are formed in the lower part of the 
 posterior wall of the pharynx, which afterward become 
 larger. 
 
 They are more common in males than in females, and 
 belong to adult life. 
 
 How it is that these sacs begin to be formed, is not 
 well understood. But as soon as they have reached 
 such a size that the food can enter and remain in them, 
 they rapidly enlarge behind the oesophagus and com- 
 press it. 
 
 There is difficulty in swallowing, at first slight, but in- 
 creasing with the pressure of the sac on the oesopha- 
 gus. 
 
 There is regurgitation of the food from the sac, rumin- 
 ation, and vomiting. There may be a tumor in the neck 
 which can be emptied by pressure. 
 
 The only treatment which has thus far been employed 
 is to feed the patients with the stomach-tube. 
 
THE OESOPHAGUS. II 
 
 (6) Small sacs are given off from the anterior wall 
 of the oesophagus, at about its middle. They seem to 
 be due to an inflammation of the bronchial glands, an 
 extension of this inflammation to the wall of the oesoph- 
 agus, and traction. 
 
 These sacs give no oesophageal symptoms, but they 
 may perforate and so give rise to inflammatory pro- 
 cesses in the mediastinum. 
 
THE STOMACH. 
 
 Digestion is effected by the stomach, the intestines, 
 the liver, and the pancreas. 
 
 The stomach receives the food, it keeps it in motion, 
 it digests certain portions of it, and after a certain time 
 it expels all of it, digested and undigested, into the in- 
 testine. 
 
 Gastric digestion is effected by the gastric juice, which 
 changes albumen, gluten, fibrine, caseine, and gelatine 
 into peptones. The starches, sugars, and fats are di- 
 gested in the intestine. 
 
 To assist the action of the gastric juice the muscular 
 coat of the stomach must move the food, and at the 
 proper time must empty the stomach. 
 
 Gastric Dvspepsia. 
 
 This name is ordinarily used to designate disturbances 
 of the digestive function of the stomach, and abnormal 
 sensations referred to that organ. 
 
 Causes. — i. Food. The introduction into the stom- 
 ach of food in such quantity and of such quality that it 
 cannot be digested causes such food to act as an irritant. 
 
 We find that the distention of the stomach with food 
 may stop gastric digestion altogether, and the patient 
 will only be relieved by vomiting. 
 
 We find also that the habitual presence in the stomach 
 
THE STOMACH. 1 3 
 
 of undigested food may produce catarrhal gastritis and 
 dilatation of the stomach. The passage of the same un- 
 digested food into the intestine causes trouble there. 
 
 2. Abnormal gastric juice. The normal production 
 of gastric juice may be interfered with by a variety of 
 mental and nervous influences, by impaired health, by 
 old age, and by diseases of the mucous membrane. 
 
 3. Diseases of the mucous membrane of the stomach 
 — inflammation, degeneration, ulcers, and new growths. 
 
 4. Changes in the muscular coat of the stomach 
 which interfere with the movement and expulsion of the 
 food, and permit of dilatation. 
 
 5. Climate and mode of life. 
 
 Symptoms. — The appetite may be diminished, there 
 may be aversion to food ; the appetite may be unnaturally 
 increased, or it may be perverted. 
 
 Pain is referred to the epigastrium, the left hypochon- 
 drium, the praecordium, the sternum, or the left shoulder- 
 blade. The pain may be continuous, or may come on 
 in attacks. 
 
 Instead of the pains there may be feelings of oppres- 
 sion, of emptiness, of burning, of gnawing, etc. 
 
 All these abnormal sensations may occur when the 
 stomach is full, or when it is empty. They are not in 
 any proportion to the actual disturbance of digestion. 
 
 Nausea is a common symptom. It is felt in the early 
 morning, at the sight of food, or after eating. 
 
 There may be vomiting of food, of mucus, of serum, 
 or of blood. Large quantities of food, which the stom- 
 ach refuses to digest, are regularly vomited. Inflamma- 
 tion and congestion of the mucous membrane, an undue 
 
14 THE STOMACH. 
 
 production of mucus and serum, the retention of food in 
 the stomach, stenosis of the pylorus, ulcers, and new 
 growths, are all causes of vomiting. Vomiting may also 
 be due to causes remote from the stomach — constipa- 
 tion, uterine disease, or anaemia. 
 
 The name of " water brash " is given to the eructation 
 of sour fluid from an empty stomach. 
 
 Flatulence is rather an intestinal than a gastric symp- 
 tom. But one of its causes is the passage into the in- 
 testine of portions of food which ought to have been di- 
 gested in the stomach. 
 
 Constipation seems, in some persons, to be entirely 
 due to disorders of the stomach. 
 
 Headache, facial neuralgia, fulness of the head, ver- 
 tigo ; pains over the heart, lungs, and abdomen ; feel- 
 ings of palpitation, oppression, and dyspncea occur in 
 persons who, besides their gastric dyspepsia, also suffer 
 from disturbances of the functions of the liver and in- 
 testine. 
 
 Acute Catarrhai, Gastritis. 
 
 Lesions. — There is an acute catarrhal inflammation 
 of the mucous membrane of the stomach, with congestion 
 and an increased production of mucus. The inflamma- 
 tion may involve only the pyloric end of the stomach, 
 or the entire mucous membrane. 
 
 Causes. — The disease occurs at all ages ; it is more 
 common in summer than in winter. It may be due to 
 improper food, or to alcohol. 
 
 Symptoms. — The prominent symptoms are pain, vom- 
 iting, a febrile movement, prostration, and constipation. 
 
 In infants the vomiting is incessant, the rise of tem- 
 
THE STOMACH. IS 
 
 perature often well marked, the prostration considerable. 
 The gastritis may be followed by diarrhoea. 
 
 If the attack occurs in hot weather, attention should 
 be given to keeping the child as cool as possible. The 
 food should consist of cream and water, of koumyss, of 
 beef juice, or of scraped meat. For drugs, calomel, oxalate 
 of cerium, and bicarbonate of soda are the most useful. 
 
 In older children the symptoms may be the same as 
 in infants. Or the child may complain of general ma- 
 laise, headache, loss of appetite, nausea, constipation, 
 and a constant pain in the abdomen. Vomiting is not 
 a prominent symptom. Fever is present or absent. 
 The patients lose flesh and strength. The attacks last 
 for about a week, and may be followed by jaundice. 
 
 The patients should be fed with small quantities of cream 
 and water, with milk, koumyss, beef juice, or scraped beef. 
 
 Calomel, oxalate of cerium, bicarbonate of soda, and 
 opium may be of service. In some cases there is an ad- 
 vantage in using ice-water enemata. 
 
 In adults, the most common form of the disease is 
 that in which incessant vomiting, prostration, and con- 
 stipation are the prominent symptoms. For these 
 patients small hypodermics of morphine are perhaps the 
 most efficient remedy. In some of these cases there is 
 added a febrile movement ; in some the prostration and 
 feeble heart action are so extreme that stimulants are 
 required. 
 
 In other adults the disease follows the type of that 
 seen in children, without much vomiting, but lasting for 
 a longer time. In these patients ice-water enemata are 
 of service. 
 
l6 THE STOMACH. 
 
 Chronic Catarrhal Gastritis. 
 
 Lesions. — In many cases the only evidence of the in- 
 flammation is the production of an increased quantity of 
 mucus, which coats the inner surface of the stomach. In 
 other cases there is added a degeneration of the cells of 
 the peptic glands. In still others there is a growth of 
 connective tissue between the gastric tubules, with 
 atrophy of the tubules. Or there may be hypertrophy 
 of the connective tissue and muscular coats of the stomach, 
 with stenosis of the pylorus. The inflamed stomach may 
 remain of its natural size, or be contracted, or dilated. 
 
 When we say that a patient has chronic catarrhal 
 gastritis, therefore, we mean either : 
 
 That the mucous glands are constantly producing too 
 much mucus. 
 
 Or, that, in addition, the function of the peptic glands 
 is disturbed. 
 
 Or, that the structure of the mucous membrane is so 
 impaired by disease that gastric digestion is seriously 
 interfered with. 
 
 Or, that, from stenosis of the pylorus, or relaxation of 
 the muscular coat, food is retained in the stomach. 
 
 Or, that the stomach is dilated, or contracted. 
 
 Causes. — Cardiac disease, pulmonary emphysema, and 
 cirrhosis of the liver produce, first, chronic congestion, 
 and then chronic gastritis. Chronic Bright's disease, 
 phthisis, gout, rheumatism, and chronic alcoholism, are 
 often attended with gastritis. Climate and mode of life 
 seem to be important factors in the production of the 
 disease. The infectious diseases, especially typhoid 
 fever, may be followed by chronic gastritis. 
 
THE STOMACH. 1 7 
 
 The Symptoms are : Pain or a feeling of discomfort in 
 the stomach while gastric digestion is going on. Attacks 
 of pain, often relieved by vomiting, due to the presence 
 in the stomach of portions of food which irritate it. The 
 peculiar feeling called " heart-burn." Attacks of neural- 
 gic pain for which it is difficult to account. 
 
 Nausea, early in the morning or nearly constant. Ex- 
 cept for the nausea, the appetite is apt to be fairly good. 
 
 Vomiting of food : To remove the portions of food 
 which irritate the stomach ; of large quantities of brown- 
 ish fluid ; of small quantities of pure mucus ; of food 
 which has not been able to escape through the p) lorus ; 
 of small quantities of very acid fluid ; of blood. 
 
 Retention of food in the stomach, with or without di- 
 latation of the stomach, or stenosis of the pylorus. 
 
 Constipation, or diarrhoea. Headache in attacks. 
 Loss of flesh and of strength, anaemia, catarrhal pharyn- 
 gitis, swelling of the tongue, abnormal sensations re- 
 ferred to the mouth, throat, and tongue. 
 
 With many cases of chronic gastritis there are also 
 developed disturbances of the functions of the liver and 
 of the intestines. 
 
 The course of the disease is prolonged, with exacerba- 
 tions and intermissions. The symptoms, therefore, are 
 not continuous, but come on in attacks. As the disease 
 progresses these attacks become more frequent, more 
 severe, and of longer duration. 
 
 In some patients the disease never becomes more than 
 an annoyance. In some the loss of flesh and strength 
 and the ansemia are so pronounced, that the patient is 
 unable to work. The addition of disturbance of the 
 
1 8 THE STOMACH. 
 
 functions of the liver to the gastritis are often attended 
 with distressing nervous and mental phenomena. The 
 pain may be so severe and continuous that the patient's 
 life is rendered miserable. 
 
 Treatment. — The mild cases of chronic gastritis are to 
 be treated by regulating the diet and the mode of life. 
 They should take three regular meals a day, composed 
 of meat, vegetables, fruit, and bread; no pepsine, no 
 peptonoids, no health foods. They should give up the 
 use of tobacco, tea, and liquor. They should have every 
 day an hour during which they take exercise sufficiently 
 active to produce a thorough perspiration. 
 
 The more severe cases are best treated by the use of 
 the stomach-tube, and the washing out of the stomach 
 with hot water. The washing the stomach is done at 
 first once a day, then every other day, and then at longer 
 intervals. The patient at first only takes one solid meal 
 a day of meat, bread, and water ; during the rest of the 
 twenty-four hours he takes only milk. After he has 
 begun to improve, other articles of food are added, until 
 he takes three ordinary meals a day. 
 
 If it is not possible to use the stomach-tube, the treat- 
 ment of these cases is much less satisfactory. They can 
 be improved for a time, but not cured. It is necessary 
 for weeks or months to put them on an exclusive diet, 
 either milk alone, or beef and hot water alone. The 
 bowels must be kept open with laxatives or enemata. 
 There may be an advantage in giving alkalies, or the 
 mineral acids, bismuth, iodoform,[carbolic acid, etc 
 
THE STOMACH. 19 
 
 Suppurative Gastritis. 
 
 Lesions. — There is a suppurative inflammation begin- 
 ning in the connective-tissue coat of the stomach, and 
 extending to the other coats. This inflammation may 
 be circumscribed, with the formation of an abscess ; or 
 diffuse, with a purulent infiltration of the entire connec- 
 tive-tissue coat. The abscesses may rupture into the 
 cavity of the stomach. The inflammation of the peri- 
 toneal coat may give rise to a general peritonitis. 
 
 Causes. — The disease belongs to adult life. It is 
 more common in males than in females. There is, in 
 some cases a history of the over-eating of indigestible 
 food. 
 
 Symptoms. — The formation of the abscesses in the 
 wall of the stomach is attended with pain in the epigas- 
 tric region, vomiting, a febrile movement, and the forma- 
 tion of a tumor. If the abscess ruptures into the stom- 
 ach, the pus may be vomited. The peritonitis often 
 remains localized. The disease may run an acute or a 
 chronic course. 
 
 The diffuse suppurative inflammation of the wall of 
 the stomach runs an acute course, terminating fatally in 
 from three to eighteen days. The patient is suddenly 
 attacked with vomiting, pain, and tenderness over the 
 stomach, fever, and great prostration. The symptoms 
 of general peritonitis are soon added, and the patients 
 rapidly get worse. 
 
 Treatment. — The best that we can do seems to be to 
 alleviate the patient's symptoms by the liberal use of 
 opium. 
 
20 THE STOMACH. 
 
 Ulcer of the Stomach. 
 
 Lesions. — Ulcers of the stomach are usually single, 
 but two or more ulcers may be formed at the same time, 
 or successively. 
 
 Welch, from a collection of 793 cases, gives the posi- 
 tion of such ulcers as follows : 
 
 On the lesser curvature, 288. 
 
 On the posterior wall, 235. 
 
 At the pylorus, 95. 
 
 On the anterior wall, 69. 
 
 At the oesophageal end, 50. 
 
 At the fundus, 29. 
 
 On the greater curvature, 2 7. 
 
 The ordinary diameter of these ulcers is from half an 
 inch to two inches, but some are very small, and some 
 are much larger. Two or more ulcers may become 
 joined, and so form a large ulcerated area. 
 
 The ulcers are round or oval, largest in the glandular 
 coat. They may destroy only the glandular coat, or the 
 entire thickness of the wall of the stomach. The edges 
 of the ulcers are clean-cut, and their floors smooth ; but 
 sometimes the edges are much thickened, and the floor 
 may be formed by tissues which have become adherent. 
 The edges and the floor are formed of amorphous gran- 
 ular matter, or of connective tissue. 
 
 If the patients recover, the ulcers cicatrize either with 
 or without deformity of the stomach. 
 
 If the ulcers perforate the wall of the stomach, this 
 perforation may be large and sudden, with the escape of 
 the contents of the stomach into the abdominal cavity ; 
 or the^perforation may be small, and set up a localized 
 
THE STOMACH. 21 
 
 peritonitis ; or the opening may be entirely closed by 
 adhesions. 
 
 The ulcer may erode either the arteries or the veins of 
 the stomach. With an ulcer there is usually more or less 
 chronic gastritis. 
 
 Causes. — These ulcers are said to be twice as com- 
 mon in women as in men. They have been observed 
 at nearly every age, but seven-tenths of them are in 
 people between twenty and forty years of age. 
 
 The ordinary explanation of the way in which these 
 ulcers are formed is, that by embolism, thrombosis, or 
 chronic endarteritis, one of the branches of the gastric 
 artery is occluded. The corresponding portion of the 
 wall of the stomach dies, and is destroyed by the action 
 of the gastric juice. 
 
 Symptoms. — Pain is often present, continuous but wiih 
 exacerbations, increased by food in the stomach, by mo- 
 tion, or by pressure ; referred to the epigastrium, to the 
 left hypochondrium, to points lower down in the abdo- 
 men, or to the back. 
 
 Vomiting is very common, but varies as to its fre- 
 quency. 
 
 Blood is vomited in one-fourth of the cases. It is 
 vomited in the form of coffee-ground matter, or of small 
 clots, or in large quantities. The patients may bleed to 
 death in a short time. 
 
 According to the extent of the chronic gastritis, there 
 are symptoms of gastric indigestion. 
 
 The Course of the Disease. — There may be no symp- 
 toms during life, and the ulcer, or its cicatrix, is found 
 after death from some other disease. 
 
22 THE STOMACH. 
 
 There are cases which last for weeks, months, or years. 
 The symptoms are marked, but more or less severe. 
 Some of the patients recover, others die of starvation. 
 
 There are cases in which one or more large hemor- 
 rhages form the prominent, and sometimes the only, 
 symptom. 
 
 There are cases in which the large or small perforation 
 of the wall of the stomach forms the prominent feature. 
 
 There are cases in which the deformity of the stomach, 
 produced by the cicatrization of the ulcer, gives symp- 
 toms for the rest of the patient's life. 
 
 Treatment. — The first point is to determine whether 
 the patients can be fed by the stomach or by the rectum. 
 If they can be fed by the stomach, milk, peptonized 
 milk, cream, beef juice, scraped beef, and koumyss are 
 usually the best articles. If they have to be fed by the 
 rectum, peptonized milk, cream, the yolks of eggs, blood, 
 and beef juice with a little brandy and opium added, 
 answsr very well. 
 
 For drugs we employ the alkalies, bismuth, cocaine, 
 oxalate of cerium, nitrate of silver, iodoform, hydro- 
 cyanic acid, or opium. 
 
 For external applications we employ heat, cold, the 
 faradic current, and counter-irritation. 
 
 Cancer of the Stomach. 
 
 Lesions. — The new growth, beginning in the glandu- 
 lar coat, takes the form of flattened tumors which ulcer- 
 ate at their centres, or of polypoid tumors projecting 
 into the cavity of the stomach, or of flat, diffuse infil- 
 trations of the wall of the stomach. With any of these 
 
THE STOMACH. 23 
 
 forms there is regularly also more or less chronic gas- 
 tritis. 
 
 Most of the tumors are situated at the pyloric end of 
 the stomach, and may extend from there to the lesser 
 or greater curvature, the anterior or the posterior wall. 
 A smaller number of tumors are found at the oesophageal 
 end of the stomach, and may extend up and involve the 
 oesophagus. The pyloric tumors may occlude the py- 
 lorus and produce dilatation of the stomach. The peri- 
 toneal coat of the stomach may be inflamed and form 
 adhesions with the surrounding viscera. 
 
 Secondary tumors are most common in the liver, the 
 neighboring lymphatic glands, and the peritoneum ; but 
 they may be found in any part of the body. 
 
 Causes. — The disease is about equally common in 
 males and females. The maximum liability is between 
 the ages of sixty and seventy, but the disease is common 
 enough between the ages of forty and fifty, and even be- 
 tween the ages of twenty and thirty it is occasionally 
 met with. 
 
 Symptoms. — The appetite is poor. Nausea and vom- 
 iting are often present. The vomiting is of food, of 
 brownish or yellow fluid, of coffee-ground matter, or of 
 blood. 
 
 In some of the cases the vomiting is an early symptom, 
 and continues throughout the disease. In some cases 
 there is no vomiting till late in the disease. Or the 
 vomiting may accompany the early stages of the disease 
 and afterward stop. Or there may be no vomiting at all. 
 
 Pain referred to the stomach is a frequent, but by no 
 means a constant, symptom. 
 
24 THE STOMACH. 
 
 A tumor is the most characteristic symptom of the 
 disease. The ease with which it can be felt depends 
 upon its position, its size, and its mobility. It is not 
 until the tumor can be felt that the diagnosis is certain. 
 
 It is not uncommon for a patient to have chronic gas- 
 tritis for some years before the development of the can- 
 cer. When this is the case the symptoms of the two 
 diseases are of the same kind and are continuous. 
 
 In the later stages of the disease there may be a mod- 
 erate rise of temperature. 
 
 The bowels are usually constipated, but there may be 
 diarrhoea. 
 
 Not infrequently the patients are jaundiced. Sooner 
 or later the patients lose flesh and strength, become 
 anaemic and cachectic, and may have some oedema of 
 the legs. 
 
 The ordinary duration of the disease is about one 
 year, but some cases go on for two, or even three, years. 
 
 The Diagnosis is often difficult. The symptoms are 
 much the same as those of chronic gastritis and of ulcer 
 of the stomach. The presence of a tumor is the only 
 positive diagnostic sign. 
 
 The Treatment consists in the regulation of the pa- 
 tient's diet, and the use of opium to alleviate pain. The 
 removal of the tumor by operation, although it has 
 been dane many times, is not yet fairly established as a 
 therapeutic measure. ' 
 
THE INTESTINES. 
 
 The small intestine is sometimes the seat of a catarrhal 
 inflammation which may be of mild or of severe type. 
 
 Such an inflammation is especially common in young 
 adults, some of whom seem to have a predisposition for 
 the disease. In some cases there is a history of indi- 
 gestible food, or of exposure to the weather ; in other 
 cases no exciting cause can be discovered. 
 
 Symptoms. — The patients have marked and constant 
 pain and tenderness referred to the lower part of the 
 abdomen. There is a rapid rise of temperature from 
 ioo° to 104° F. There is marked prostration from the 
 first, the patients being at once confined to bed. There 
 may be vomiting, the bowels are constipated. The in- 
 vasion of the disease is sudden, the patients often seem 
 seriously ill, but yet they regularly recover. The fever 
 subsides first, then the pain, and in one or two weeks 
 the patients are well. Sometimes, however, the pain 
 persists for a longer time after the subsidence of the 
 other symptoms. 
 
 Diagnosis. — The disease may be mistaken for inflam- 
 mation of the vermiform appendix, or for peritonitis. 
 
 Treatment. — The patients are to be kept in bed ; 
 at first on a fluid diet ; when the fever has subsided, on 
 meat principally. Continuous heat or cold should be 
 
2 THE INTESTINES. 
 
 applied over the abdomen. At first, morphine and 
 calomel together are given in small doses, later bella- 
 donna and ipecac. The bowels are to be moved every 
 day by enemata. 
 
 Cholera Morbus. 
 
 This name is given to an acute catarrhal inflammation 
 of the gastro-intestinal tract, probably associated with the 
 growth of pathogenic bacteria. 
 
 J^esions. — After death the mucous membrane of the 
 stomach and intestines is found coated with mucus, 
 congested, sometimes with little abscesses in the gland- 
 ular coat. 
 
 Causes. — The disease is especially common in the hot 
 weather of Aijgust and September. As exciting causes 
 improper food and contaminated water are probable. 
 
 Symptoms.^Tht attacks are apt to come on in the 
 night. There is first a feeling of abdominal oppression 
 and of prostration. Then the patients empty the 
 stomach of food and the intestines of fseces. After this 
 there is frequent vomiting and purging of white or 
 brownish fluid. There may be colicky abdominal pains, 
 and painful contractions of the muscles of the abdomen 
 and of the legs. The patients are anxious, restless, 
 much prostrated, tormented by thirst, the skin cold, the 
 body soon emaciated, the heart's action rapid and 
 feeble. The patients often seem seriously ill, but yet as 
 a rule recover. Occasionally, however, the disease 
 proves fatal, especially in old or feeble persons. 
 
 Treatment. — The patients are to be kept in bed, hot 
 fomentations are to be applied over the abdomen, and 
 opium and stimulants are to be given according to the 
 
THE INTESTINES. 3 
 
 indications of each case. The food should be in small 
 quantities — koumyss, beef-juice, milk, or cream and 
 water. 
 
 Cholera Infantum. 
 
 This name is given to a disease of young children 
 which resembles cholera morbus, and is probably due to 
 the growth in the intestines of pathogenic bacteria. 
 
 Lesions. — After death the intestines contain white or 
 brownish fluid. The mucous membrane is pale, the sol- 
 itary and agminated glands are sometimes swollen, some- 
 times ulcerated. 
 
 Causes. — The disease belongs to children under two 
 years of age. It is most apt to_ attack those who, from 
 bad food, bad air, or heat, have their intestinal tract 
 already in an unhealthy condition. 
 
 Symptoms. — The disease may follow an ordinary diar- 
 rhoea, or begins suddenly with purging, vomiting, and 
 prostration. Vomiting is usually, but not always, pres- 
 ent, and varies as to its frequency and persistence. 
 Purging is constant and frequent. The movements are 
 at first fecal, afterward of white or brownish fluid. The 
 patients rapidly lose fl£sh and strength, the heart's action 
 is rapid and feeble, there is constant thirst, the skin is 
 cold, the urine is diminished. The patients are, always 
 jestless and miserable, some of them have muscular 
 twitchings, general convulsions, alternating delirium and 
 stupor. 
 
 The disease may not last for more than twenty-four 
 hours, or it may continue for several weeks. -It is always 
 serious, and often fatal. 
 
 Treatment. — The children are to be fed with small 
 quantities of koumyss, cream and water, wine whey. 
 
4 THE INTESTINES. 
 
 beef-juice, or milk and barley-water. In the pl'olonged 
 cases oil may be rubbed into the skin. The children 
 should be kept as cool as possible, and sent to a differ- 
 ent climate from' that in which they have been taken 
 sick. Of drugs the most reliable seem to be combina- 
 tions of mercury, alkalies, and opium in small doses. 
 Stimulants may be necessary. 
 
 Constipation. 
 
 In the healthy adult there should be a movement from 
 the bowels once in each twenty-four hours. The faeces 
 should be formed, of natural consistence and color. In 
 some individuals the regular interval is shorter, in some 
 it is rather longer, the character of the faeces remaining 
 normal. If the bowels cease to move regularly, and the 
 fecal matters accumulate in the colon, the patient be- 
 comes liable to a variety of disorders. 
 
 In the treatment of constipation it is important to de- 
 termine its cause and then to manage it, principally by 
 attention to the diet and mode of life. 
 
 In some persons constipation is merely due to the 
 habit of only going to the water-closet when they feel 
 the impulse to defecate, whether it is once a day or once 
 a week. In many of these patients the temporary use 
 of a simple laxative or of a glycerine enema, with the en- 
 forcement of a regular daily hour for defecation, is all 
 that is necessary. 
 
 In some patients the constipation is due to chronic 
 gastritis. If the gastritis is improved by treatment the 
 constipation will disappear. 
 
 The constipation may be due to an insufficient pro- 
 duction of bile. Then we must at first use the drugs 
 
THE INTESTINES. 5 
 
 which increase the formation of bile — ipecac, podophyl- 
 lin, bichloride of mercury, sulphate of magnesia, the al- 
 kalies, or the mineral acids. Later the patient must take 
 sufficient exercise and gradually give up the use of the 
 drugs. 
 
 The constipation may be due to general bad health or 
 anaemia, and the treatment has to be directed principally 
 to the relief of these conditions. 
 
 Improper food and drink may be the cause of the con- 
 stipation. The patients require fruits, vegetables, and 
 starches in considerable quantities. They must take 
 sufficient water, or one of the alkaline waters, coffee, or 
 beer. 
 
 The most difficult cases to manage are those in which 
 the sensibility of the mucous coat of the colon is dimin- 
 ished and its muscular coat relaxed. In these patients 
 we apply massage and electricity to the abdomen, en- 
 force proper exercise and diet, and give strychnia, aloes, 
 and belladonna. 
 
 Rktention and Impaction of F^ces. 
 
 1. In old persons there may be a large accumulation 
 of hard, fecal matter in the rectum. The patients com- 
 plain of constipation or diarrhoea. They lose strength 
 and flesh ; if not relieved, they die, apparently from fecal 
 poisoning. In order to empty the rectum it is necessary 
 first to break up and dislodge the fecal mass with the 
 finger or some instrument, then to use repeated ene- 
 mata, and then colocynth, aloes, and strychnia. 
 
 2. In adults there may be an accumulation of fecal 
 matter in the colon at some point above the rectum. 
 This may only be attended with constipation, colicky 
 
6 THE INTESTINES. 
 
 pains, flatulence, and a tumor ; or there may be also 
 localized pain and tenderness, fever and prostration. 
 
 By the use of calomel, castor-oil, and large enemata 
 these fecal masses can be removed. 
 
 3. There are rare and obscure cases in which the pa- 
 tients have diarrhoea, lose flesh and strength, and die. 
 After death no lesion is found, except the distention of 
 the entire colon with fecal matter. 
 
 DiARRHCEA. 
 
 A person is said to have diarrhoea if he has every day 
 several loose, fecal evacuations without tenesmus. 
 
 Causes. — Extremes of heat and cold, decided emo- 
 tions, such as fear, and a variety of nervous influences 
 can produce a temporary diarrhoea. 
 
 Some of the fruits and vegetables, especially if they 
 are unripe or partly decayed, or any undigested portion 
 of food, act as irritants to the intestine and produce di- 
 arrhoea. 
 
 Any inflammation or new growth of the colon is liable 
 to produce diarrhoea. 
 
 Children are especially liable to diarrhoea. 
 
 The milder forms of diarrhoea in adults require but 
 little treatment. Rest, a restricted diet, a laxative, a 
 little opium are sufficient. 
 
 There is a peculiar form of diarrhoea in adults, which 
 behaves as if it were caused by a subacute catarrhal 
 colitis, which often lasts for years, and which is difficult 
 to manage. The patients have nearly every morning 
 several large fluid passages, and then during the day no 
 further trouble. Or, similar diarrhceal passages may be 
 repeated after each meal ; or, in addition, the patients 
 
THE INTESTINES. 7 
 
 have a good deal of abdominal pain. . In the mild cases 
 the general health hardly suffers ; in the severe cases 
 there is decided loss of flesh and strength. The disease 
 continues for years, and comes back repeatedly after 
 ceasing for a time. 
 
 An exclusive diet of milk, or of meat and hot water ; 
 change of climate ; cold water enemata ; castor-oil, 
 arsenic, iron, quinine, salicylic acid, are among our most 
 efficient methods of treatment. 
 
 Infantile Diarrhcea. 
 
 Diarrhoea is a common disorder of infants and of young 
 children. It is especially common during the period of , 
 dentition, in hot weather, and in bottle-fed children. 
 
 The diarrhcea may follow an acute gastritis, an acute 
 colitis, or begin of itself. The children have every day 
 a number of loose, bad-smelling, green, or light-colored 
 fecal passages. There may be a febrile movement, es- 
 pecially in the afternoon. The patients gradually lose 
 flesh and strength. Such a diarrhcea may last, for days, 
 weeks, or months. 
 
 Treatment. — If the children have a good nurse they 
 continue to nurse. If not, they are fed on cream arid 
 water, milk diluted with a thin gruel, or koumyss. 
 Older children can take beef-juice and scraped meat. 
 For medicines opium, castor-oil, calomel, sulphate of 
 magnesia, and rhubarb are the most efficient. If the 
 disease continues care must be taken that the child gets 
 enough food. Small doses of opium, castor-oil, ipecac, 
 podophyllin, bismuth, and bichloride of mercury are of 
 service. 
 
 Occasionally we see cases in which there is first an 
 
8 THE INTESTINES. 
 
 ordinary diarrhoea. Then the passages become white, 
 larger and larger, until the child passes three or four 
 times a day enormous quantities of white, pasty faeces. 
 The children are tormented by hunger and thirst, and 
 become very much emaciated. They should be removed 
 to as different a climate as possible from the one where 
 they were taken sick. The most efficient medicine 
 seems to be a combination of hydrochloric acid, arsenic, 
 and opium. 
 
 Intestinal Colic. 
 
 This name is given to attacks of pain due to spas- 
 . modic contraction of the muscular coat of the colon^ 
 
 Such attacks may be due to the presence in the intes- 
 tine of irritating pieces of food, or fecal matter. Or the 
 -attacks may come on without discoverable cause. 
 
 Symptoms. — The pain is apt to come on suddenly, its 
 severity varies, it may be referred to any part of the ab- 
 domen. The abdominal wall is retracted and hard, or 
 distended. There may be nausea and vomiting, the 
 bowels are constipated until the end of the attack. 
 During the attack the skin is cold, or bathed in perspi- 
 ration ; the temperature remains normal, or is raised. 
 
 The attacks vary as to their severity and duration. 
 Some of them are very alarming. 
 
 Treatment. — The obj ect of treatment is to relax the 
 muscular spasm ani to remove irritating substances 
 from the intestine. To relax the muscular spasm we 
 use hypodermic injections of morphine and belladonna, 
 hot fomentations over the abdomen, and hot water en- 
 emata. To remove the irritating substances we give 
 castor-oil. 
 
THE INTESTINES. 
 
 Chronic Intestinal Colic. 
 
 The patients have attacks of colic at first at long in- 
 tervals, then at shorter intervals, finally nearly every day. 
 With the pain there is more or less tenderness over the 
 colon. The patients after a time lose flesh and strength, 
 some of them acquire the opium habit. The disease 
 continues for years, steadily getting worse ; between the 
 attacks constipation and flatulence are often present. 
 
 Treatment. — The worst cases require for a time an 
 absolute diet of meat and hot water. In the less severe 
 cases it is sufficient to exclude milk, tea and coffee, beer, 
 soup, and most of the fruits and vegetables. The most 
 efficient drugs are ipecac and belladonna, given together 
 at regular intervals. Opium must be discarded alto- 
 gether. 
 
 Colitis. 
 
 The colon may be the seat of acute or chronic catarrhal, 
 croupous, or follicular inflammation. If the inflamma- 
 tion involves the rectum, and blood and mucus are passed, 
 the patients are said to have dysentery. Or if the dis- 
 ease has the characters of an infectious inflammation, 
 they are also said to have dysentery. 
 
 Causes. — Sporadic cases of colitis occur in all climates, 
 they are especially common in August, September, and 
 October. Contaminated water, food, and atmospheric 
 conditions seem to act as exciting causes. 
 
 In tropical countries the disease is endemic. It . may 
 occur as a local epidemic anywhere. In armies it is de- 
 veloped frequently. It often behaves as if it. were an 
 infectious inflammation due to pathogenic bacteria. 
 
lO THE INTESTINES. 
 
 Acute Catarrhal Colitis. 
 
 Lesions. — The mucous membrane is swollen, con- 
 gested, it may bleed, the mucous glands produce an in- 
 creased quantity of mucus. In severe cases there is an 
 emigration of white blood-cells which infiltrate the 
 mucous membrane and are mixed with the mucus. The 
 inflammation may involve the rectum alone, the rectum 
 and the lower part of the colon, or the upper part of the 
 colon alone. 
 
 Symptoms. — If the rectum is inflamed there may or 
 may not be first an ordinary diarrhoea. The inflamma- 
 tion of the rectum is accompanied by pain, an inclina- 
 tion to defecate, and the passage of small quantities of 
 blood and mucus. The patients feel moderately sick, 
 there is sometimes a rise of temperature. The inflam- 
 mation regularly runs its course within a week, and is 
 rarely fatal. 
 
 Treatment. — The patients are to be kept in bed and 
 fed with milk, gruel, beef-juice, and scraped meat. The 
 bowels are to be opened every other day by castor-oil 
 or sulphate of magnesia ; the pain is to be relieved by 
 opium. 
 
 If the upper part of the colon alone is inflamed, the 
 patients do not have the small, painful passages of 
 mucus and blood. The passages are large, fluid, and 
 partly fecal, sometimes with blood. There are colicky 
 pains in the abdomen, prostration, and a febrile move- 
 ment. In adults the disease usually lasts as long as two 
 weeks, in children even longer. In the longer cases 
 there is considerable loss of flesh and strength. 
 
 Treatment. — ^The patients are to be kept in bed, and 
 
THE INTESTINES. II 
 
 fed with beef-juice, scraped meat, and gruel ; milk is to 
 be avoided. The bowels are, at first, to be moved with 
 castor-oil or sulphate of magnesia. Later we give 
 small doses of castor-oil, sulphate of magnesia, ipecac, 
 belladonna, or opium. 
 
 Acute Croupous Colitis. 
 
 Lesions. — The mucous membrane is congested, swol- 
 len, infiltrated with fibrine and pus, and a layer of fibrine 
 and pus is formed on its free surface. There is superficial 
 or deep necrosis of the inflamed portions of the colon. 
 The inflammation is sometimes diffuse, more frequently 
 confined to anumber of small, circumscribed portions 
 of the mucous membrane. The inflammation may in- 
 volve the rectum alone,, the rectum with more or less of 
 the colon, or the upper and middle portions of the colon 
 without the rectum. After the inflammation has sub- 
 sided superficial or deep ulcers are left, according to the 
 extent of the necrosis. 
 
 This form of colitis is always severe and often fatal. 
 It behaves as do the infectious inflammations. 
 
 Symptoms. — The patients have numerous small, pain- 
 ful passages of blood and mucus. If the inflammation 
 extends above the rectum they also pass large quantities 
 of brownish fluid. There is nearly constant pain, irrita- 
 bility, and a desire to go to stool. There may also be 
 colicky pains, strangury, vomiting, and jaundice. There 
 is regularly a febrile movement, sometimes preceded by 
 chills, throughout the disease ; but in some of the bad 
 cases the temperature is low throughout. In the severe 
 cases the prostration is marked, the heart's action is 
 rapid and feeble, delirium, stupor, or convulsions are 
 
12 THE INTESTINES. 
 
 developed. The disease lasts for from one to four 
 weeks. 
 
 If the inflammation involves the upper portions of the 
 colon alone, the patients at first have a moderate diar- 
 rhoea. This diarrhoea continues, the patients lose appe- 
 tite, flesh, and strength, they have fever in the afternoon. 
 After one or two weeks they have one or more hemor- 
 rhages from the bowels. After this they have higher 
 temperatures and get worse much more rapidly. The 
 disease lasts for several weeks, and is very fatal. 
 
 Prognosis. — Croupous colitis is a very serious disease. 
 It is often fatal ; it is often followed by chronic colitis. 
 It is especially fatal in old persons, in young children, 
 in tropical countries, with epidemics, with inflammation 
 of the entire length of the^ colon. 
 
 Treatment. — The patients are to be kept in bed and 
 on a fluid diet ; they may require stimulants. Of med- 
 icines, the most efficient are castor-oil, sulphate of mag- 
 nesia, ipecac, and opium. The castor-oil and sulphate 
 of magnesia are given at long intervals and in full doses, 
 to empty the colon of faeces. They are given in small 
 doses, at short intervals, to lessen the colitis. The ipe- 
 cac is given once or twice a day, in doses of from ten to 
 twenty grains. The opium is given to relieve pain. 
 
 Follicular Colitis. 
 
 Lesions. — The lymphatic glands in the wall of the 
 colon are inflamed, swollen, softened. They slough and 
 leave small, round ulcers. Associated with these changes 
 there will be more or less catarrhal or croupous inflam- 
 mation of the mucous membrane between the ulcers. 
 
THE INTESTINES. 1 3 
 
 The inflammation is apt to involve a large number of 
 glands throughout the whole length of the colon. 
 
 Causes. — This form of colitis is especially common in 
 armies. 
 
 Symptoms. — The patients have small, painful passages 
 of blood and mucus, and large diarrhoea! passages. At 
 first there is fever, the passages continuej the patients 
 lose flesh and strength. The great danger of this form 
 of colitis is its persistence. 
 
 Treatment. — Change of climate, the regulation of the 
 diet, and the use of every means to improve the general 
 health, are indicated. 
 
 Chronic Catarrhal Colitis. 
 
 Lesions. — The mucous membrane alone, or all the 
 coats of the colon, are thickened. There may be little 
 polypoid growths on the surface of the mucous mem- 
 brane. There is an increased production of mucus. 
 Such an inflammation may involve the rectum alone, or 
 the colon also.- 
 
 Symptoms. — The patients pass mucus in small or large 
 quantities, blood, and loose fecal matter. There is of- 
 ten constipation. The patients steadily lose flesh and 
 strength. The natural tendency of the disease is to 
 continue, but with periods of improvement. 
 
 Treatment. — The patients do best in a dry inland cli- 
 mate. The food must be restricted, even an exclusive 
 milk diet may be necessary. The best medicines are 
 castor-oil in small doses, the mineral acids, and ipecac. 
 
14 THE INTESTINES. 
 
 Chronic Colitis with Ulckrs. 
 
 Lesions. — The ulcers are small or large, numerous or 
 few, close together or scattered, confined to the rectum 
 or extending up on the colon. The mucous membrane 
 between the ulcers is more or less changed by catarrhal 
 inflammation. The walls and floor of the ulcers are 
 formed of granulation tissue. 
 
 Causes. — *rhe ulcers are regularly formed during the 
 course of an acute croupous or follicular colitis. 
 
 Symptoms. — The patients have frequent passages of 
 blood, of mucus, or of fecal matter. They steadily lose 
 flesh and strength. 
 
 Treatment. — The patients are to be managed in the 
 same way as those who suffer from chronic catarrhal 
 colitis. But if the ulcers are situated low down in the 
 rectum, there is also ari advantage in the use of local ap- 
 plications to the ulcers. These applications may be made 
 by suppositories, or by enemata, or the patient is ether- 
 ized and the ulcers brought into view with the speculum. 
 
 Membranous Enteritis. 
 
 This is a chronic catarrhal colitis attended with a large 
 production of very tenacious mucus, which comes away 
 with the stools in the form of masses, cords, or tubes 
 looking like membranes. 
 
 Causes. — The disease belongs to middle life, apd is 
 more common in women than in men. 
 
 Symptoms. — So far as the colon is concerned, the symp- 
 toms are : constipation, sometimes diarrhoea, flatulence 
 with its attendant pains, and the passage at varying in- 
 tervals of the so-called membranes already mentioned. 
 
THE INTESTINES. 15 
 
 But with these symptoms are usually associated com- 
 plicating conditions which are often more distressing 
 than the intestinal symptoms. There may be gastric 
 dyspepsia, functional disorders of the liver, diseases of 
 the uterus and ovaries, hysteria, or hypochondriasis. 
 
 Prognosis. — The disease is not a fatal one, but yet a 
 considerable time may elapse before the patient entirely 
 recovers. 
 
 Treatment. — In the mpre severe cases the patients 
 must be put on milk diet, or the use of scraped beef 
 and hot water. An out-of-door life in a dry inland cli- 
 mate is regularly of service. 
 
 The most useful drugs are the alkalies, the mineral 
 acids, small doses of castor-oil, ipecac, and sometimes 
 small doses of opium. There is also sometimes an ad- 
 vantage in the use of large enemata of cold water, and of 
 massage of the abdomen. 
 
 Carcinoma of the Colon, 
 
 The new-growth usually follows the type of colloid 
 cancer, or of glandular cancer with cylindrical cells. 
 The favorite situations are the rectum and the caput coli. 
 The new-growth surrounds the gut and extends longitud- 
 inally for one or two inches ; less frequently it involves 
 a considerable part of the length of the colon. The 
 growth may cause a stricture of the colon, or may pro- 
 ject inward in soft masses, or may ulcerate. It often 
 infiltrates the surrounding tissues, it may cause a local 
 peritonitis, or the ulceration may go on to perforate the 
 wall of the colon. 
 
 Causes. — The disease occurs regularly in persons over 
 thirty years of age. 
 
l6 THE INTESTINES. 
 
 Symptoms. — If the growth is situated in the rectum 
 the first symptoms are constipation, flatulence, pain, and 
 constricted stools ; or diarrhoea and passages of blood 
 and mucus. As the disease continues the local symp- 
 toms become more marked, and the patients lose flesh 
 and strength and become cachectic. The tumor can be 
 felt in the rectum as a hard ring constricting the gut, or 
 as a hard diffuse mass about the gut, or as a soft tumor 
 projecting inward. 
 
 As the disease goes on the stricture becomes tighter 
 and tighter ; or there is paralysis of the sphincter with a 
 constant flow of brown, sanious fluid. 
 
 The patients die worn out with the disease, or with 
 retention of faeces, or from perforation of the intestine, 
 or from peritonitis. 
 
 If the growth is situated in the caput coli the first 
 symptoms are gradual loss of flesh and strength, flatu- 
 lence, alternating diarrhoea and constipation, nausea, and 
 vomiting. Or the first symptom is pain coming on in 
 attacks, first at long intervals, then more and more fre- 
 quently. These symptoms continue, the patients lose 
 flesh and strength, and become cachectic ; there may be 
 distention of the small intestine. The tumor can be felt 
 in the right side of the abdomen, when it has reached a 
 sufficient size. 
 
 Occasionally we see cases of cancer of the rectum, or 
 of the caput coli, in which there are no local symptoms. 
 The only evidences of the disease are the loss of flesh 
 and strength, and the tumor. 
 
 Treatment. — The only efficient treatment is the re- 
 moval of the tumor by a surgical operation.