V^'U MA mtl)e€ttpofl!rmg(n:k COLLEGE OF PHYSICIANS AND SURGEONS LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/treatmentofdiseOOwilc TREATMENT OF DISEASE WILCOX BY THE SAME AUTHOR. Manxial of Fever Nursing. " In this little book the author has presented the medical profession with a hand-book of the highest value to nurses and one which will prove most useful to physicians as well. The subject is treated thor- oughly and exhaustively and the guide followed by the author has been his lectures to the nurses of St. Mark's Hospital of New York City. The book is divided into nine chapters, which are respectively devoted to fever, its definition and diagnosis, and its general treatment. Then the nurse, the sick-room and its furniture, the patient, etc., are considered. Infections of continued type, and the same with local manifestations, are noted. Infections of intermittent type are next taken up, and following this, the exanthemata. The concluding chap- ter deals with thermic fever. The book is a well written one and practical in every detail. The author is a well-known writer, who has made many valuable contributions to medical literature. We feel cer- tain that his little work will be eagerly taken up by trained nurses and we unhesitatingly recommend it to them as well as to their teacher. It is a timely work and full of good suggestions, useful to patients, nurses, and to physicians alike." — St. Louis Medical and Surgical Journal. i2mo. 236 pages. Cloth, $1.00 net. P. BLAKISTON'S SON & CO., - - Philadelphia. THE TREATMENT OF DISEASE A MANUAL OF PRACTICAL MEDICINE BY REYNOLD WEBB WILCOX, M.A., M.D., LL.D. PROFESSOR OF MEDICINE AT THE NEW YORK POST GRADUATE MEDICAL SCHOOL AND^HOSPITAL; CONSULTING PHYSICIAN TO THE NASSAU HOSPITAL; VISITING PHYSICIAN TO ST. MARK's HOSPITAL; FELLOW OF THE AMERICAN ACADEMY OF MEDICINE; MEMBER OF THE AMERICAN THERAPEUTIC SOCIETY AND OF THE AMERICAN MEDICAL ASSOCIATION; PERMANENT MEMBER OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK; HONORARY MEMBER OF THE CONNECTICUT STATE MEDICAL SOCIETY; VICE-CHAIRMAN OF THE REVISION COMMITTEE OF THE UNITED STATES PHARMACOPCEIA, ETC. PHILADELPHIA BLAKISTON'S SON & CO. 1012 WALNUT STREET 1907 Copyright, 1907, By P. Blakiston's Son & Co. Printed by The Maple Press, York, Pa. TO THE MEMORY OF MY GRANDFATHER, REYNOLD WEBB, M. D., AND MY UNCLE, DANIEL MEIGS WEBB, A. M., M. D., THIS VOLUME IS DEDICATED. PREFACE. Twenty-three years' experience in teaching more than ten thousand medical graduates has impressed upon the author that the practitioner desires especially the latest views upon questions of diagnosis and methods of treatment. Under the influence of Post Graduate Schools the medical student is more thoroughly grounded in diagnosis, and particularly in physical diagnosis, than formerly. There still remains an anxious endeavor on the part of the physician to increase his knowledge of therapeutics, whether physical, medicinal or dietetic, which goes to make up what may be termed the management of a patient suffering from disease. While aetiology is important, pathology is interesting and a sound basis, and diagnosis is essential, it is from a thorough and broad knowledge of therapeutics in its larger sense that the practitioner will achieve his greatest success and win his most endiiring reputation among his patients and the public at large. The therapeutic awakening which is now being experienced, shows that more to-day, than ever before, is expected of the clinician. With the practical needs of the physician always in view, this book has been written. To Dr. Henry Hubbard Pelton, Instructor in Medicine at the New York Post Graduate Medical School and Hospital, and Chief of Medical Clinic, Presbyterian Hospital Dispensary, who has diligently collected his lectures during the sessions of 1904-6, who has filled the lacuncB inseparable to clinical teaching and who has borne the labor of proof-reading and index-making, the author would tender his heart- felt acknowledgment of his varied and valuable services. vii TABLE OF CONTENTS. PREFACE. INTRODUCTION. I. THE INFECTIOUS DISEASES. Enteric Fever i Paratyphoid Fever 22 Mountain Fever 23 Typhus Fever 24 Malta Fever 28 Relapsing Fever 30 Yellow Fever 33 Influenza 38 Dengue 43 Malaria] Fevers 45 Nasha Fever 54 Cholera 55 Dysentery 6i Catarrhal Dysentery 62 Tropical Dysentery 63 Amoebic Dysentery 64 Diphtheritic Dysentery 67 Epidemic Gangrenous Proctitis 71 Hill Diarrhoea 72 Sprue 73 The Plague 75 Climatic Bubo 77 Diphtheria 78 Mumps 88 Whooping Cough go Cerebrospinal Fever 95 Erysipelas 102 Acute Articular Rheumatism 105 ix X TABLE OF CONTENTS. Septicaemia; Pygemia iii Hydrophobia 114 Tetanus 118 Anthrax 122 Glanders 125 Actinomycosis ' 127 Epidemic Stomatitis 128 Milk Sickness 129 Gonorrhoeal Infections 130 Syphilis 134 Tuberculosis 144 Acute Miliary Tuberculosis 147 Acute General Miliary Tuberculosis 148 Acute General Tuberculosis of Pulmonary Form . . . . ; 149 Acute General Tuberculosis of Meningeal Form 150 Pulmonary Tuberculosis 150 Acute Pneumonic Pulmonary Tuberculosis 150 Chronic Pulmonary Tuberculosis 151 Fibroid Phthisis 158 Tuberculosis of the Lymphatic Glands 173 Tuberculosis of the Pleura 175 Tuberculosis of the Peritonseum 175 Tuberculosis of the Pericardium 176 Tuberculosis of the Kidney 177 Tuberculosis of the Pelvis of Kidney, Ureter and Bladder 177 Tuberculosis of the Testicles, Prostate Gland and Seminal Vesicles. 178 Tuberculosis of the Ovaries, Uterus and Fallopian Tubes 178 Tuberculosis of the Mammary Gland 179 Tuberculosis of the Heart and Blood-vessels 179 Acute Infectious Pneumonia 179 Bronchopneumonia 187 Chronic Interstitial Pneumonia 192 Embolic Pneumonia 194 Hsemorrhagic Infarct of the Lung 194 Septic Embolic Pneumonia 195 Beriberi 195 Mycetoma 198 Febricula 199 Protracted Idiopathic Continued Fever 200 Weil's Disease 201 Glandular Fever 201 Miliary Fever 202 TABLE OF CONTENTS. XI Japanese River Fever 203 Tick Fever 204 Trypanosomiasis 205 Kala-Azar 206 Kubisagari 207 Leprosy 208 Framboesia 211 Verruga 212 Measles 214 Rubella 218 Scarlatina ■ 220 Fourth Disease 228 Varicella 229 Smallpox 231 Vaccinia 242 n. CONSTITUTIONAL DISEASES. Gout 245 Purineemia 252 Diabetes Mellitus 254 Diabetes Insipidus 262 Chronic Rheumatism 265 Muscular Rheumatism ■ 267 Arthritis Deformans 269 Obesity 273 Scurv}^ 276 Infantile Scurvy 279 Rickets 280 III. THE INTOXICATIONS, INCLUDING THE EFFECTS OF EXPOSURE TO HIGH TEMPERATURES. Lead Poisoning 286 Arsenical Poisoning 290 Mercurial Poisoning 292 Antimonial Poisoning 294 lodism 295 Bromism 295 Borism 296 Xll TABLE or CONTENTS. Alcoholism 297 Acute Alcoholism 297 Chronic Alcoholism 299 Delirium Tremens 302 Chloralism 304 Sulphonmethane (Sulphonal) Poisoning 305 Sulphonethylmethane (Trional) Poisoning 305 Veronal Poisoning 306 Morphinism 306 Haschisch Poisoning - 09 Cocainism 309 Tobacco Poisoning 310 Carbon Bisulphide Poisoning 311 Lacquer Poisoning 311 Food Poisoning 312 Grain Poisoning 313 Ergotism 313 Pellagra •. 314 Lathyrism 315 Atryplicism 316 The Effects of Exposure to High Temperatures 316 Heat Exhaustion 316 Sun-stroke 317 IV. DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. DISEASES OF THE MOUTH AND TONGUE. Mycotic Stomatitis 320 Gangrenous Stomatitis 321 The Geographical Tongue 322 Leucoplakia Buccalis 323 DISEASES OF THE SALIVARY GLANDS. Ptyalism 324 Dry Mouth 324 Acute Parotitis 324 Ludwig's Angina 325 DISEASES OF THE TONSILS AND PHARYNX. Acute Catarrhal Pharyngitis 325 Acute Follicular TonsiUitis 327 Quinsy Sore Throat 329 TABLE OF CONTENTS. Xlll DISEASES OF THE (ESOPHAGUS. Acute CEsophagitis 330 Chronic Catarrhal CEsophagitis 331 CEsophageal Spasm 331 Cancer of the (Esophagus 331 Benign Stricture of the CEsophagus 332 Dilatations of the (Esophagus 333 DISEASES OF THE STOMACH. A-c ':^^^ : Catarrhal Gastritis 334 Chronic Catarrhal Gastritis 337 Phlegmonous Gastritis .• 343 Traumatic and Toxic Gastritis 343 Diphtheritic Gastritis 344 Mycotic Gastritis 344 Gastric Ulcer ' 345 Cancer of the Stomach 356 Hypertrophic Stenosis of the Pylorus 360 Gastric Dilatation 361 Acute Gastric Dilatation 364 Hour-glass Stomach 365 Visceroptosis .*" 366 Neuroses of the Stomach 369 Hyperchlorhydria 369 Hypochlorhydria 372 Cardiospasm 373 Pylorospasm 374 Gastric Hyperperistalsis 375 Merycismus 375 Nervous Eructation of Gas 376 Gastric Hyperaesthesia . . . . 376 Gastralgia 377 Bulimia 378 Anorexia Nervosa 379 Cyclic Vomiting 379 Haematemesis 380 DISEASES OF THE INTESTINE. Simple Acute Catarrhal Enteritis 381 Chronic Catarrhal Enteritis 383 Cholera Morbus 387 XIV TABLE OF CONTEXTS. Diarrhoeas of Children 389 Acute Gastro-enteritis 389 Cholera Infantum 391 Acute Entero-colitis 393 Pseudo-membranous Entero-colitis 395 Phlegmonoius Enteritis 396 Haemorrhagic Infarct of the Bowel 396 Ulceration of the Bowel 397 Ulcer of the Duodenum ■ 397 Primar}' Tuberculous Ulceration of the Intestine 398 EmboHc Ulcer of the Intestine 399 S}^hilitic Ulcer of the Intestine 399 Appendicitis 399 Intestinal Obstruction 404 Enteroptosis 411 Constipation 411 Colitis 415 Dilatation of the Colon 416 Ner\'ous Affections of the Intestine 416 Malignant Gro'n1;hs of the Intestine 419 Proctitis 420 Heemorrhoids 420 DISEASES OF THE LIVER. Abnormalities in Shape and Position of the Liver 422 Perihepatitis 424 Abscess of the Liver 425 Cirrhosis of the Liver 429 The Fatty Liver 437 The Amyloid Liver 438 Syphilis of the Liver 439 Acute YeUow Atrophy of the Liver 441 Neoplasms of the Liver 443 Cancer of the Liver 443 Parasites of the Liver 447 Echinococcus Disease of the Liver 447 Other Parasites of the Liver 450 DISEASES OF THE HEPATIC BLOOD-VESSELS. Anaemia and Hyperaemia of the Liver 45° Thrombosis and Embolism of the Portal Vein 452 TABLE OF CONTENTS. XV DISEASES OF THE BILIARY TRACT. Jaundice 453 Acute Catarrhal Jaundice 453 Toxic Jaundice 457 Icterus Neonatorum 458 Acute Cholecystitis 458 Cholelithiasis 460 Neoplasms of the Gall-bladder 468 Neoplasms of the Gall Ducts 469 Stenosis of the Gall Ducts 469 Parasites of the Gall Ducts 470 DISEASES OF THE PANCREAS. Acute Pancreatitis 470 Acute Haemorrhagic Pancreatitis 471 Acute Suppurative Pancreatitis 471 Acute Gangrenous Pancreatitis 472 Chronic Pancreatitis 473 Tumors of the Pancreas 474 Cancer of the Pancreas 474 Cysts of the Pancreas 475 Pancreatic Calculi 476 DISEASES OF THE PERITONEUM. Acute Peritonitis 476 Chronic Peritonitis 481 Neoplasms of the Peritonaeum 483 Ascites 484 V. DISEASES OF THE BLOOD. The Anaemias 487 Secondary Anaemia 487 Primary or Essential Anaemias 490 Chlorosis 490 Progressive Pernicious Anaemia 494 Leucaemia 498 Leucanaemia 503 Chloroma 503 Chronic Cyanosis 504 Anaemia Infantum 504 XVI TABLE OF CONTENTS. Purpura 505 Arthritic Purpura 506 Purpura Haemorrhagica 507 Hasmorrhagic Diseases of the New-born 508 Haemophilia 509 VI. DISEASES OF THE DUCTLESS GLANDS. DISEASES OF THE SPLEEN. The Wandering Spleen 512 Perisplenitis 513 Splenitis 513 Abscess of the Spleen 513 Rupture of the Spleen 514 The Amyloid Spleen 514 Neoplasms of the Spleen 514 Echinococcus Cysts of the Spleen 515 Splenic Anaemia 515 Banti's Disease 516 Pseudo-leucaemia 516 Status Lymphaticus 519 DISEASES OF THE THYROID GLAND. Simple Goitre 521 Congestion of the Thyroid Gland 523 Acute Thyroiditis 523 Exophthalmic Goitre 523 Myxoedema 528 Neoplasms of the Thyroid Gland 532 DISEASES OF THE THYMUS GLAND. Hypertrophy of the Thymus Gland 533 Thymus Death 533 Atrophy of the Thymus Gland 533 Haemorrhage into the Thymus Gland 533 Abscess of the Thymus Gland 533 Neoplasms of the Thymus Gland 533 Tuberculous Inflammation of the Thymus Gland 533 DISEASES OF THE SUPRARENAL GLAND. Addison's Disease 534 TABLE OF CONTENTS. XVll VII. DISEASES OF THE HEART AND BLOOD-VESSELS. DISEASES OF THE PERICARDIUM. Acute Pericarditis 537 Chronic Adhesive Pericarditis 542 Hydropericardium 543 Hccmopericardium 543 Pneumopericardium 543 Calcification of the Pericardium 543 DISEASES OF THE MYOCARDIUM. Cardiac Hypertrophy 543 Cardiac Dilatation 546 Cardiac Atrophy 551 Myocarditis 551 Parenchymatous Myocarditis 551 Fatty Myocarditis 552 Fatty Infiltration of Heart 552 Fibrous Myocarditis 553 Acute Suppurative Myocarditis 555 Aneurysm of the Heart 555 Rupture of the Heart 555 DISEASES OF THE ENDOCARDIUM. Acute Endocarditis 556 Simple Acute Endocarditis 556 Malignant Endocarditis 556 Chronic Endocarditis 561 Mitral Insufficiency 562 Mitral Obstruction 564 Aortic Insufficiency 566 Aortic Obstruction 569 Tricuspid Insufficiency 570 Tricuspid Obstruction 571 Pulmonic Insufficiency 572 Pulmonic Obstruction 572 Combined Valvular Lesions 573 Congenital Cardiac Defects 573 The Neuroses of the Heart 585 Palpitation 585 Tachycardia 586 XVm TABLE OF CONTENTS. Bradycardia 586 Arrhythmia 587 Angina Pectoris 590 DISEASES OF THE BLOOD-VESSELS. Arteriosclerosis 593 Aneurysm . 597 Aneurysm of the Thoracic Aorta 598 Aneurysm of the Abdominal Aorta 602 Aneurysm of the Branches of the Abdominal Aorta 603 VIII. DISEASES OF THE RESPIRATORY SYSTEM. DISEASES OF THE NOSE. Acute Rhinitis 607 Hay Fever 608 DISEASES OF THE LARYNX. Acute Catarrhal Laryngitis 610 Simple Chronic Catarrhal Laryngitis 611 Spasmodic Laryngitis 613 Tuberculous Laryngitis 614 OEdema of the Glottis 616 DISEASES OF THE TRACHEA AND BRONCHI. Acute Bronchitis 617 Chronic Bronchitis 621 Fibrinous Bronchitis . 623 Spasmodic Bronchitis 625 Bronchiectasis 628 DISEASES OF THE LUNGS. Pulmonary Emphysema 631 Syphilis of the Lung 637 Neoplasms of the Lung 638 Hydatid Disease of the Lung 639 Abscess of the Lung 639 Gangrene of the Lung 641 DISEASES OF THE PLEURA. Acute Fibrinous Pleurisy 643 Acute Serous Pleurisy 645 Empyaema 650 Chronic Adhesive Pleurisy 653 Hydrothorax 654 TABLE OF CONTENTS. XIX Hydropneumothorax and Pyopneumothorax 654 Haemothorax 656 Neoplasms of the Pleura 656 DISEASES OF THE MEDIASTINUM. Carcinoma and Sarcoma of the Mediastinum 657 Non-malignant Neoplasms of the Mediastinum 659 Abscess of the Mediastinum 659 Simple Lymphadenitis of the Mediastinum 659 Indurative Mediastino-pericarditis 659 Mediastinal Emphysema 660 IX. DISEASES OF THE URINARY SYSTEM. Anomalies of the Kidney 661 The Movable Kidney 662 Albuminuria 664 Functional Albuminuria 665 •Acute Congestion of the Kidney 666 Chronic Congestion of the Kidney 666 Uraemia 668 Acute Nephritis 671 Chronic Parenchymatous Nephritis 678 Chronic Arterial Nephritis 683 The Amyloid Kidney 689 Suppurative Nephritis, Pyelonephrosis and Pyelitis 691 Hydronephrosis 694 Paranephritis 697 Nephrolithiasis 698 Neoplasms of the Kidney 703 The Cystic Kidney 705 Idiopathic Haematuria 706 Haemoglobinuria 707 Toxic Haemoglobinuria 708 Paroxysmal Haemoglobinuria 708 Chyluria 709 X. DISEASES OF THE NERVOUS SYSTEM. DISEASES INVOLVING CHIEFLY THE BRAIN AND ITS MEMBRANES. Acute Encephalitis 710 Cerebral Meningitis 711 XX TABLE OF CONTENTS. Pachymeningitis 711 External Pachymeningitis 711 Internal Pachymeningitis 711 Leptomeningitis 712 Tuberculous Meningitis 714 Chronic Hydrocephalus 715 Apoplexy 716 Cerebral Heemorrhage 716 Embolism and Thrombosis of the Cerebral Arteries 720 Thrombosis of the Venous Sinuses of the Brain 722 Aphasia 722 General Paralysis 723 Disseminated Sclerosis 725 Abscess of the Brain 727 Tumors of the Brain and its Membranes 729 Cerebellar Disease 734 DISEASES INVOLVING CHIEFLY THE SPINAL CORD AND ITS MEMBRANES. Acute Myelitis 735 Chronic Myelitis 735 Myelomalacia 739 Acute Anterior Poliomyelitis 739 Chronic Anterior Poliomyelitis 742 Lateral Sclerosis 742 Amyotrophic Lateral Sclerosis 744 Locomotor Ataxia 745 Friedreich's Ataxia 751 Hereditary Cerebellar Ataxia 752 Bulbar Paralysis 752 Acute Ascending Paralysis 753 Syringomyelia 755 Morvan's Disease 756 Haemorrhage into the Spinal Cord 757 Caisson Disease 758 Compression of the Spinal Cord 759 Tumors of the Spinal Cord and its Meninges 761 Spinal Meningitis 763 Spinal Pachymeningitis 763 Acute Spinal Leptomeningitis 764 Haemorrhage into the Spinal Membranes 766 TABLE or CONTENTS. XXI DISEASES INVOLVING CHIEFLY THE PERIPHERAL NERVES. Netiritis 767 Multiple Peripheral Neuritis 770 Sciatica 773 Diseases of the Cranial Nerves 775 Diseases of the First Pair — The Olfactory Nerves 775 Diseases of the Second Pair — The Optic Nerves 776 Diseases of the Third, Fourth and Sixth Pairs — The Oculo-motor Nerves, the Trochlear Nerves and the Abducentes 779 Diseases of the Fifth Pair — The Trigeminal Nerves 781 Diseases of the Seventh Pair — The Facial Nerves 782 Diseases of the Eighth Pair — The Auditory Nerves 785 Diseases of the Ninth Pair — The Glosso-pharyngeal Nerves 787 Diseases of the Tenth Pair — The Pneumogastric Nerves 788 Diseases of the Eleventh Pair — The Spinal Accessory Nerves 791 Diseases of the Twelfth Pair — The Hypoglossal Nerves 794 FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM. Acute Chorea 795 Choreiform Affections 799 Convulsive Tic 800 Impulsive Tic 800 Saltatory Spasm 801 Chronic Chorea 801 Epilepsy 802 Myotonia Congenita 808 Paramyoclonus Multiplex 809 Paralysis Agitans 810 Eclampsia 812 Infantile Eclampsia 812 Puerperal Eclampsia 813 Tetany 814 Hysteria 816 Neurasthenia 821 The Neurasthenia of the Menopause 825 Amok 827 Astasia-Abasia 828 Traumatic Neuroses 828 Occupation Neuroses 829 VASO-MOTOR AND TROPHIC DISORDERS. Raynaud's Disease 832 Ery thro melalgia 833 XXll TABLE OF CONTENTS. Angioneurotic (Edema 834 Migraine 835 Facial Hemiatrophy 837 Myasthenia Gravis 838 Periodical Paralysis 839 Adiposis Dolorosa 840 Acromegaly 840 Leontiasis Ossea 842 Osteitis Deformans 842 Hypertrophic Pulmonary Osteoarthropathy 842 Scleroderma 843 Ainhum 844 XI. DISEASES OF THE MUSCULAR SYSTEM. Myositis - 846 Infectious Myositis 846 Ossifying Myositis 847 Muscular Dystrophies 847 Pseudo-hypertrophic Paralysis 847 Juvenile Muscular Dystrophy 848 Muscular Atrophy of the Landouzy-Dejerine Type 849 Muscular Atrophy of the Peroneal Type 849 XII. PARASITIC DISEASES. Psorospermiasis 850 Distomiasis 851 Nematodes 853 Ascariasis 853 Anchylostomiasis 858 Trichiniasis 861 Filariasis 864 Dracontiasis 866 Trypanosomiasis 868 Cestodes 868 Echinococcus Disease 868 Intestinal Cestodes 868 Parasitic Insects 874 Arachnidse and Ticks 874 Parasitic Flies > 875 Other Parasitic Insects 876 INTRODUCTION. In a treatise upon Practical Medicine the classification of the various diseases is to be undertaken with circumspection, for the progress which is daily taking place in the study of pathologic states is continually rendering it necessary for us to change our opinions of the nature of morbid condi- tions. Theories which have been credited as facts are frequently being controverted or are becoming hypotheses while apparently established facts may be overthrown to give place to their successors. As an instance, pneu- monia and acute articular rheumatism are now regarded as infections while previously the former was classed with diseases of the lungs and the latter with morbid conditions of the joints. It is not at all improbable that soon we shall be considering certain affections, now classed as splenic, as diseases of the blood and vice versa, and other changes in classification are quite as possible. Hence the difificuky of arranging a given list of diseases in a manner which shall not be subject to criticism. On the other hand it matters httle under what heading a disease is con- sidered, for the various organs and bodily systems are so intimately related that an affection of one of these can hardly exist as a distinct entity. In almost every instance associated morbid processes are taking place in other structures which have a definite bearing upon the primary state. For this reason the present-day tendency toward speciaUsm in internal medicine is to be decried and a reversion to the type of physician commonly designated as the "General Practitioner" advocated. It is such a medical man who, when confronted by a difficult problem, will grasp the moment when the aid of the surgeon or that of another worker in special fields is necessary; and this consultant will take in hand the work properly begun by the practitioner and carry it to a successful conclusion which shall be quite as much a result of the skill of the one as that of the other. The tendency of the speciahst is to attribute all the symptoms of which he complains to some lesion of the organ or system in which he is interested, for- getting, perhaps, that other organs exist; thus the gastrologist loses sight of the possibility that the stomach symptoms of a patient, to ascertain the reasons for which the resources of chemistry are exhausted, may be an evidence of a beginning tuberculous process at a pulmonary apex and are not due to some dis- order of the gastric motility or to a secretory abnormaHty of the glands of the stomach. Likewise the specialist upon thoracic diseases must not neglect nor be unable to treat intelligently the renal condition associated with a given instance of pulmonary emphysema or aortic obstruction, and the clinician who devotes himself exclusively to the subject of acute diseases should recol- lect the extreme probability of the occurrence of cardiac involvement when treating a patient affiicted with acute polyarthritis. Numerous instances xxiii XXIV IXTRODUCTION. might be cited showing the intimate relation of the diseases of one system to those of others but these will sufl&ce. In ehciting a patient's history the importance of the consideration of heredity hes less in the possibihty of the direct transmission of disease than in that of the inheritance of a constitution predisposed to morbid affections by reason gf its inherited vitiated powers of resistance. Not only may such a diminished resistance to disease be handed down from father to child but there is a definite possibility that the offspring of physically strong for- bears may possess an increased resistance to disease which may account for some of the instances of apparent natural immunity which are observed. In considering the ailments from which an individual has previously suf- fered we must not lose sight of the fact that these may have a material bear- ing upon the disease which now brings him to the physician, in obtaining the history of which we must revert to the first noticed symptom, and its char- acter. The associated manifestations must then be ascertained until we are able to learn which organ is chiefly affected and the others which are probably involved in consequence. Having elicited the patient's history, we should proceed to the physical examination, and this being accomplished we are finally ready to make the diagnosis. Here it is a weU-recognized fact that, in every instance, we must proceed by a process of exclusion, all the possibilities being ruled out one by one until we have sifted the matter to its bottom and the true diagnosis is established. After diagnosis, treatment is to be considered and, while not underrating the value of pathological knowledge nor decrying the importance of aetiology or history and without ignoring the advantage of expert physical diagnosis, or minimizing the weight of trained and logical reasoning or deprecating the assumption of conclusions based on long-continued experience — all of which are necessary for a correct diagnosis— we must insist that learning and experi- ence are in greatest demand in deciding upon the treatment to be prescribed. This is, to the mind of the patient, the most important consideration, for to him history and diagnosis are merely subsidiaries, his object in consulting the physician being less to learn the character of his ailment than to obtain relief. In formulating a method of treatment for a given affection the various therapeutic measures at oiu" disposal must be considered separately, and, more than aU, in prescribing for our patient we must not use the diagnosis as a figur- ative peg upon which to hang a varied series of methods of treatment selected haphazard, but we should, remembering the while that most important and very definite entity the personal equation, treat the patient and not his disease. With a view toward systematizing and correlating our knowledge careful records of all patients should be kept and the following method of recording histories, physical examinations and other data is suggested. CASE RECORD: Record data'jbelow: Name — Age — Occupation — Social Condition — Birth-place — Place of Residence — Date oe Examination. History. — Hereditary Tendencies — Notable Habits — General Surroundings — Previous Illness and Ac- cidents — Causes, Manner of Attack, Duration and Course of Present Illness. SYMPTOMS: Alimentary System. — Deglutition — Appetite — Sensa- tions during Fasting and after Eating {Discomfort — Pain — Weight — Distention — Heartburn — Nau- sea) — Acidity — Flatulence — Eructation — Pyrosis — Vomiting. State of Bowels {Frequency — Color of Stools — Tenesmus.) Circulatory System. — Subjective Phenomena {Pain — Palpitation — Faintness — Dyspncea). Respiratory System. — Breathing {Painfulness) — Cough — Larynx {Pain). Integumentary System. — Subjective Phenomena — Skin {Dryness — Itching — Moisture) . Urinary System. — Subjective Phenomena {Pain in Loins, Bladder or Urethra) — Micturition {Frequency). Reproductive System. — Male — Abnormal Discharges — Functions — Subjective Phenomena. Female — Catamenia — Pregnancies — Abnormal Discharges — Subjective Phenomena. Nervous System. Sensory Functions. — Sensations {Pain — Heat — Cold — Formicatio7i — Numbness— Tingling — Girdle Pain — Vertigo) . Motor Functions. — Organic Reflex {Swallowing — Breathing — Micturition — Defcecation). Vasomotor and Trophic Functions. — Subjective Phenom- ena. Cerebral and Mental Functions. — Subjective Phenomena — Sleep. Locomotory System. — Subjective Phenomena. XXV SIGNS: Status Pr^skns. General Facts.— Height— Weight— General Appearance {Temperament— A ttitude and Expression)— Tem-per- ature. Alimentary System. — Lips— Teeth— Gums — Tongue- Fauces — {Characters, Macroscopic and Microscopic, of Vomitea Matters) — Character of Fjeces — {Macro- scopic aiid Microscopic Examinations) — Abdomen {Prominence — Retraction — Distention — Flaccidity — Tenderness — Fluctuation — Outline of Normal or Abnormal Contents) — Rontgen-ray Examination. Hemopoietic System. — Lymphatic Vessels and Glands — Ductless Glands {Spleen— Thyroid) — Microscop- ical Characters of Blood — Hsemoglobin Percentage— - Specific Gravity — Coagulation Time — Cryoscopic Examination. Circulatory System. — Inspection {Form and Appear- ance of Precordium) — Palpation {Position and Char- acter of Cardiac Impulse) — Percussion {Superficial and Deep Outline) — Auscultation {Rhythm and Quality of Somids in Mitral, Tricuspid, Aortic and Pulmonary Areas, over General Surface of Heart and Main Vessels) — Pulse {Frequency — Rhythm — Character — Sphygmo graphic Tracings) — Arteries, Veins and Capillaries — -Rontgen-ray Examination — Blood Pressure Estimation. Record data below: Respiratory System. — Breathing {Frequency — Rhythm — Type) — Sputa {Macroscopic and Microscopic Char- acters) — Nares {Rhinoscopic Examination) — Phar- \Tix — LarvTix — {Voice — Tenderness — Laryngoscopic Examination) — Inspection {Form and Action of Thorax) — Mensuration {Spirometric Tests) — VaXpz.- tion {Vocal Fremitus) — Percussion {Anterior and Pos- terior, on both 5/(fe5)— Auscultation {Determination, during Natural and Deep Respiration, of the Dura- tion of the Sounds, their Character, Acco?npaniments, and of the Vocal Resonance — Tussive Signs) — Ront- gen-ray Examination. xxvi SIGNS (Continued) : Integumentary System. — Obesity — Emaciation- (Edema — Emphysema — Eruptions {Distribution- Elements of Skin Involved — Type — Cause). Urinary System. — Urine — Quantity — Color — Specific Gravity — Chemical Reactions (Acidity — Alkalinity — Albumin — Sugar — Bile — Indican — Amount of Urea and Uric Acid) — Sediment {Macroscopic and Microscopic Characters) — Cr}'oscopic Examination — Rontgen-ray Examination. Reproductive System. — Male — Testicle — Epididymis — Prostate — Urethra {Endoscopic Exa?nination) — Bladder {Cystoscopic Examination and Result of Ureteral Catheterization) — Abnormal Discharges. Female — Ovaries — Tubes — Pelvic Cavity — Uterus — Vagina {Examination with Speculum) — Urethra {Endoscopic Examination) — Bladder {Cystoscopic Examination and Result of Ureteral Catheterization) — Abnormal Discharges. Nervous System. Sensory Functions. — Sensibility to Touch {Msthesio- m,etric Examiiiation) — Heat — Tickling — Pain — Muscular Sense — Sight {Ophthalmoscopic Examin- ation) — Hearing {Otoscopic and Horological Exam- ination) — Taste^Smell. Motor Functions. — Skin Reflex — Tendon Reflex — \o\- untary {Systematic Exa?nination of Muscles) — Co- ordinating — Electric Irritability {Faradic, Galvanic). Vasomotor and Trophic Functions. — {Congestion — Pallor — (Edema — Inflammation — Sloughing — Wasting — Perspiration.) Cerebral and Mental Functions. — Intelligence {Halluci- nations — Illusions — Delusions — Delirium — Torpor — Coma — Coma- Vigil) — Attention — Memory — Emotion — Speech — {Comprehension of Language, heard, seen — Utterance of Language, spoken, written) — Rontgen-ray Examination. Record data below: Locomotory System. — Bones — Joints — {Pain — Swelling — Effusion — Mobility — Rontgen-ray Examination) — Muscles {Rigidity — Flaccidity — Cramp — Twitch- ing, general or fibrillary — Hypertrophy — Atrophy — Dynamometric Examinatiort) . XXMl DIAGNOSIS: PROGNOSIS: TREATMENT: Medicinal: Physical: (Electricity, massage, hydrotherapy, etc.). Dietetic : Hygienic: General Directions: Subsequent History: XXVlll PRACTICAL MEDICINE CHAPTER I. THE INFECTIOUS DISEASES. ENTERIC FEVER. Synonyms. Typhoid Fever; Typhus Abdominalis; Gastro-enteric Fever; Nervous Fever. Definition. Enteric fever is an acute infectious febrile disease character- ized by inflammation and ulceration of the Peyer's patches or lymph follicles of the intestine, by swelling and inflammation of the mesenteric glands, enlargement of the spleen and a petechial eruption. .etiology. The specific cause of enteric fever is the bacillus typhosus of Eberth-Gaffky. This bacillus is to be found in the stools, the inine, the blood, the lymph patches of the intestines, the lymph glands, the spleen, the skin eruption and in the marrow and various organs. It usually enters the organ- ism in infected water or milk or upon contaminated food, such as oysters which have been bedded near sewer exits, or green vegetables which have been fertilized by means of sewage. It is contended by some that the bacillus is air borne and may enter the respiratory system upon the inspired air and thus reach the blood. Sewage to be contaminated by the bacillus must have received either directly or indirectly the discharges from a case of the disease. Enteric fever is more common in the young adult than in childhood, middle or old age and seems to attack the vigorous and healthy as often as the weak and enfeebled. Men seem more susceptible than women, but this is probably because they are more liable to exposure. The disease is most frequently seen in the late summer and early autumn and may occur in almost any climate. It is commonly endemic but epidemics occur at intervals. One who has once had the disease seldom suffers from a second attack. Pathology. The most characteristic lesion of enteric fever is the inflam- mation of the solitary and agminated glands of the small intestine. These glands are first congested and swollen, later they disintegrate and necrose, and the formation of ulcers takes place. When a solitary gland is involved the ulcer is small and round; in the agminated glands it is oval with its long z 2 THE INFECTIOUS DISEASES. diameter parallel to the long axis of the intestine. The borders of the ulcers are raised; their bases, which may consist of the sub mucosa, the muscular coat of the bowel or of peritoneeum are necrotic. The ulcer may erode all the coats of the gut and the peritonaeum, and perforation take place, local or general peritonitis resulting. More usually, fortunately, the ulcer gradually heals but the return of the glandular tissue to normal does not take place. In a mimber of the cases the large intestine is involved as also may be the appendix. In either of these situations perforation may occur. Inflammation of the mesenteric lymphatic glands and of the spleen is likely to occur, resulting in increase in the size of these structures. The spleen is usually palpable and may be enlarged to two or three times its normal size. Abscesses have been reported. Thromboses of the veins may occiu", especially of those of the leg. Arterial thrombosis is rare. The pericardium, myocardium or endocardium may be the seat of inflammation due to the infection. Respiratory lesions such as inflammations of the larynx, bronchi, or pleura are not infrequent. Empyaema is rare. The liver is the seat of an acute degeneration, with granular and at times fatty changes in its cells. Abscess may occur. The bacillus has been found in the gall bladder and a typhoid cholecystitis may occur. The kidneys also imdergo an acute degeneration in their parenchyma, rarely there may be an acute nephritis. Abscesses of the kidney are rare. Pyelitis and cystitis may complicate the disease. Lesions in the nervous system are infrequent, but meningitis has been met as well as cerebral abscess. Abscesses in various parts of the body, notably under the periosteum and in the parotid gland, are not uncommon. Course and Symptoms. The incubation period is usually about two weeks, and may be accompanied by lassitude and lack of appetite. Occa- sionally the patient may continue up and about after the onset of the disease (walking typhoid). The inception of enteric fever is gradual, with headache, general bodily pains, nausea and vomiting and a rise of temperature. Chilly feelings may occur, but a distinct chill is not common. There may be nose- bleed and slight bronchitis, evidenced by cough. In children the onset is more usually acute. The bowels may be loose or constipated. There may be abdominal tenderness and distention. About the eighth day the eruption, consisting of small isolated, rose-colored, slightly elevated round or oval spots of about 2 to 4 millimeters in diameter, appears. These disappear on pressure only to reappear when the pressure is removed. They are seen earliest upon the back, and sHghtly later upon the front of the chest and abdomen. They may be found upon the arms and thighs, but very rarely upon the forearms and legs. They appear in successive crops, each crop lasting 2 to 4 days, ENTERIC FEVER. 3 while the eruptive period lasts from 2 to 21 days. Relapses show afresh eruption and the spots may appear after the establishment of convalescence. The course of the disease usually lasts about four weeks and to each week belong certain symptoms. The typical temperature of enteric fever is as follows: After the chill at onset the temperature rises and during the week following it is high at night and lower in the morning, but day by day the differences between these temperatures become less. During the second week the temperature is continuously high and there is little difference between that of the morning Fig. I. — Clinical chart of and showing the temperature enteric fever of four weeks' duration without complications as uninfluenced by baths or other treatment. and that of the evening. In the third week the morning temperature becomes lower while that of the evening remains as high as during the second week. The typical fourth week temperature is one in which the morning temperature falls gradually lower and that of the evening does likewise, dropping to a lower level each day until both it and the morning temperature reach normal. Complications may alter the course of the temperature. Intestinal haem- orrhages are usually followed by a rapid and distinct fall. The height of the temperature is commonly in direct proportion to the severity of the infection and usually in fatal cases, unless death results from one of the complications 4 THE INFECTIOUS DISEASES. above mentioned, the temperature remains high \mtil death takes place; infrequently, however, death may supervene without the temperature ever having reached a very high level. The pulse usually bears a direct relation to the temperature curve. In the first week it is full, tense and strong and from 90 to 100 per minute; during the second week, especially in severe infections, it is likely to become rapid, feeble and possibly dicrotic. Various departures from the typical temperature are not rare. When the disease begins with a chiU the temperature may rise at once as high as 103° F. or 104° F. (39.5°-4o° C). Not infrequently does defervescence take place at the end of the second week and the temperature fall to normal within 24 hours. A temperature higher in the morning and lower in the evening may occur but has no especial significance. Sudden falls in tem- perature usually indicate an intestinal haemorrhage or perforation. Hyper- pyrexia is rare but may be observed just before death. Chills may occur, as stated, at the onset of the disease; at intervals during its progress; with the incidence of complications; after the use of antipyretic drugs or baths; or during convalescence with no assignable cause. The chills may be accompanied by sweating, but profuse diaphoresis is rare, though at times the abdomen and chest may be moist especially during the reaction from a bath. Rises of temperature after defervescence (recrudescences) may take place even after there has been no febrile movement for several days. These may continue for a nimiber of days and then cease. Accompanying them there is no constitutional disturbance, but they caU for increased vigilance on the part of the physician. They are usually the result of improper feeding, constipation or mental excitement. Certain cases in which convalescence has apparently become estab- lished continue to show an evening rise of temperature of one or two degrees (F.). This may be due to starvation but should cause the physician to search for compHcations, such as abscess. In excessively nervous patients such an evening rise is frequent, but if no other symptoms are manifest it may be disregarded and it often disappears if the patient be allowed to sit up, allowed small amounts of sohd food and the use of the thermometer be dis- continued. Relapses are due to a fresh infection with the bacillus typhosus and last varying periods of time; as a rule they are shorter in course than the original attack. The temperature rises and declines gradually and is accompanied by a return of the symptoms. Afebrile enteric fever has been described by certain observers but is appar- ently of rare occmrence. The facial appearance of enteric fever has been described as typical. Early ENTERIC FEVER. 5 in the disease the face is flushed and the eyes are bright; by the beginning of the second week the expression becomes apathetic and at the height of the disease it is dull and listless — the typhoid facies. The lips and cheeks may retain a good color throughout the disease. The typhoid tongue is at first moist with a white coat down its center. Its edges and tip are red. In mild cases the tongue continues moist but in severe types of the disease it becomes dry, brown, cracked and glazed in the later weeks. Sordes may make its appearance. As convalescence progresses the tongue gradually assumes its normal condition. The spleen is regularly enlarged, soft and may usually be palpated with- out difficulty. Unusual Modes of Onset, a. Ambulatory or walking enteric fever: In this type of the disease the patient remains up and attempts to go about his usual occupation. He realizes that he is not in perfect health but feels hardly ill enough to go to bed. When he is first seen by the physician he may have a high fever and a well-developed rash. These cases often prove severe because of lack of proper treatment in the early stages. b. With marked gastro-intestinal symptoms: The nausea may be severe and the vomiting almost continuous and very difficult to control. Profuse diarrhoea may be present. c. The usual cough accompanying the onset may be much accentuated and the chill and pain in the side of such character as to suggest pneumonia. d. With symptoms referable to the kidneys: Rarely we may observe an onset distinguished by bloody urine containing albumin and casts. e. With pronounced nervous symptoms: Agonizing and obstinate head- ache or facial neuralgia may be initial symptoms. In certain cases when the patient has continued about during the early weeks delirium may be the first marked symptom. Rarely the disease may begin with muscular twitchings or convulsions, stiffness of the neck and photophobia. Drowsiness, apathy and stupor may exist for some days before other and more typical symptoms develop. Very infrequently is mania the first symptom. In alcoholic patients the various nervous manifestations are especially marked. f. Intestinal haemorrhage or perforation rarely occur as symptoms of onset. Each week of the course of enteric fever in a typical case is marked by a special set of symptoms. During the incubation period — varying from lo to 21 days, usually about two weeks — the patient suffers from indefinite malaise, nausea, headache and general soreness. First Week. The invasion of the disease is marked by chilly feelings, more rarely by a distinct chill, severe frontal headache and pains in back and limbs; the tongue is coated down its center, its edges and tip are redder and the papillae more prominent than normal. There often is spontaneous 6 THE INPECTIOUS DISEASES. nose-bleed and there is likely to be cough due to slight laryngitis or bronchitis. The eyes are suffused. The patient is thirsty and often conscious that his temperature is elevated. He complains of weariness, insomnia and nausea which is often accompanied by vomiting. Constipation is the rule but diarrhoea may be present. There may be sore throat with discomfort on deglutition. During this stage of the infection the patient may continue up and about, but usually he finds that he is more comfortable in bed. The course of temperature has been described; by the fifth or sixth day it reaches an evening elevation of 103° to 103.5° F. (39.5° to 39.8° C). The pulse is rapid, strong and tense, 90 to 100 per minute. Very rarely is it dicrotic. By the end of the week the typical enteric facies is evident. A few spots may be seen and the spleen may be palpable. Second Week. As the second week progresses all the symptoms become more marked vnth the exception of the headache and other pains and the nausea and vomiting; these usually cease. The temperatiire continues high (io3°-io4° F. — 39.5° to 40° C.) with slight morning remissions. The pulse becomes softer, feebler and more rapid (ioa-120). Bodily weakness is pro- nounced. The tongue is drj^, brown and tremulous; there is likely to be diarrhoea, 3 to 5 thin, pale, yellowish-brown movements a day (pea-soup stools). Mild delirium may appear late in this week; at first it is present only at night, later it lasts through the day as weU and the patient shows other effects of the toxin of the disease upon the nervous system, such as photophobia, slight deafness and muscular twitchings. If there is no delir- ium the patient lies in a lethargic condition, takes no interest in his surround- ings and makes no requests. Third Week. The symptoms of the second week continue and become more pronounced. The temperature continues high but as the week nears its close the morning temperature is likely to fall to a lower level (ioi°-io2° F., 38.4°-38.8° C). The pulse may become very rapid and weak and dicrotism may be manifest. The tongue becomes more dry and cracked and the patient may be unable to protrude it. Bed sores may appear and retention of iirine and incontinence of fseces may occtir. The symptoms of cerebral poisoning become more marked, the muscular twitchings {suhsuUus tendi- num) are more noticeable and the patient may pick at the bed coverings or grasp at imaginary objects. Intestinal hsemorrhage may be evidenced by blood-tinged stools or blood in considerable quantity may flow from the rectum, leaving the patient in collapse with a sudden fall in temperature, imperceptible pulse and other symptoms of extreme weakness. Pulmonary congestion or pneumonia may complicate the disease during this week. Meteorism is not rare. The patient may die or continue to the Fourth Week. Now the morning temperature faUs stiU lower and the evening rise gradually becomes less until the former reaches normal and the ENTERIC FEVER. 7 latter ioi°-io2° F. (38.4°-38.8° C.)- As the temperature diminishes the other symptoms gradually ameliorate, the tongue loses its dry, cracked appear- ance and becomes moist, the pulse is stronger, the nervous manifestations disappear, and the appetite becomes more vigorous. Fifth Week. The patient may immediately proceed to complete recovery, the febrile movement may last two or three weeks longer, or after a normal temperature lasting several days a relapse may take place. Convalescence is slow. The patient is extremely weak although he may feel well and be very hungry. He is able to sit up but for a few moments at a time and walking is quite impossible. Relapses may be brought on by errors in diet or by over-exertion. The patient often loses his hair for a time and it usually is a number of months before full strength is recovered. Dysmenorrhcea is a common sequel in women. Menstruation usually takes place as in health diuring the first or second week, but later and in convalescence it may be absent. Pregnant women, though they seldom contract the disease, often abort during its course. Complications. Thrombosis of the veins, more particularly of the left femoral — although it may occur in both femoral veins — takes place in about I percent, of all cases. Recovery is the rule unless emboli dislodged from the clot find their way to the heart, in which case sudden death takes place. There is usually phlebitis of greater or less extent as well as thrombosis, and arterial thrombosis is a possible occurrence. The bacillus typhosus has been found in the thrombi. Hcemorrhage from the bowel is a serious complication and is the result of the erosion of a vessel wall by the ulcerative process. It is said to occur in about 5 percent, of the cases. It is by no means necessarily fatal, recovery having taken place after the loss of large quantities of blood per rectum. Such a haemorrhage is evidenced by rapid drop of temperature, pallor, coldness of the extremities and other symptoms of collapse. Perforation is also marked by a sudden fall in temperature as well as by severe abdominal pain and symptoms of coUapse. The pain is rarely localized but is usually general over the whole abdomen. This is a markedly fatal complication, the only chance for recovery being immediate siu-gical inter- ference; otherwise general peritonitis results. Peritonitis without perforation may occur by extension of the inflammation within the intestine to the peritoneeum surrounding it. It is a grave, though not necessarily fatal complication. Parotitis followed by suppuration is rare. The infection reaches the gland by means of Stensen's duct. Cancrum oris may complicate or follow the disease in children. Gangrene of other parts may occur but is rare. Pneumonia due either to the bacillus typhosus or the pneumococcus may 8 . THE INFECTIOUS DISEASES. occur either early or late in the disease. In the later weeks hypostatic pneu- monia may complicate the course of the infection. Suppuration in various parts of the body as a result of enteric infection is not rare. The most common situations are the middle ear, the periostexmi, the urinary bladder and the gall-bladder. Furunculosis is not uncommon. The pus of these lesions usually contains the bacillus typhosus. Osteitis and perichondritis are common. These may result in necrosis. Typhoid spine is a rare complication and is the result, in all probability, of an inflammation in and around the bodies of the vertebrae. Cholelithiasis as a sequel of typhoid fever is well-recognized. It is prob- ably the result of changes in the gall-bladder or in the biliary secretion due to the presence of the bacillus typhosus and which facilitate the formation of calculi. Neuritis is fairly common and may occiir during the coiu^se of the disease or in convalescence. Its onset is marked by great tenderness along the coiurse of the affected nerves. There may be a slight degree of paralysis, usually involving the extensor muscles of the limbs and evidenced by wrist and foot-drop. Endocarditis, paricarditis and pleuritis are infrequent complications. Bed sores may develop in severe cases and in those not weU cared for. They are a dangerous and unnecessary complication. The Blood. Diiring the coiurse of enteric fever the red blood cells and haemoglobin are diminished; during the early weeks the diminution is gradual. As the temperature becomes normal this diminution takes place more rapidly. The red corpuscles are usually fewest when convalescence begins and as recovery progresses they increase in number. The haemoglobin percentage is usually lower than the number of red cells would lead us to expect and it increases more slowly than does the number of erythrocytes. The leucocytes early in the disease show a diminution, in a very large per- centage of cases they are less than 7000 per cu.mm. Non-typhoid com- plications do not seem to diminish this tendency to hypoleucocytosis. Haem- orrhage and perforation are followed by an increase in the white cells. It may be considered that a leucocyte count above 12,000 at the beginning of an iUness is strong evidence against enteric fever. The leucocytes diminish as the disease progresses, reaching the minimum at the termination of the febrile movement, and as convalescence is established beginning to increase again. Cold baths seem to temporarily increase the number of leucocytes but this is believed to be due to a tendency upon their part to seek the surface capil- laries rather than a true leucocytosis. A sudden increase in the number of leucocytes is considered to be a warning of threatened peritonitis or per- foration. In complicating suppurative conditions there is, as one would expect, a leucocytosis. ENTERIC FEVER. 9 During the disease the blood contains the bacillus typhosus and this organ- ism may be cultivated from it, which fact may be utilized in diagnosis. The Widal reaction is based upon the fact that the blood-serum of persons suffering from enteric fever possesses the property of arresting the motion of and agglutinating the causative germ. This reaction exists in over 95 percent.* of cases and is a valuable diagnostic aid. It is seldom observed before the patient has been ill enough to have been in bed for from 5 to 7 days. At times the reaction is not present until after the establishment of convalescence. If it is not obtained upon the first attempt, others should be made at intervals. The reaction may disappear after the cessation of the pyrexia or it may persist for months or even years. The urine in enteric fever is dark in color, high in acidity and specific gravity, and may contain albumin and casts. The bacillus typhosus in a large percentage of cases is present in the urine, appearing therein usually in the second or third week and persisting into the period of convalescence. At times these organisms may continue to be present for many months, probably being propagated in the bladder. Their presence is of no impor- tance in prognosis. Ehrlich's diazo-reaction is so often present in the urine of enteric fever that its aid in diagnosis should always be invoked. It is not pathognomonic, since it may occur in other conditions. It is usually present early in the in- fection. -j- Prophylaxis. The prevention of enteric fever resolves itself primarily into the destruction of the specific bacillus, or failing this, the prevention of its entrance into the human body. All excreta, faeces, urine, pus from abscesses, etc., as well as aU bed clothing, bath waters and all utensils which have in any way come into contact with the patient should be properly disinfected or otherwise disposed of. The faeces should be passed into glass or porcelain vessels and must be thoroughly macerated and allowed to stand for at least one hovir mixed with a freshly prepared disinfecting solution such as calcium chloride, four ounces, water, one gallon. The urine should stand for ten minutes mixed with one- tenth of its volume of mercury bichloride i to 1000. Sputum should be expec- torated into vessels containing phenol i to 10, or the lime solution given above. Bath water and remnants of food should be disinfected with lime or phenol solution. Bed linen and clothing, before being sent to the laundry, should be immersed in a solution of phenol 3 to 100, or boiled in soapsuds to which washing soda has been added. Pus dressings and the like should be burned. The sick-room should be disinfected in the manner customary after the infectious diseases. * Simon. t For technique of the Widal and Ehrlich reactions see works on laboratory diagnosis. lO THE INFECTIOUS DISEASES. Since the bacillus typhosus usually enters the system by way of the mouth too great care cannot be taken to be certain that all ingested substances are above suspicion. The specific bacillus of enteric fever being excreted in the lu-ine naturally necessitates the thorough disinfection of this fluid as is suggested in a previous paragraph. An additional safeguard in this connection is the administration of hexamethylenamine (urotropin) in doses of 7^ grains (0.5) three times daily. This drug is believed to render the urine sterile since it is excreted in this fluid as formaldehyde. This means of safeguarding the public health should never be neglected; rendering the urine free from infective properties is also ' important from the standpoint of the patient and is not to be neglected in the treatment of the disease. The administration of the drug should be begun not later than the third week of the affection and should be continued for several weeks into convalescence. Antienteric inoculation has been attempted by various experimenters and the result of their observations may be summed up in the statement that the measure is one which, in properly selected cases, is fraught with little or no danger, and, so far as we are able to judge, one which should not be neglected when there is probability of exposure to the infection of the disease. Treatment. In the treatment of typhoid fever it is of the greatest impor- tance that all patients should be strictly confined to bed during the febrile stage of the disease and well beyond this into convalescence. In a private house the bed should, when possible, be in a large, well-ventilated room from which all hangings and superfluous furniture have been removed. The temperature should not be above 60° F. (15.5° C.) and in favorable weather the windows should be open. Too bright light and too much darkness are to be avoided. The bed should not be too heavily covered, and the bed linen must be kept perfectly smooth and frequently changed. In severe cases the air or water bed may be necessary. Early iu the disease dorsal decubitus is the best position, but later the patient may be encouraged to change his attitude lest there be any tendency to pulmonary hypostasis. The mouth, teeth and tongue should be frequently cleansed. Studious attention should be given to the proper cleanliness of the body and all points at which bed sores are likely to develop must receive special care. The bowels and bladder should be evacuated only when the patient is lying on his back. Since febrile diseases actively consume the body proteid this loss must be supplied in so far as possible, by nourishing food. The fact that the diges- tive fluids are altered makes this a complicated problem and the pathological changes in the digestive tract add to the difficulty. During the febrile move- ment of tj^hoid fever and usually for some time thereafter fluid diet should be strictly enforced. If the patient has a lack of appetite the physician may ENTERIC FEVER. II combat this by careful variation of the diet in accordance with the tastes of the patient. Cold drinks need not be restricted, water, plain or with fruit juices, natural mineral waters containing not too much carbon dioxide, and cold tea may be allowed. Milk is the most perfect food, though some patients object to it and others do not bear it well for any length of time. In such cases it may be diluted with plain water, mineral water or lime water, or to it may be added tapioca or arrowroot. If milk appears undigested in the stools too much has been administered; the quantity should be lessened and broths should be given. Buttermilk, peptonized milk, thin barley gruel and albumin water are allowable. Simple ice-cream made of milk with the addition of a little sugar and vanilla may prove acceptable. Often the artificial infant foods, meat broths and bouillon are useful and well borne. One week after the cessation of the febrile stage the patient may be given solid food; at fiist toast, a soft egg, scraped beef, to be followed a few days later by roast fowl and puree soups. At the end of the second afebrile week, steak, chops and green vegetables may be added. Some patients, after the acuity of the disease has subsided, continue to have an evening rise of tem- perature of two or three degrees; to such, if the noiurishment is impaired and the need of food is manifest, we may allow a gradual return to solid diet. Usually the temperature promptly subsides and no harm is done. The specific treatment of typhoid fever by means of an antitoxin has as yet given no very favorable results. The difficulty in the preparation of an antityphoid serum is that typhoid fever, unlike diphtheria, which is merely a toxaemia, is more especially a bacteriaemia. The problem, therefore, is the production of a serum which is principally bactericidal, though it probably must be, to a certain extent, antitoxic as well. Chantemesse, in his latest reports upon the serum treatment of this disease, claims that by the use of a serum taken from horses which have been immu- nized by the injection of a soluble enteric toxin he has reduced the death rate to foiu: or five percent., as against a mortaUty of eighteen percent, in other hospitals in Paris where the cold bath treatment only is used. He states the interesting fact that patients profoundly poisoned by the disease should receive small doses of the serum as against the large doses given in mild cases. He uses cold bathing in connection with his serum and con- siders the prognosis under this form of treatment best when the injections are begun early in the disease. Much experimentation has been done by various observers along the lines of serum treatment but this apparently has resulted in the production of only a very slight influence on the disease and as regards therapeusis little more has been proven than that the treatment is harmless. Treatment by Elimination and Intestinal Antisepsis. From the time 12 THE INFECTIOUS DISEASES. that typhoid fever was recognized as a distinct disease, and more particularly since it was demonstrated to be of bacterial origin, the eliminative and antiseptic treatment has been foremost in the minds of advanced clinicians. The only questions have been, can the antiseptic treatment be efficient, and, how shaU we best secure its efficiency? An extended experi- ence shows that many patients may be treated effectively by the use of such insoluble antiseptics as naphthalene, the various preparations of salicylic acid and bismuth naphtholate or tetraiodophenolphthaleinate. Of these the two bismuth salts are to be preferred. The bowels should be first flushed with calomel followed by a saline, and then the bismuth salt should be adminis- tered in divided doses of from 90 to 120 grains (6.0 to 8.0) per day. If the disease is not inhibited in the first week of the exhibition of these salts the problem is complicated by the fact that the infection has become systemic. We must now administer an antiseptic which will be disseminated as far as the blood goes and which can permeate every organ and tissue. At present the administration of the compound solution of chlorine accom.- plishes the purpose better than any other drug. It should be given in doses of one drachm (4.0) every three or four hours. In such dosage it may be given until complete disinfection of the alimentary tract is obtained; not only this; it also is taken up by the blood, as is proven by the fact that free chlorine has been found post mortem in the ventricles of the brain, and combats the infec- tion there. All the chlorine is not changed in the stomach into alkaline chlorides, but some passes through the intestine in its original form for its odor can be detected in the fasces. It is not irritating to the mucous membranes of the gastro-intestinal tract. The author considers that there is nothing in medicine more striking than the clearing up of the tongue, the improved mental condition, the lessened local disturbances and the general betterment which chlorine brings about in enteric fever and especially is it effective in the severer forms of the disease. In concluding the discussion of the treatment by chlorine it may be safely asserted: 1. That in the treatment of enteric fever chlorine can be safely admin- istered, without fear of digestive or other disturbance, until the alimentary tract has been completely disinfected. 2. That under its use the tongue becomes cleaner, the appetite and diges- tion better, the fever lower and the stools devoid of odor save that due to the chlorine. 3. The general strength, intellectual processes and nervous conditions im- prove. 4. The duration of the disease is shortened and the patient usually pro- ceeds to a rapid and complete recovery. ENTERIC FEVER. I3 The mortality should not be greater than 2 percent. Complications are rare because this form of treatment limits the infection. In children it is better to begin the administration of chlorine early in the disease, no preliminary treatment by means of the insoluble intestinal anti- septics being necessary or advisable. During the course of the disease elimination is encouraged by the use of high rectal irrigations of i gallon of normal (0.9 percent, sodium chloride) saline solution. The tube should be gently passed into the rectum for at least 12 inches, the bag or irrigator should be three feet above the patient, and the temperature of the solution 112° F. (44.5° C). The irrigations should be given twice a day. They hasten the elimination of toxic products, keep the bowels active and have a considerable stimulant effect upon the patient. If constipation is present sufficient magnesium sulphate to keep the bowels freely open should be prescribed. Treatment by Means of Cold Baths. At the present time the treatment of enteric fever by means of the Brand, or more properly the Currie-Jiirgensen bath is enjoying considerable vogue. The history of this method is a curious one. In the early period of the use of this method it was advocated because it was thought that it reduced the fever. When it became apparent to anyone who made careful observations that its effect upon the fever was transient, that almost as frequently the temperatiure rose after the bath as fell, this theory became untenable and was abandoned. But tubbing was continued without theory. Later the patients were subjected to the bath on the ground that it was a nerve stimulant. The truth of this hypothesis can hardly be affirmed or denied for it can neither be proven nor disproven. When this theory was rejected the baths were continued as before. The last and present theory is that bathing increases the elimination of ptomaines. The baths certainly are diuretic, but that they eliminate ptomaines is incapable of proof because at present we have no method by which ptomaine elimination can be accurately measured. It has been said that the urotoxic co-efficient is increased after the baths, but it is perfectly safe at the present time to say that until chem- istry shall afford a method of obtaining quantitative and qualitative results as to the toxins found in the urine all theorizing as to the increased urotoxic co-efficient must be absolutely worthless as a guide to clinical procedure. Much as the author deprecates the continued popularity of the cold bath treatment it is meet that it should receive proper description in a work of this nature. Brand's original method has been so modified that the consensus of opinion of the advocates of this form of treatment seems to be in favor of tub bathing at a temperature of from 8o°-9o° F. (26.5° to 32.5° C), although certain authorities beheve that tubbing at 98° F. (36.5° C.) produces quite as good results and is much less disturbing to the patient. 14 THE INFECTIOUS DISEASES. The technique of the procedure may be described as follows: To carry- out the process properly at least two attendants are necessary for the patient must be lifted into the tub which is placed at his bedside. The tub shoiild contain water enough to cover the patient to the neck, the head should be sup- ported upon a rubber air pillow attached to the edge of the tub and his com- fort will be augmented by placing a rubber air cushion beneath the buttocks. If the initial plunge into the cold water be disagreeable the bath may be begun at a comfortable temperature and cold water gradually added until the temperature is reduced as low as required. It is better, however, to use cold water from the beginning for the effect sought is a reaction and for this a certain amount of shock is necessary. The patient, wearing swimming trunks or covered by a sheet, should be gently lifted by two attendants and lowered into the water. Cold water — 60° F. (15.4° C.) or less — should be poured over the head or a frequently changed cool compress should be applied to the forehead. The cold water may be applied to the head by means of an ordinary irri- gating apparatus. Vigorous rubbing of the body by the hands of the atten- dants is an absolute necessity. The bath should last from 10 to 20 minutes according to the reactive power of the patient. At the end of the procedure the patient should be lifted from the tub and placed on the bed — over which a rubber sheet and a blanket have been previously spread — the water having been allowed to drain off for a few seconds to prevent wetting the blankets. Now being wrapped in the blankets he should be thoroughly dried by rub- bing. If the patient shows signs of poor reaction while in the bath, such as blueness of the lips and extremities or decided shivering, or if the effect upon the heart is untoward, the duration of the bath should be lessened and its temperature raised. In most patients chattering of the teeth may be dis- regarded and cyanosis of the extremities alone need not be considered sufficient reason for stopping the bath, but if marked blueness of the face, especially about the nose, be noticed, the patient should be immediately taken from the water. Before the patient is put into the bath and after he is taken out some authorities are accustomed to administer a glass of wine, a half ounce (15.0) of whiskey or a half to one drachm (2.0 to 4.0) of the aromatic spirit of ammonia, diluted, but these stimulants seem hardly necessary as a routine and would better be husbanded against an occasion of real need. During the bath a glass of cold water may be allowed. The patient's reactive powers may be measured by a tentative bath at 90° F. (32.5 C), reduced to 80° F. (26° C.) and lasting five minutes, and the initial temperature, the reduction and the length of the following bath may be determined accordingly. If possible the physician should be present during this bath, both to guard against the possibility of shock and to make sure that the good effects of the procedure are not lessened by too early termi- ENTERIC FEVER. 1 5 nation. If the cold tub is not well borne by the patient warm baths given in the same manner are often followed by good results. In private practice the carrying out of this method of treatment is fraught with difficulty for obvious reasons. It is best managed by procuring an ordinary tin bath tub which may be easily moved from place to place. This as well as the wheeled tubs used in hospitals should be filled freshly for each bath. The preparation of the bed for the reception of the patient after the bath is of utmost importance. All should be ready before the beginning of the procedure, so that should it become necessary to terminate the bath suddenly there may be no delay. Two warm blankets should be provided and several hot water bags as well, and an ice cap should be ready for the head. Under the lower blanket should be placed a piece of water proof cloth, over it a warm sheet upon which the patient should be laid upon being lifted from the tub. The sheet should then be wrapped about him and tucked between the arms and body so that no two skin sm-faces shall come in contact. The patient is thoroughly dried by being rubbed outside the sheet. This is then removed and he is allowed to lie between the blankets with the hot water bottles against his feet and the ice cap upon his head. About 20 to 30 minutes after the bath is over the patient will have ceased to be cold and his temperatmre should be taken to ascertain the effect of the procedure; it should be taken again three hours after the beginning of the bath in order to learn if a second is necessary, it being the custom to give the cold tubs every three hours if the temperature reaches 102.5° F. (39.1° C.) or more. The fall in temperature following the bath varies in different cases as well as in the different weeks of the disease. In the first week it may not fall so much as one degree, but in the later weeks drops of from two to three degrees are common. In addition to the lowering of the temperatiure the bath is said to mitigate the other symptoms, increasing the strength of the heart, and lessening the tendency toward cerebral distmrbance. Contraindications to bathing are few. The menstrual period and preg- nancy do not contraindicate but at the slightest sign of haemorrhage, peri- tonitis or perforation the procedure should be stopped. Extreme heart weak- ness, marked arteriosclerosis, old age, and complicating pneumonia, pleuritic effusion, or phlebitis are contraindications. Obese patients should be bathed with care. There are certain persons who, for no apparent reason, do not bear tubbing well. In such it is wise to omit the process. The Bed Bath. In cases where tub-bathing is inconvenient or impossible the bed or slush bath may be employed. Many patients to whom the cold tub is almost unendurable bear it well and are favorably affected by it. It is given upon a bed around the edges of which rolled blankets have been placed 1 6 THE INFECTIOUS DISEASES. SO as to form a sort of wall. Over this is placed a rubber sheet and into the trough thus formed several pails of water are poured. The patient is placed in this and treated just as when the tub bath is employed. The bed bath may be constructed also by passing a piece of clothes line around the head and foot of the bed, connecting these by two parallel ropes and throwing over the whple a rubber sheet which is attached to the rope by clothes pins; or a rectangular fence about eight inches in height and slightly smaller than the mattress may be constructed over which a rubber sheet may be thrown. The water from these improvised tubs is best drawn off by a siphon made of a few feet of rubber hose. The sponge hath is indicated when the temperature is hardly high enough to warrant the more drastic tub bath and yet is sufl&ciently elevated to cause discomfort. In any case the patient should receive two sponges daily for the sake of cleanliness. The method is as follows : The water may be of various temperatures as indicated; often the addition to it of a little alcohol is grateful to the patient. An ice cloth should be applied to the head and a sponge or soft cloth wet just sufl&ciently to leave a thin film of moisture on the skin is used; this cools the patient by rapid evaporation and does not wet the bed clothing and with it he is thoroughly rubbed, while the other hand is performing friction, and then dried, one part at a time. Care should be observed to keep the portions of the body not being sponged, covered. Particular attention should be given the back for here the tissues retain heat longest. Proper reaction is evidenced by redness of the skin. No such effect is pro- duced upon the temperatiure by sponging as by tubbing. The sprinkle hath as a method for the reduction of temperature may be considered to rival the tub bath. It is better borne by many patients and is of peculiar adaptation to private practice. The technique is as follows: The head of the bed should be raised about lo inches from the floor, and, to keep the mattress from sagging, crosswise under it should be placed several boards as long as the width of the bed. The mattress should be covered with a rubber sheet upon which a pillow and ordinary sheet are adjusted. The patient should be stripped and sprinkled with water of the desired temperature from a watering pot or from an irrigating apparatus to the tube of which a sprinkling nozzle is fitted. The water as it flows from the foot of the bed is received in any large vessel and may be used over and over, the proper temperature being maintained by the addition of ice. The water should not be poured from too great a height and should be applied chiefly to the abdomen and legs. Rubbing with the hands should be con- tinued throughout the procedure, otherwise the patient should be dealt with exactly as in tub bathing. The wet pack is another useful hydrotherapeutic procedure less unpleasant lo the patient than the tub. The body from the axillae to the groins is ENTERIC FEVER. 1 7 wrapped in a sheet which is kept cool enough by repeated wettings to con- trol the temperature. Antipyretic Drugs. Certain drugs of this class, such as antipyrine, acetphe- netidin, acetanilide. pyramidon, etc., may be used in excessively high tempera- tures but they are not to be recommended because of the possibility of their causing cardiac depression. Neither do they, although they may bring about a fall in temperature, act favorably upon the other symptoms of the disease. Lactophenine, in daily dosage of 60 to 75 grains (4.0 to 5.0) m^ay cause a prompt fall in temperature, quiets the nervous system and induces sleep. Quinine and euquinine also cause the temperature to drop, but none of this class of drugs affects the course of the disease and they are not to be recom- mended save as adjuncts to other forms of treatment. Treatment by intestinal antiseptics other than chlorine has been frequently advocated. Among the drugs discussed in this connection may be mentioned: Phenyl salicylate (salol) in doses of from 5 to 10 grains (0.33 to 0.66) four to five times a day. The possibility of injuring the kidneys more than over- balances any possible good effect that this drug can accomplish. Thymol in the same dosage is open to the same objections. Calomel as an intestinal antiseptic is practically inert and the good effects reported from its use have doubtless been due to the free purgation in the early period of the disease which its exhibition induces. Betanaphthol in 5 to 10 grain (0.33 to 0.66) doses three or four times daily, is claimed to be capable of causing intestinal antisepsis without toxic symp- toms. Its use is recommended in combination with bismuth salicylate when there is diarrhoea, with magnesium sulphate when there is constipation. It is asserted that under the influence of this drug there is less tendency to ab- dominal pain and tympanites, the tongue becomes clear, the stools odorless, convalescence advances rapidly and there is a diminished tendency to com- pUcations. Phenol and iodine, one part to two in doses of one to three minims (0.065 to 0.2) well diluted, three to six times a day have been recommended. Naphthalene is objectionable on account of its large dosage, unplea,sant taste and liabiUty to cause strangury. Beer yeast, three teaspoonsful (12.0) in milk per day, has been given in the hope that its micro-organisms might inhibit the growth of the typhoid bacilli in the intestine, but little is to be accom- pHshed by this agent save a checking of the diarrhoea. Acetozone is the commercial name given to a mixture of benzoyl-acetyl peroxide, an inert absorbent substance. It is administered as an intes- tinal antiseptic, the daily dosage being 10 to 20 grains (0.66 to 1.33) dissolved in a quart of water. Various observers have reported favorably upon this preparation, claiming that when taken early in the disease and in large amounts the course is shortened to 10 to 12 days. Also under its influence l8 THE INTECTIOUS DISEASES. the abdominal, nervous and other symptoms are less marked than usual. There is much difficulty in inducing patients to take sufficient amounts for long enough periods of time. Treatments by Means of Intestinal Antiseptics and Free Elimination. The object of these methods is to render the alimentary tract as aseptic as possible and to remove without delay the cause and products of the infection. As far as the antiseptic part of the treatment is concerned it differs in no way from the methods hitherto described, but added to these is the free exhibition of purgatives, which are given to carry off the fascal accumulations, the patients being encouraged to drink large quantities of fluid to replace that removed by purgation. The simplest of these forms of treatment is as follows: This consists of the daily administration of calomel in ^ to J grain (0.016 to 0.032) every half hour up to six doses; two or three hours later one-half ounce (15.0) of Epsom or Rochelle salts is given. The object is to bring about three to four free movements per day. Phenyl salicylate (salol) in five grain (0.33) doses, every three hours, is the antiseptic used in connection with this treatment. The claims are not excessively extravagant, but it is believed that under this treatment haemorrhage and perforation are rendered less frequent. The possi- bility of salivation from the calomel must be considered, but it is not likely to take place, probably because of the frequent movements from the bowels. Another method of treatment which at one time created a considerable amount of discussion is as follows : Tablets consisting of podophyllum resin 1-960 grain (0.00067), calomel 1-16 grain (0.004), guaiacol carbonate 1-16 grain (0.004), menthol 1-16 grain (0.004), eucalj-ptol, q.s. were ordered. One of these tablets was given every 15 minutes during the first 24 hours and in larger doses during the second day, if necessary, until at least five or six free defse- cations had taken place during the second and third day. On the third or fourth day tablets containing podophyllum resin 1-960 grain (0.00067), calomel 1-16 grain (0.004), guaiacol carbonate J grain (0.016), menthol 1-16 grain (0.004), thymol 1-16 grain (0.004), eucalyptol q.s. were prescribed; one every two or three hours. Both these tablets were given at longer intervals if there was a faU in temperature. On the fourth or fifth day guaiacol carbonate three grains (0.2), thymol one grain (0.065), menthol J grain (0.033), eucal- yptol five minims (0.33) were administered in capsules, one every three hours alternating with the tablets. This plan of treatment in some instances failed to accomplish the result claimed for it and is now in little vogue. Treatment of Special Conditions and Symptoms. The mouth and tongue should be kept clean by the employment of regular and frequent washings with diluted liquor antisepticus, tincture of myrrh, etc. A very useful mouth wash consists of equal parts of liquor antisepticus, hydrogen dioxide solution, lime water and water. The mouth should be cleansed after every administra- ENTERIC EEVER. 19 tion of food and there is no contraindication to the use of the tooth brush. Sordes and coating upon the tongue may be removed by cotton swabs wet in one of the above mentioned solutions. A convenient tongue-scraper may be constructed of a piece of whale bone bent into a loop. In cases where the tongue is extremely dry the " tongue-bath " often affords much relief. This consists simply in holding the mouth full of fluid for several moments. In this way considerable moisture is absorbed by the mucous membranes. Heart Weakness. In this condition it is better not to use alcohol unless the patient has been accustomed to the stimulant in health. In such a case it may be employed (brandy or whiskey) in doses necessary to produce the desired effect. As a heart stimulant strychnine — 1-60 to 1-15 of a grain (0.00 1 to 0.004) depending upon the condition to be met — is the stimulant of choice. Extreme heart weakness may necessitate the additional employ- ment of digitaHs — the tincture 5 to 10 minims (0.33 to 0.66) — glyceryl nitrate — i-ioo to 1-50 of a grain (0.0006 to 0.0012) — or aromatic spirit of ammonia — one to two drachms (4.0 to 8.0.) Collapse may be treated by hypodermatic injections of camphor — one grain (0.065) — ^^^ olive oil or «ther — 15 minims (i.o). Marked asthenia may necessitate the intravenous infusion or hypo- dermatic injection of normal (0.9 percent.) sodium chloride solution. Symptoms Referable to the Nervous System. The headache and general pains of the onset may be mitigated by antipyrine salicylate in 10 grain (0.66) doses every two hours, and by hot or cold applications. The delirium may be controlled by the use of the ice cap, and various sedatives, sodium bromide ^ to I drachm (2.0 to 4.0), sulphonmethane (sulphonal) 15 to 20 grains (i.o to 1.33); chloralformamide 20 to 30 grains (1.33 to 2.0), sulphonethyl- methane (trional), 10 to 15 grains (0.66 to 1.0); hydrated chloral or morphine may be employed as a last resort, the latter best hypodermatically as Magendie's solution, 10 drops (0.66). Tympanites may be lessened by the very careful introduction of a rectal tube, through which large quantities of gas are often voided, and by the internal administration of oleum terebinthinse, 5 to 10 minims (0.33 to 0.66) in capsule. The food should be diminished in quantity as the meteor- ism is the result of fermentative processes. High rectal irrigations of nor- mal saline are also useful in this connection. Diarrhxa, if obstinate, may usually be controlled by the use of bismuth, with the addition of opium if necessary. Constipation is best treated by the use of saline enemata, though certain observers, as will have been noticed in the foregoing sections, have no objection to the use of calomel and other purgatives. Bed sores should never be allowed to occur and may be prevented by atten- tion to the points where they are likely to appear. The strictest cleanliness must be maintained about the back of the heels and over the buttocks and 20 THE INFECTIOUS DISEASES. sacrum. The sheets must be kept smooth and the bed thoroughly clean and free from crumbs, moisture and contamination from the rectal or vesical discharges. In addition to the maintenance of careful cleanliness, measures should be taken to harden the skin of the susceptible parts. To insure a good blood supply to these the patient should be turned upon his side several times a day and the skin of the back thoroughly rubbed with a dry towel and dusted with powdered talc. Applications rubbed into the skin to harden it, such as salt, two drachms (8.0), to whiskey, one pint (^ litre), or a dilute solution of lead subacetate may be employed. When the skin becomes red and irritated but is still unbroken it should be painted with a solution of silver nitrate, 20 grains (1.33) to one ounce (30.0) of water. When the bed sore has appeared, with the object of preventing its spread and of accelerating its cure, the patient must be so placed as to take all weight from the affected part, this may be accomplished by the use of a rubber bed ring. The sore itself must be kept clean by swabbing with i to 5000 mercury bichloride solution and dusted with iodoform. A dressing of zinc oxide ointment spread upon gauze may be apphed. In marked cases the use of the water bed may become necessary. If the sore spreads or burrows through the surrounding parts free opening and thorough irrigation are indicated. Complications should, in general, be treated as when occurring independ- ently, but the treatment of intestinal haemorrhage, peritonitis and perfora- tion needs special consideration. Upon the appearance of any symptom suggestive of hemorrhage all hydro- therapeutic measures should be stopped immediately and absolute quiet insisted upon. An ice coil should be applied to the abdomen and the food should be of the most non-irritating character; it is often wise to stop feeding entirely for six or eight hours. If the hsemorrhage is extreme a hypodermatic injection of from ^ to ^ of a grain (0.016 to 0.022) of morphine should be given and the foot of the bed should be elevated. The administration of morphine or opium has the disadvantage that it may mask the symptoms of a concur- rent perforation of the intestine and on this ground certain clinicians con- sider it better omitted. If symptoms of collapse are present hypodermatic stimulation by means of aether or camphor with sterile oil is necessary. In this connection hypodermatoclysis of hot normal saline solution or direct infusion into a vein is also useful. The most efl&cient drug in the control of the haemorrhage is calcium lactate in doses of 20 grains (1.33) three times daily. Calcium chloride is also effective, both these substances having a decided influence in increasing the coagulabihty of the blood. Their use should not be continued for more than three or four days for their more pro- tracted administration is likely to result in a diminution of the blood's coagu- lability. Gelatin in doses of 75 to 120 grains (5.0 to 8.0) has been recom- mended in the treatment of haemorrhage, and ergot — | drachm (2.0) of the ENTERIC FEVER. 21 fluid extract — also has its advocates. Internal styptics such as tannic and gallic acids, lead subacetate, etc., may be employed but their effect is prob- lematical. Perforation of the intestine and peritonitis necessitate early operative treat- ment and by this means many patients are now saved who under less radical treatment would formerly have died. The earlier the operation is under- taken after the establishment of the diagnosis the better are the chances of recovery. Operation should be performed even in desperate instances and when the condition is obscure an exploratory incision is advisable, the resis- tance to the shock of operation being usually good in typhoid patients. Such surgical complications as periostitis and cholecystitis often recover without operation but when the presence of pus is clearly demonstrable radical treatment should be undertaken. Nevu-itis following enteric fever is frequently characterized by paralysis and although its symptoms may persist for months, as a rule recovery takes place under the influence of massage, electricity and general tonic treat- ment. The so-called typhoid spine may prove an obstinate sequel of the disease; it is usually accompanied by a nemrotic condition of the patient and requires practically the same treatment as neurasthenia, namely, rest in an institution where anxious and sympathetic friends are not given access to the patient, hydrotherapeutic measvires, massage and proper exercises. The application of the acutal cautery may prove effective. During convalescence the patient should be guarded against recrudescences and relapses, the treatment of which, should they occur, is practically the same as that of the original attack. With regard to diet it may be stated that if the patient's nutrition remains good it is best to allow no solid food before the 7th to the loth day after the return of the temperature to normal; solid food may be permitted earlier than this to patients who are weak and much emaciated and in certain instances a persistent slight afternoon fever has been known to subside upon giving the patient simple solid food. The danger of inducing perforation by the too early administration of solids, however, must not be forgotten and the same is true of too early muscular exertion. The first solid foods usually allowed are scraped raw beef sandwiches, soft boiled eggs, milk toast, boiled rice and other cereals. These should be given tentatively and with caution at first and if no ill-effects follow, their quantity may be increased and a gradual return to ordinary diet permitted. As stated, muscular exertion should be undertaken with great care and any excess of this as well as of emotional excitement should be studiously guarded against upon the ground that recrudescence may follow. Protracted diarrhoea is often due to the presence of an unhealed ulceration 22 THE INFECTIOUS DISEASES. and in view of possible perforation the patient should be kept in bed and on a fluid diet until there is evidence that the lesion has disappeared which will usually take place if bismuth naphtholate or tetraiodophenolphthaleinate is prescribed in doses of about 5 grains (0.33) three or four times daily in con- nection with astringent injections such as those advised for the treatment of ulcerative colitis. Obstinate constipation is better treated by simple enemata than by drugs. With regard to the time when the patient should be first allowed to sit up, in general it may be said that by the end of the first week after the return of the temperatiire to normal he may be moved to a chair for a gradually increased time each day and after a few days he may venture upon his feet and walk about slowly. Little by little he may resume his ordinary mode of life. PARATYPHOID FEVER. This is a term applied to a group of diseases which in clinical course closely resemble true enteric fever. jEtiology. The cause of these affections is a micro-organism intermediate between the bacillus typhosus and the bacillus coli, and closely simulates or is identical with the paracolon bacillus. The modes of infection are probably similar to those of enteric fever. Pathology. The morbid changes found in these affections consist of constant splenic enlargement and intestinal ulcerations resembling those of dysentery rather than those of enteric fever. The solitary and agminated follicles and the mesenteric glands are not involved. Rose spots have been observed. Symptoms. The incubation period is shorter than that of enteric fever and the onset, which may be preceded for several days by prodromata such as malaise, headache and torpor, is usually more sudden. The lethargy appears earlier and this symptom as well as the headache is, as a rule, more marked. The temperature rises more rapidly than in enteric fever; an initial temperature as high as 104° F. (40° C.) has been noted. Splenic enlargement and rose spots occur. The course of the disease varies; it may be short or, in other instances, prolonged; convalescence is usually shorter than in enteric fever; relapses may occur. The differentiation from enteric fever is based upon the absence of the Widal reaction and the causative micro-organism may be cultivated from the faeces, urine, the blood and from the rose spots. The disease may result fatally, but most patients recover. The prevention of paratyphoid infections is identical with that of enteric fever. MOUNTAIN FEVER. 23 Treatment is essentially the same as that of enteric fever with the excep- tion that serum employed in specific treatment must of necessity be a product of the growth of the paracolon bacillus. MOUNTAIN FEVER. Synonyms. Rocky Mountain Fever; Spotted Fever. Definition. An acute infectious disease characterized by a typical skin eruption, a chill and high fever. .Etiology. The disease occm-s in the Rocky Mountain region of Idaho, Montana, Wyoming and Nevada; it is especially common in the Bitter Root valley. It is most likely to prevail in the spring and early summer, being very rarely observed at other seasons. Males are more commonly affected than females and the disease attacks individuals in early or mature adult life. It occurs less frequently in children. Persons who live in farming or grazing districts and who spend most of the time in the open air are most prone to infection. Observers residing in regions where the disease is common have con- sidered its specific cause to be the pyroplasma hominis, an organism nearly related to the pyrosoma bigeminum (the cause of Texas cattle fever) ; this parasite is found within the body of the red blood cells and is transmitted to the patient through the bite of a tick, the dermacentor reticulatus. Symptoms. The period of incubation is from 3 to 10 days, being char- acterized by prodromal symptoms consisting of malaise, nausea and sen- sations of cold. The invasion of the disease is marked by a distinct chill followed by an abrupt rise of temperature which by the second day reaches 103° to 104° F. (39.5°-4o° C.) and by the 8th to the loth day may increase .0 an afternoon maximum of 105° to 107° F. (4o.5°-4i.6° C.).. The morning temperature is slightly lower than that of the evening. About the middle of the 2d Week the temperature falls by lysis, usually reaching normal by the 14th day. With the initial rise in temperature there is general pain in the body and limbs; during the 2d week nose-bleed, more or less severe in character occurs; the tongue is coated down the middle, red at the tip and edges; nausea and vomiting and usually constipation are present. The urine is scanty, dark, and contains an increased amount of urates; albumin and casts may be present. The spleen and liver are increased in size and the conjunctivas may be of subicteroid hue. The pulse is weak and rapid; the respirations are rapid and regular but shallow. They may reach 60 per minute but are usually about 40. Bronchitis may develop at the end of the istweek. In severely infected patients the mental condition may resemble that of enteric fever. The leucocytes may be slightly increased, there is destruction of the red cells and diminution in the amount of haemoglobin. 24 THE INFECTIOUS DISEASES. The eruption appears from the 3d to the 5th day, first upon the wrists, ankles or back, thence it spreads to the arms, legs, forehead and body, the abdomen being last involved. The spots may appear so rapidly as to cover all the skin within 12 hours, but usually two to three days pass before the height is reached. The rash first consists of bright red circular spots from the size of a pin point to that of a pea; they are not elevated and in the beginning dis- appear on pressure; they may be tender and in severe types of the disease are dark blue or purplish in color and increase in size until the skin assumes a mottled appearance. They begin to fade at the end of the first week and lose their petechial character as the fever declines. Desquamation begins during the third week but the spots may not wholly disappear for weeks or months. The skin may become jaundiced or gangrenous over the elbows, fingers, toes or scrotum. The prognosis in the severer types of the affection is bad; in the Bitter Root valley the disease is particularly fatal, 84 deaths out of 121 instances of the disease having been reported. In other regions the mortality is less great. Death usually occvirs during the 3d week, in some instances com- phcations, especially pneumonia, being responsible. Prevention. The districts in which the disease is common should be avoided during the months in which mountain fever is prevalent. Measures to avoid tick bites should be taken and when these have taken place the insect should be at once removed by the application of kerosene, ammonia or tur- pentine and the wound cauterized by pure phenol. Treatment. This is in general symptomatic. The employment of quinine given in large doses hypodermatically has given favorable results in a few cases. The temperature may be controlled by the hydrotherapeutic measures indicated in enteric fever; the bowels should be kept open and the severe pains may be relieved by the administration of Dover's powder or small doses of morphine. The diet and general management applicable in enteric fever are indicated. TYPHUS FEVER. Synonyms. Jail, Camp, Ship, Hospital, Putrid or Spotted Fever; Black Death. Definition. An acute infectious disease characterized by a typical skin eruption, nervous symptoms and a high temperature terminating usually by crisis in about two weeks. .Etiology. Typhus, while comparatively rare during the past few decades, was formerly one of the world's greatest scourges. Its gradual disappearance is undoubtedly due to the increased attention paid to sanitation and the education of the masses along general hygienic lines. TYPHUS FEVER. 25 The disease is of markedly infectious nature but up to the present its specific cause has not been determined. It is most common in young adults but no age is exempt. Its occiurence is favored by crowded and filthy conditions, unhygienic surroundings and mode of life, poor ventilation and famine. ■As these factors are becoming year by year less conspicuous features of our civilization there is every reason to hope that the disease will ultimately dis- appear from the earth. Isolated cases at times have occiu"red, but despite this evidence and the fact that Murchison considered the spontaneous origin as possible, it is not to be regarded as a probability in the light of present day knowledge. While the nature of the contagion is unknown it is recognized that it is of easy acquirement and difi&cult of destruction. It seems to be transmitted through the atmosphere and to be given off from the patient's body. Con- sequently it is communicable from one person to another and through furnitiure, bedding, clothing, etc., to which the poison of the disease clings for long periods. It is said that the contagium cannot pass through the air from hospitals or other structures in which patients suffering from the disease are confined, to dwellings in the vicinity. To acquire the infection intimate and fairly con- tinuous association with the patient seems to be necessary, consequently nurses are much more frequently affected than physicians who are with the sufferer for but a few moments each day, unless indeed these latter are in attendance upon a typhus hospital or ward. It has been thought that the contagium is given off from the skin and in the expired air; it may, however, be in all the body excretions and discharges for anything that is certainly known to the contrary. Pathology. There are no characteristic post mortem lesions. The tissues show the changes which always accompany acute febrile disease of severe type. The petechial eruption persists after death, in contradistinction to that of enteric fever, and bed sores may be present ; the blood is dark and fluid. The spleen and lymph glands are enlarged and soft, the kidneys and liver may be increased in size. The tissues, including the muscles, and particularly that of the heart, and organs are in a condition of acute degen- eration (cloudy swelling). There is no intestinal ulceration; the lungs are frequently the seat of hypostatic congestion and there may be evidences of bronchial inflammation. Symptoms. The incubation is from 10 to 12 days and while the invasion is usually sudden general malaise may occur before this event takes place. The invasion is marked by one or more chills followed by fever and headache and severe bodily pain especially in the back. After the initial chill the tem- perature rises rapidly and reaches its maximum (104° to 106° F. — 40° to 41.1° C.) from the fourth to the seventh day. The patient is greatly prostrated, his tongue is coated and soon becomes dry, nausea and vomiting are commonly 26 THE INFECTIOUS DISEASES. present, the eyes are suffused and the expression is apathetic. Bronchitis is frequent. The bowels are usually constipated. After reaching its maximum at the end of the first week the fever continues with sUght morning remissions for from 12 to 14 days. At the end of this period it usually begins to fall by crisis and may drop to a subnormal level within 24 hours. Death in severe infections may be preceded by a tempera- ture of 108° to 109° F. (42.2° to 42.7° C). The pulse is at first rapid and full but soon becomes weak and perhaps dicrotic as the disease progresses; the first sound of the heart may be indis- tinct and a systohc apical murmur may be present. The respirations are rapid, their rate often being further increased by DISEASE L 2 ■3 4 .5 G 7 s 9 10 1: 12 13 14 15 16 17 18 [^ 20 21 ""'" "" viiM kk ^ i^ Li - - LI i^ 1^ -i ii Li i^ LI Li iii ^ i^ ij_ ^ ,~j -+ ^- -^ — — L- -J- -+- — j— H^ — - -42 107 - -^ — 1- _j_ i_ — p — '— — ^ — —J— — — — — E-ii° - ^ C- 105' = A S p 1 1 3 = EE EE =:^ =rE ^ E^ EE EE 5 104- E. los' = a z: -^ ^ ^ — 1 = w p = ^ 1 1 = i 1 1 ~— =E E= E o5 -40 2 5 102 = zz: z£ = ^ ^ EE E^ EE = = = = ^ z-89°S S ,,,.- — — — 1 — — — ^ — — — — - ^- ^- — :- Z 3 -— = rr rz EE EE -- iE =r ~z ZZ = EE :zz z~ zz: a 100 - ir — ^ B= rz == E= e: EE 4 ^ S EE ^ EE ^z EE — 3S ^ k a, - •? 98- --- — 1 — — — 1 -i- -^ - ^7° E£ ^ == =^ — ~ E^ =E =E ^ 1 ^ ~ EE :^z m = 9fi- — ^ =^ == ^ ± ziz 3= EE EE Z3 ^ ^ ^ ^ = ± ^ 1 1 ^6° Fig. 2. — Clinical chart of typhus fever ending in recovery. pulmonary congestion, bronchitis or a co-existent broncho-pnemnonia which may be foUowed by pulmonar}^ gangrene. The urine is scanty and high colored and frequently contains albumin and casts. There may be a slight increase in the number of the leucocytes, the opposite of this condition obtaining in enteric fever. The eruption is constant and appears on the third to the fifth day; its evolu- tion is rapid. It presents itself first upon the chest and abdomen and, quickly spreading to the limbs and face, involves the whole body within two or three days. The rash consists of two elements: a dark mottling of the skin char- acterized by blotches of light or dark purple; these may be rendered lighter TYPHUS FEVER. 27 in color by pressure and at times become the seat of subcutaneous haemor- rhage; and a slightly raised petechial eruption. This is pinkish in color and resembles the rash of enteric fever, disappearing at first on pressure but later persisting; these spots also are hasmorrhagic and like the mottling persist post mortem. After the eruption, which lasts from 7 to 10 days, has disappeared desquamation usually takes place. Children, in whom the disease is seldom fatal, may show no rash whatever, or the skin may be covered by an eruption not unlike that of measles. Diuring the second week all the symptoms become more marked. The prostration is severe, and delirium changing into stupor with subsultus tendi- num, nystagmus and even coma vigil, develops. The tongue is cracked and dry, the teeth are covered with sordes, the temperatiure is persistently high, the pulse rapid, weak and perhaps dicrotic, the respiration is accelerated and the patient may die exhausted by the infection. In the event of his recovery the temperatiire rapidly falls by crisis and a deep sleep occiurs from which the patient awakes greatly improved, the mental and all other symptoms being in a much ameliorated condition. The convalescence now progresses unless a relapse, which rarely takes place, occiurs. Variations in the coiuse of the disease may be observed. Both malignant forms, in which death supervenes within a few days, and mild types with only slight rise in temperature and the other insignificant symptoms, are described. Complications. Of these broncho-pneumonia is the most frequent. Gan- grene of the extremities, paralysis and septic infections such as subcutaneous abscesses, parotitis and arthritis may occur. Noma has been observed in children. The diagnosis in epidemics is easily made but isolated cases may be mis- taken for enteric fever, from which typhus fever may be differentiated by its more rapid initial rise in temperature and otherwise more sudden invasion, by its eruption and the absence of Widal reaction. In malignant smallpox the more common occurrence of haemorrhages is an aid in differentiation. Epidemic cerebrospinal meningitis at the onset may closely resemble typhus fever but after a few days the diagnosis is usually clear, and malignant measles may be differentiated by the accompanying conjunctivitis and coryza and the fact that other cases of measles are in the vicinity. The eruption of measles is of brighter red, presents itself first on the face and is Kkely to be crescentic in form. The prognosis varies in different epidemics ranging at times as high as 50 percent., the usual figures are, however, from 12 to 20 percent. In children the disease is seldom fatal. Treatment. Patients suffering from typhus fever should be strictly isolated, preferably in tents where the free ventilation not only exerts a favor- 28 THE INFECTIOUS DISEASES. able effect upon the patient but renders the physicians and attendants less likely to contract the disease. The fever should be controlled by the hydro- therapeutic measures employed in typhoid fever. By these means not only is the temperatm^e lowered but a favorable influence is exerted upon the nervous system. Coal tar antipyretics should not be relied upon although they may be occasionally prescribed in connection with other antipyretic treat- ment. Their weakening effect upon the heart should never be lost sight of, and if given, these drugs should be administered in connection with stimu- lants which shall counteract this action. Heart stimulants are indicated early in the disease and of these alcohol in the form of whiskey or brandy is to be preferred ; digitaUs and strychnine are also useful in this connection. Quinine is strongly recommended. Attacks of cardiac failure should be combated by the hypodermatic administration of gether and camphor and the general treatment of symptoms is practically identical with that indicated in enteric fever. The bowels should be kept freely open from the onset of the disease, it being usual when seeing the patient for the first time to prescribe a course of calomel in fractional doses to be followed by a saline laxative. The specific treatment by means of the sulphocarbolates, phenol and other antiseptics is probably useless. In the treatment of this disease the one fact to be kept in mind is that sufl&cient stimulation is necessary to counteract the continued tendency to heart weakness. In order to control this symptom the dosage should be regulated in accordance with the patient's condition. In markedly asthenic states the administration of as much as an ounce (30.0) or more of whiskey hourly may be necessary. The diet should be entirely of fluids during the febrile stage, milk either plain or in the form of punch with egg and brandy, nourishing soups and the like should be frequently given. As convalescence becomes established soft solids and a gradual return to ordinary diet may be allowed. (See diet of enteric fever, pp. 10 and 11.) When the disease is treated in hospital wards or private dwellings the most thorough ventilation must be insisted upon. During the coiu-se of the disease the excreta and aU articles which come into contact with the patient should be disinfected and if possible destroyed. After recovery the patient's room and its contents must be thoroughly fumi- gated. MALTA FEVER. Synonyms. Mediterranean Fever; Neapolitan Fever; Rock Fever; Undu- lant Fever. Definition. An acute infectious disease typified by an irregular tem- perature, profuse sweats, diffuse pains and a tendency to relapse. MALTA FEVER. 29 etiology. This disease prevails at Malta and in other countries whose shores skirt the Mediterranean Sea. While infrequent in other regions it has been observed in the West and East Indies, in China and the Philippines. While one or two cases have made their appearance in England none has ever originated in the United States. Malta fever attacks young adults most frequently and prevails chiefly in the summer; its occurrence is favored by unsanitary conditions. The specific cause of this affection is the micrococcus melitensis. This organism is found in the spleen in all cases which have come to autopsy but as yet has not been isolated from the blood. When inoculated into monkeys a similar disease to that occurring in human beings is produced and the micrococcus may be isolated from the tissues of the infected animals. The organism probably enters the body either upon the inspired air or in drinking water; in one instance the infection has taken place through the conjunctiva. It has been shown that the blood of patients siiffering from Malta fever causes agglutination of pure cultures of the bacillus. Pathology. No definitely characteristic lesions are found in patients dying of this disease. It has been stated that the spleen is enlarged and that other typical lesions of enteric fever are present. Symptoms. The incubation period is from a few days to three or four weeks. The invasion of the disease is gradual without chill or marked rise in temperature, but is accompanied by malaise, headache, restlessness and anorexia. These symptoms persist from one to three weeks when the tem- perature falls and remains normal for two or three days, when it rises once more, is accompanied by chills, associated with which is the return of the other symptoms previously mentioned. This relapse lasts a month or six weeks when a second remission takes place. This may last from one to two weeks and is succeeded by a second relapse which is accompanied by more marked symptoms than the first, and in addition others such as sweats, joint pains, effusions, constipation, inflammations of the fibrous tissues, and orchitis; following this is a third remission, after which in turn another relapse appears, characterized by the symptoms of those preceding, with high fever, night sweats and severe pains. The spleen is as a rule enlarged and may be tender. The characteristic features of this disease consist in the recurrence of rises of temperature lasting from one to three weeks and separated by afebrile intervals lasting a few or more days. The relapses may recur for two or three years but the usual length of the disease is three or four months. The fever, pain and other symptoms, if long continued, must necessarily exert an exhaust- ing effect on the patient which may prove fatal. Cardiac and pulmonary complications may augment the severity of the disease and become factors in its fatal outcome. Variations in the type of Malta fever occur, a malignant variety, which 30 THE INFECTIOUS DISEASES. . may result fatally within one or two weeks and a mild form with few symp- toms save an evening rise of temperature having been described. One attack of the disease is likely to confer immunity, for several years at least. The differential diagnosis from enteric fever may be made by means of agglutination tests. The prognosis is usually favorable, the mortality being put at about 2 percent, by most observers. Treatment. No drug has a specific effect upon this disease. Attempts have been made to elaborate an antitoxin and at least one patient seems to have been successfully treated by this means. The bowels should be kept open and the kidneys active. Hydrotherapeutic measures, particularly sponging with cool water, should be employed to control the temperature and the symptoms should be relieved by the methods applicable in like conditions, such as those which occur in enteric fever. Recently it has been suggested that an exclusively milk diet is unnecessary unless the temperature runs above 103° F. (39.5° C). To patients whose evening temperature does not rise above this point easily digestible solids such as the cereals, eggs and bread are allowed in addition to milk and broths. Even fish and meat are permitted if no iU-effects result from the lighter solids. During convalescence the patient's exhaustion and ansemia should receive tonic treatment, he should keep in the fresh air as much as possible and his emaciation may derive benefit from inunctions of codliver oil and lanoline. A change of climate, when the patient is able to travel, is distinctly indicated. RELAPSING FEVER. Synonyms. Famine Fever; Recurrent Typhus; Spirillum Fever; Seven Day Fever. Definition. A specific acute infectious disease characterized by a febrile movement lasting six or seven days, followed by an afebrile interval of about a week, after which the febrile paroxysm recurs and may be repeated three or four times. Etiology. The most favorable conditions for the development of this disease are those of over-crowding, famine and filth, just as is the case with typhus fever. It is common in East India and has prevailed at times in Europe and the United States. It has not been observed, except in isolated instances, in this country, however, since 1869. Age and sex seem to have no influence upon its incidence. The specific cause of the infection is the spirochaete of Obermeier which was discovered in 1873. This organism is a spiral shaped bacterium in length from three to six times the diameter of a red blood cell. It is found in the blood, but only during the febrile stage; it has never been demonstrated RELAPSING FEVER. 31 in the secretions or excretions. The disease has been produced in human beings and monkeys by the injection of blood from a patient during the febrile stage. Formerly it was believed that recurrent fever was transmitted by means of fomites but the more recent studies of Tictin tend to confirm the idea that it may be carried by means of suctorial insects such as bed bugs, since blood taken from one of these insects which had bitten an infected individual has produced the disease when injected into apes. One attack of the disease does not confer immunity. Pathology. No typical morbid changes are observed after death from this disease. During the febrile movement, however, the spleen is enlarged, and the viscera are swollen and are the seat of an acute degeneration. DAY OF DISEASE 1 2 3 4 5 [^ n m r^ N 11 p [^ 14 15 pn 17 is|i 9 20 21 ^42° HOUR A P a!p ft p A P A P M fi £ M M M M £ M £ iS ^M S S £ p mIu M M« MU p M M M _ _ _ _ _ _ _ _ _ 1 _ _ ^ _ _ 107 - - — - - - - " - - — — — ' — — — 1 loe' ^ - = i = = = = = : ; = z = z = I z ^ I = zz : z 1 104 = — ^ E 5 = = = z r = = ^ z = : = E $ i z ^ zz z z - oS -^ - ^ -4 — - - - - - f- - — - P - H - — 1 - - - 103 -~J z - -.- -f -t- J n - - - - - P 4 - - - - 1 - - — f a f 102 ^39° B z < a 101 - - - - -- — - - - — - - - - - - - - - - --- - ^ 100 - - -- -- -^ - - — - - - - - - - p - - - a. — 38°3 - — — 1 — - - — - - — - - - - - - — - - 09 - - - — — 1 — - — - ^ — - - - — - - - - - - — - — _ p _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. — — -1 — ' — — — — ~~ I— — — — — -^ r- — - — -1 : 9f? 97' : 96 1 — 1 — 1 1 — 1 1 — 1 — 1 — I — 1 1 — 1 1 u 1 — 1 — 1 1 — 1 — 1 — L 1 — 1 — 1 — 1 — 1 — 1 1 — 1 — 1 — 1 — Fig. 3. Clinical chart .of relapsing fever. The skin may be jaundiced and ecchymotic and the bone marrow is in a state of hyperplasia. Symptoms. The incubation period is usually about one week although the symptoms in certain instances may appear within a day or two after infection. The onset is sudden with a chill followed by fever, malaise and general pains; nausea and vomiting may occur and sweating is common. The temperature rises rapidly and may reach 104° F. (40° C.) upon the first day. In children the disease may be ushered in by a convulsion. The pulse is rapid (no to 130). Jaundice is not infrequent and severe nausea and vomiting and cerebral symptoms may be observed. The spleen 32 THE INFECTIOUS DISEASES. is enlarged and, rarely, may rupture. There may be herpetic vesicles upon the lips and petechias or mottling of the skin may be noted. The liver may be palpable. During the paroxysm the blood contains the spirochaete. The leucocytes are often increased in number. After the fever has lasted about seven days it falls by crisis in a few hovurs to normal or below this point and with this fall there is profuse perspiration, sometimes diarrhoea or nose-bleed, and a general amelioration of the symp- toms. Within a few hours or at most a day or two the patient is apparently well. The crisis may occur as early as the third day or as late as the tenth. In the aged or in weak individuals it may be associated with collapse. After about one week and usually on the 14th day from the invasion, the paroxysm is repeated, being ushered in by one or more chills, the fever recurs and the other symptoms reappear. The relapse is, as a rule, shorter than the primary paroxysm and is terminated by crisis in the same manner. After another afebrile interval there may be a second, and following this, a third relapse. Rarely has a fourth been observed. Each succeeding relapse is shorter than its predecessor. At times there is no relapse, the patient recover- ing after the first crisis. Convalescence, while usually rapid, may be much protracted in patients who have been weakened by severe types of the infec- tion. Complications such as nephritis with hsematuria, haematemesis, rupture and infarct of the spleen, paralyses and obstinate ophthalmia may occur. In females, if pregnant, abortion usually takes place. The disease is not very fatal; death, however, may take place during the paroxysm in aged and feeble patients or as a result of a complication. The differential diagnosis from enteric fever and from malaria, the two diseases with which relapsing fever is most likely to be confounded, may be made by examination of the blood. Specimens should be taken from a finger-prick, spread thinly and may be examined fresh or stained with various aniline colors. Treatm.ent. No drug has yet been found which exerts any influence upon this disease; a serum has, however, been elaborated from the blood of infected horses, the use of which has been attended with good results. The treat- ment in other respects is symptomatic. The patient should be kept in bed during the paroxysms and should be exposed as little as possible during the intervals lest a relapse be induced. At the onset a mercurial purge should be given and followed by a saline. Throughout the disease the bowels should be kept open and the kidneys active. The temperature should be controlled by hydrotherapeutic measures and the pains by small doses of the coal tar analgesics. Patients in whom the pain is marked and distressing may be allowed small quantities of powder of ipecac and opium or morphine. In enfeebled patients the early exhibition of stimulants, especially alcohol YELLOW PEVER. 33 and strychnine is necessary. Emesis may be controlled by pellets of cracked ice, sips of iced champagne, small doses of cocaine or the hypodermatic administration of morphine should this become unavoidable. The diet during the febrile paroxysm should be entirely of fluids, while during the remissions easily digestible and nourishing soHds may be allowed. During the progress of convalescence the patient should receive general tonic treatment. YELLOW FEVER. Synonyms. Febris Flava; Bilious Remittent Fever; Typhus Icteroides; Typhus Tropicus. Definition. Yellow fever is an acute infectious disease characterized by a febrile paroxysm which is followed by a short remission which in turn is succeeded by a relapse. It is often accompanied by jaundice and a tendency to haemorrhages, especially into the stomach. .etiology. This disease prevails endemically in certain tropical cities and according to Guiteras these zones of infection may be recognized: a. The focal zone, from v/hich yellow fever is never absent, including Vera Cruz, Rio de Janeiro and other Spanish American ports, h. The perifocal zone or region of periodic epidemics, which includes the tropical ports of the Atlantic coast of America and Africa, c. The zone of accidental epidemics, between the parallels of 45° north and 35° south latitude. Yellow fever is seldom seen far from the sea-coast or at an altitude greater than 1000 feet. It is a disease of the summer months, disappearing with the incidence of frost and is prone to attack cities, especially in their most thickly populated and unsanitary districts. Males seem to be more subject to infec- tion than females, "and the disease attacks all ages except young infants. Negroes and mixed races seem to be less prone to the affection than whites possibly because during their continued residence in regions where the disease is endemic they may have suffered from an abortive and unrecognized type of infection. Immunity is usually but not always conferred by one attack. The specific cause of yellow fever, which is in all probability a micro-organism has not yet been isolated; several observers have described bacteria which they have considered to be the specific germ but their observations have not been confirmed. The chief and very probably the only mode of transmission of yellow fever is through the bite of a species of mosquito, the stegomyia jascmta. Rigid experiments have shown that the disease is not conveyed by means of fomites. That the infection may be transmitted to a non-immune by injec- tion of blood drawn from yellow fever patients has also been proven. Pathology. The skin is of icteroid hue although jaundice may not have 3 34 THE INFECTIOUS DISEASES. been evident ante mortem and subcutaneous extravasations of blood may be present. The blood-serum contains haemoglobin resulting from the destruc- tion of the red blood cells. The heart may be the seat of fatty degeneration. The Uver is enlarged and congested, later it undergoes fatty changes and is yellowish-brown in color. Spots of necrosis are usually present. The kidneys are enlarged, congested and the seat of acute inflammation. Areas of necrosis may occur in these organs as well as in the liver. The gastric mucosa is congested and swoUen, there may be submucous haemorrhages and the organ may contain blood-serum and degenerated blood pigment (black vomit). There may be general enlargement of the lymph nodes, particularly those of the peritonaeum, of the neck and axiUae. Changes characteristic of yellow fever alone have never been noted. Symptoms. The incubation period is from three to four days, rarely over five days. Prodromata are rare, the invasion being usually sudden with chilly feelings or by convulsions, in the case of children, followed by head- ache, general pains, prostration and fever. The onset usually takes place between midnight and dawn. The temperature soon reaches 102° to 105° F. (38.9° to 40.5° C). The face is flushed, the eyes are injected and watery and photophobia is present. The pulse is weak and at first rapid in proportion to the height of the temperature, after a day or two, even though the fever is higher than before, the pulse rate begins to decrease and gradually continues to do so until it may become slower than normal before the fever declines. This lack of proportion between the pulse rate and the height of the tem- perature is characteristic of this disease and is an important diagnostic point. The skin is hot and dry, the tongue is red and cracked and the throat and gums may be sore. Slight jaundice may appear early in the disease. Nausea and vomiting may appear at the invasion but are more likely not to occur until the second or third day. In severe infections thevomitus may be of coffee-ground material, tar-like or even of unchanged blood, while in milder forms it consists merely of blood particles, mucus and bile. The bowels are usually constipated but the stools are not clay colored. With slight varia- tions in temperature this, the first stage of the disease, lasts three or four days and is terminated by the return of the temperature by lysis to normal. At this time the second stage or stage of calm begins, the symptoms dis- appear and in mild cases convalescence becomes established. In the severe infections this stage, after lasting from a few hours to a day or two, merges into the third stage. In this stage, although rarely there may be no fever, the temperature rises again while the pulse rate may decrease to even as low as 60. The jaundice becomes more pronounced, the tongue is dry, brown and cracked, and nausea and vomiting return. Haematemesis with abdominal pain is frequent, there may be tarry stools and haemorrhages from the nose, gums, uterus, kidneys YELLOW FEVER. 35 and into the skin. There may be suppression of urine and death from uraemia or the patient may grow progressively weaker and die of the profound toxaemia, the fever remaining elevated until this has occiirred. In more favorable cases after a secondary fever of two or three days, the temperature falls by lysis, the symptoms amehorate and the patient goes on to a protracted convalescence during which jaundice may be persistent. Albuminuria is a feature of this disease, appearing in mild cases even on the OAY OF DISEASE 1 "^ 8 1 rFi 6 7 8 9 10 11 12 m 14 15 ~" -42° ^41' - 1 r39°i HOUR MM a'p mIm MM a|p S'm m'm m'm A !? MM a'p *'m mS A P m'm 1 107 lOti' r— ^ ^— — — !— -^— ~^— - p- r- -p-i -^~ ? 105" — — — -^ — —^ - -- r — ^ — — — -L —^ i 104' " 103' S 102; i 101 -^ 1 * — H — f -r- -^ ^— — ^ — —^ ^L_ 1 A^^ — — -!— — ^ — ^ — -^ ^— ^ — 1— -4— — -^ S lOo" — — ■ — — i -j- 1 - t— i— -|- — -p -^ -|- : S 99' ' — 3z: -r- — 5^ =fs — -^- -H — — — 9s ~ ~ ~^ = 131: "T— = ^ v= =P ~i~ ~ ~~ -^ =: TiZ -36° 97' — p ^— -i— ^— ^— — ^— ^— -t- -J— -f- -]-" ~H ^ -^ -^- -l- -i— 96 ^— ^— — — ^— ^-J — ^ -^ ^- ^-J -1- ^— — — — |— 150 140 1.30 .. 12" ~. 110 S 100 "" 90 SO f 1 A 70 V^ \ 60 / ' •^ y oO 40 1 I— u_ 1 1 LL u_ 1—1— u_ LL LL LL 1 1 1 1 1 LL LU LL 1 -li JJ — L Fig. 4. — Clinical chart of yellow fever^showing the pulse typically slow in comparison to the height of the temperature. second or third day. It may be merely transitory but in severe infections it is present in large amounts and accompanied by casts. At times the neph- ritis may result in anuria and death from urasmic poisoning. Relapses sometimes take place; complications are not very common; such sequelae as parotitis and multiple abscesses have been observed. The diagnosis of the disease may at times be difficult. Malarial fever of the remittent type may be differentiated from yellow fever by the earlier incidence of the remission, the longer duration of the chill and the presence 36 THE INFECTIOUS DISEASES. in the blood of the malarial parasite in the former disease. Here also the three salient characteristics of yeUow fever are aids, these being the typical facial expression, slow pulse and early occurrence of albuminuria. These points are serviceable in the separation of the disease from dengue as are also the haemorrhages and the early occurrence of jaundice in yellow^ fever in con- tradistinction to the absence of the former and the possible later incidence of the latter in dengue. The prognosis in yellow fever is grave, the severer forms of the infection being particularly fatal. In weak, poorly-nourished and alcoholic subjects the chances of recovery are less than in those in whom the opposite conditions obtain. Of patients who exhibit the "black vomit" by no means all die, but those profoundly poisoned and in whom mental and kidney symptoms occur seldom recover. The prevention of yellow fever consists in the guarding of patients suffering from the disease from the bites of mosquitoes, in the obstruction of ways of ingress of the mosquito to the house, of the destruction of these insects within dwellings and of the employment of means with a view to prevent their prop- agation. How effectually the disease may be prevented is evidenced by its rarity in Havana, where it formerly prevailed largely, since proper steps have been taken in prophylaxis. Mosquitoes in dwellings may be destroyed by means of sulphur fumigation and may be prevented from entering by means of screens. Patients suffering from the disease should be surrounded by netting. Although the most recent observers believe that yellow fever is not transmitted in any other way than by the mosquito and that disinfection of clothing, bedding and the like is unnecessary it may be wise to employ the usual disinfection methods of the sick-room and its contents after the patient's recovery. Preventive inoculation has not been employed with success. Treatment. The patient should be isolated and screened. He must be strictly confined to bed from the onset and should be moved as little as possible. The bowels and bladder must be evacuated while in the recumbent position and, should it be impossible to urinate under these circumstances, catheter- ization must be undertaken. AU body and bed linen must be kept scrupu- lously clean and when these are changed the utmost care not to disturb the patient to the least degree must be observed. Food and medicines when taken by mouth should be given by means of a spouted cup or through a tube so that the head need not be raised. At the onset of the disease the bowels should be opened by fractional doses of calomel followed by a saline laxative; here magnesium, in the form of the effervescing citrate, or sodium sulphate is to be preferred. The kidneys should be mildly stimulated by one of the alkaline diuretics and the skin kept active by means of tepid sponge baths. During the febrile stages it is YELLOW FEVER. 37 wise to feed entirely per rectum and to administer medication by means of this channel or hypodermatically. For the temperature and nervous symp- toms hydrotherapeutic measures are indicated. Cool sponging is perhaps best and the baths shoiild be given with great care so as to disturb the patient as little as possible. The pain may be reheved by means of smaU doses — gr. V (0.33) — of acetphenetidine (phenacetine) combined with caffeine sodio-benzoate if there is the slightest tendency to cardiac weakness. While most authorities advise the hypodermatic administration of morphine if this symptom is severe, certain observers, whose experience of the treatment of yellow fever has been considerable, consider this drug contraindicated at all stages of the disease; quinine given per rechcm — gr. xx (1.33) — is useful in this affection. Formerly this drug was extensively employed in yellow fever and while it is probable that it exerts no specific effect its administration does no harm. Vomiting is difficult of control and should be treated by pellets of cracked ice. Small doses of cocaine — gr. \ (0.016) — of hydro- cyanic acid, of creosote or of carbolic acid have been recommended but ice alone usually accomplishes all that is possible. Haemorrhage may be com- bated by the hypodermatic administration of ergot or by means of calcium chloride, gr. xl (2.66) per rectum. The latter drug is said to cause an increased coagulability of the blood. Lead acetate and iron perchloride have been advocated but are probably better omitted. During the course of the disease the kidneys and the circulatory system may be stimulated and the toxaemia lessened by high rectal irrigations of hot — 110° to 116° F. (43.5° to 46.5° C.) — normal sahne solution. Two of these may be given daily and the quantity should be at least i gallon (4 litres). The ursemic symptoms respond very favorably to this means of treatment; here also hot baths and packs are useful. If at any time there are symptoms of cardiac weakness free hypodermatic stimulation by means of alcohol, strych- nine, digitalis, camphor and aether, or camphor and oil are indicated. Collapse may be treated by this means, by the hypodermatic or intravenous adminis- tration of considerable quantities of normal salt solution and by enemata of strong black coffee. During the stage of remission the patient's strength must be supported by means of stimulants and tonics. The following treatment of the disease has been recommended. Sodium bicarbonate gr. vii ss (0.5) and mercury bichloride gr. J-^ (o.ooi) are given dissolved in ice water every one or two hours depending upon the severity of the infection; the sodium bicarbonate tends to lessen the excessive acidity of the gastric juice and urine and by rendering the latter alkahne the tendency to nephritis and aniiria may be diminished. At the invasion the patient is given a hot mustard foot bath and for the following three or four days cool sponges are given, an ice bag is applied to the head and a sinapism to the 38 THE INFECTIOUS DISEASES. epigastric and lumbar regions. No food is given during the first three days of the disease. The serum treatment of yellow fever, although the subject of much exper- imentation, has as yet yielded no very favorable results. During convalescence the patient should be kept in bed or at any rate until the profound prostration which is a feature of yellow fever has disappeared and the heart and kidneys have retmrned to their normal action, he should be kept at rest. Tonics such as iron, strychnine and quinine should be pre- scribed. The food during the febrile stages should be administered wholly per rectum, nutrient enemata such as those suitable in gastric ulcer being indicated (see p. 353); during the remission fluids may be given by mouth and after con- valescence has become established the greatest caution must be observed in feeding. No solids should be given for at least ten days after the symptoms have subsided and too large quantities at a time must be avoided. The first foods allowed by mouth are peptonized milk, milk, milk and vichy, kumyss or matzoon, one drachm (4.0) every hah hoiu*, later beef juice may be given, then the whites of eggs, the proprietary infant foods, broths and gruels. Gradually the various semi-solids, junket, cereals, milk toast, etc., may be added until finally the patient is able to tolerate solid diet. INFLUENZA. Synonyms. Epidemic Catarrhal Fever; Grip. Definition. An acute infectious disease, generally endemic and from time to time occurring in widespread epidemics^ characterized by catarrhal inflammations of the various mucous membranes, prostration and a tendency to involvement of the nervous system. iEtiology. At various periods of the world's history since the sixteenth century widespread epidemics of this disease have occurred, the last of these in 1889, when within a year it had prevailed in most parts of the civilized world. Since this epidemic in most American cities there are seen yearly a number of cases of epidemic influenza. Epidemics remain in a locality from one to two months and the affection is prone to attack a very large proportion of the population. Epidemics differ greatly in severity and in liability to com- plications. The specific factor in the causation of this disease is the influenza bacillus which was discovered by Pfeiffer in 1892. It occurs in great numbers in the nasal, tracheal and bronchial secretions of patients affected and may be easily demonstrated. Epidemic influenza is markedly contagious and rapid in its spread, and occurs with its greatest degree of severity in the colder seasons of the year. Unhy- INFLUENZA. 39 gienic surroundings do not seem to affect its incidence; it attacks all ages and both sexes and those who have suffered from one infection seem more prone than others to a second. Authorities differ as to the portal of entry of the contagium, probably, however, it reaches the organism upon the inspired air and the infection takes place through the respiratory tract. It is asserted that the primary lodgment of the bacillus may be either the gastro-intestinal tract or the conjunctiva. Pathology. This disease is characterized by no typical lesions; only those due to the complications are found post mortem. In the abdominal type of the infection there may be enlargement of the solitary and agminated follicles of the intestine. Symptoms. The incubation period is from one to three or four days, although at times the interval between the entrance of the contagium into the body and the manifestation of symptoms may be longer. The onset is usually sudden with a chill followed by a rise in temperatiu-e — ioi° to 104° F. (38.4° to 40° C.) — severe headache and marked bodily pains; nausea and vomiting, together with the other symptoms usual at the beginning of an acute infection, and very pronounced prostration may be present. The fever lasts from two to six days and may be of remittent or intermittent type; in certain instances the elevation of the temperature may be the only symptom and rarely the patient may exhibit a continuously high temperature lasting for several weeks and which closely reseml^les that of enteric fever; the pulse is rapid and may, in severe types of the disease and in the aged, become feeble. During the course of the disease various skin eruptions, erythematous or even purpuric, may appear and simple pharyngitis may be present. As the tem- perature approaches the normal at the termination of the disease, sweating may occur and the symptoms gradually subside. The disease manifests itself in one of several types which are very prone to merge into one another. a. The catarrhal type is characterized by symptoms referable to the mucous membranes of the respiratory tract and conjunctivae. At the onset the symp- toms of coryza with sneezing, nasal discharge, a feeling of fulness in the head, sore throat, hoarseness and conjunctival injection, are present. In the milder instances of the disease there may be no further symptom.s, but more often there is bronchial inflammation, with cough, at first dry, later with muco- purulent and sometimes very copious expectoration; rarely the sputum is dark and blood-stained. Various pulmonary complications may ensue. h. The nervous type begins with severe headache, pains in the bones and joints and extreme depression and prostration; rarely there may be convulsions. In some instances there are symptoms resembling those of meningitis, such as photophobia, hypersensitiveness to sounds, pain in the back of the head and stiffness of the neck. Delirium may be present. The nervous symptoms 40 THE INFECTIOUS DISEASES. gradually subside after a few days but during convalescence there is a marked tendency to mental depression and neuralgia in various parts of the body. c. The gastro-ititestinal type is evidenced by nausea and vomiting at the invasion, or abdominal pain, distention and diarrhoea; the symptoms may be so severe as to suggest appendicitis or peritonitis. Jaundice and splenic enlargement may be present. Complications and sequelae. Of these one of the most common and serious is pneumonia due to the influenza bacillus alone or to a mixed infection. It is rarely if ever of the lobar form^ usually being catarrhal or lobular, and is frequently fatal. Pleurisy is not a common complication but when it occurs is likely to become purulent. Bronchiectases may occur. Circulatory complications may appear. Peri- carditis is rare; less so is endocarditis which may be of malignant type. In a few instances the influenza bacillus has been grown from the vegetations. Myocarditis may occur and functional cardiac disorders, such as palpitation, irregular heart action, bradycardia and tachycardia are frequently met. Sudden cardiac failure may cause death. Thrombosis and phlebitis have been observed. Peritonitis, cholecystitis and septicaemia are rare sequelae; nephritis and orchitis have been noted. Complications referable to the nervous system are not infrequent and among them may be mentioned encephalitis, meningitis — the bacilli having been demonstrated in the fluid withdrawn by lumbar puncture — cerebral abscess, myelitis, neuritis of various types, and paralyses. Mental disorders such as melancholia or even dementia may occur. Optic neuritis and iritis have been described; otitis media and dizziness due to affection of the labyrinth are possible consequences. It is of the utmost importance to keep in mind the fact that an attack of influenza is very prone to render any latent disease active and to increase the intensity of any slight organic afJection that may be present. The diagnosis of influenza during an epidemic is usually easy and may be confirmed when doubtful by the detection of the causative bacillus in the mucous discharges. The prognosis is usually good. Death may take place from the complica- tions, particularly from pneumonia. Treatment. The prevention consists in the avoidance of exposure to cold and wet during epidemics and of association with patients suffering from the disease. Isolation of patients should be carried out whenever prac- ticable and the sputum and nasal discharges should be disinfected and des- troyed. When influenza is prevalent it is well to practise spraying of the oral and nasal cavities with some mild antiseptic such as liquor antisepticus. So long a? we are ignorant of any specific agent which will abort an attack INFLUENZA. 4I or mitigate the severity of the infection we must formulate a treatment for each type of the disease. In treating the respiratory form of epidemic influenza we should first bear in mind the fact that the prostration, fever and systemic disturbance are out of all proportion to the extent or severity of the disease as evidenced by physical signs; secondly, that, granted a moderate involvement of respiratory area or even a disease stationary so far as extent of tissue is involved, this is no guarantee as to prognosis in an individual case. The logical deduction from this observation is that we are dealing with an infectious process in which prostration is marked and in which supporting treatment is urgently needed. The patient should be kept in bed, while the fever persists, in a room of equable temperature, not too hot, and his diet should be of fluids and as nutritious as possible. The bowels should be opened by means of repeated fractional doses of calomel followed by a saline. If the patient's temperature must, in the physician's opinion, be lowered this may be effectually accom- plished by means of the application of an ice water coil placed over the heart or by sponging with cool water. In most instances the fever may be allowed to run its course undisturbed. Antipyretic drugs, for their influence upon this symptom need not be given. The use of morphine for the pain is likely to interfere with nutrition, dam up the excreta and leave the patient in worse condition than before its employment. The treatment of the respiratory system consists first in relieving the irri- tation of the nose and throat by means of a spray of ten drops (0.66) of eucal- yptol, 10 grains (0.66) of menthol to an ounce (30.0) of albolene. One of the alkahne antiseptic sprays should be first used in order to dissolve the accu- mulations of mucus as much as possible and render the mucous membranes clean in order that the full soothing effect of the oily spray may be evidenced. The bronchitis necessitates the administration of an expectorant which does not distiu"b the heart. Here we may give ammonium carbonate in doses of from 5 to 10 grains (0.33-0.66) and repeated as frequently as the condition may require, each dose to be given in two ounces (60.0) of milk. The exhibition of this drug will relieve unnecessary coughing, will remove much of the oppression of the chest, will fortify the heart and has the single disadvantage of being prone to disturb the stomach after five or six days. If the ammonium carbonate is not well borne, strychnine, either as good- sized doses of tincture of nux vomica or strychnine sulphate or nitrate, should be administered. With the strychnine not only is a stimulant effect exerted on the heart muscle and respiratory center, but also an improvement in nutrition resulting from the drug's action on the spinal cord. In administering alcohol the previous habits of the patient and the urgency of the symptoms must be considered; in most instances the patient is better without it. When the physical signs and clinical symptoms indicate that pneumonia 42 THE INPECTIOUS DISEASES. is present the patient should be bled from the less into the greater circulation by the nitrites, preferably glyceryl nitrate in doses of y^ to -5V of a grain (0.0006 to 0.0012) — and increasing and frequently repeated doses of strychnine must be administered until convalescence takes place. In slowly resolving pneumonias and for an obstinate bronchitis which persists into convalescence,, no drug yields better results than creosote carbonate, 30 or 40 drops (2.0-2.66) given in sherry several times a day. In order to eliminate the toxins of the disease the skin, bowels and kidneys must be kept active. The pains may be treated by the means described below. In the gastro-intestinal form of epidemic influenza the pain, nausea and vomiting require relief. At the onset of the infection the bowels should be thoroughly evacuated by calomel given in frequently repeated small doses (gr. |-o.oi6). Later intestinal antisepsis may be accomplished by the admin- istration of the organic bismuth salts, the naphtholate, gr. v to x (0.33 to 0.66), the iodophenolphthaleinate, gr, v to x (0.33 to 0.66) or the subgallate, gr. x to XV (0.66 to i.o). High intestinal irrigations are great aids in the elimination of toxins, not only by the bowels but by the kidneys as well. Frequently rectal alimentation becomes necessary when the stomach is unable to retain even liquid food. In the nervous type the distressing pain particularly calls for treatment and while quinine has been much lauded, the author considers that the results obtained hardly warrant its administration to the extent that the severe infection would seem to justify. Euquinine seems to be somewhat more efl&cient although the statements made that it causes tinnitus are incorrect. Its dose is from 5 to 15 grains (0.33 to i.o). The giving of the coal tar anal gesics has the disadvantage that the drugs of this class that are sufficiently analgesic are also to a greater or less extent cardiac depressants; consequently their unrestricted employment is by no means advisable, and may be even dangerous. It is possible, however, to reheve the pain of influenza to a considerable extent, without dangerously depressing the heart or respiratory system. This may be accomplished by alternating acetanilide or acetphe- netidin, of which the untoward effects are neutralized by combination with caffeine, with acetanilide and methyl salicylate or antipyrine sahcylate (sali- pyrine), a combination of antipyrine and salicylic acid. Of this 10 grains (0.66) may be given every 2 or 3 hours until the pain is relieved. Depression may follow the use of this drug in certain instances and it should always be employed with caffeine in consequence. Kryofine may also be used as an analgesic in doses of from 5 to 8 grains (0.33 to 0.52) and may prove more effective and less depressant than most of this series. Gelsemium often will afford great relief from the headache and backache which are common in this disease. It should be pushed until slight ptosis appears, when the Hmit of its physiological activity has been reached. This drug merits a trial, since DENGUE. 43 the success, when attained, is brilliant although it is difficult to furnish exact indications for its administration. At times the muscular pains if limited to the back may be mitigated by means of a local application of cataplasma kaolini. This should be spread in sufficient thickness over the painful area^ covered with a layer of muslin and kept hot. It is cleanly, retains its heat for some time and is easily renewed. The meningeal symptoms should be controlled by the use of the ice helmet and the application of cold to the back of the neck. Elimination of the toxins of the disease as has been previously stated should be safeguarded. The neutralization of the infectious material in the intestine should be brought about as has been already shown. Diarrhoea, if pres- ent, should be considered beneficial. Warm baths relieve the muscular pain and, when accompanied by friction, keep the skin in good condition and add to the comfort of the patient. Not only should the presence of albumin and casts in the urine be determined but the specific gravity, the urea excretion and above all the quantity of urine passed should be carefully noted. For urinary insufficiency no better treatment exists than continuous enteroclysis with decinormal salt solution at a temperature of iio° F. (43.5° C); this not only aids renal elimination but is a cardiac stimulant of considerable efficacy. The treatment of influenza in children is practically identical with that of the disease in adults; doses should, however, be regulated in accordance with the age of the patient. CompHcations should be treated as when occurring independently. Dm-ing convalescence the patient should avoid too early exposure to out- door air and any possible risk of reinfection. Before going out for the first time the temperature should have been normal for from five days to a week. Nourishing diet and tonics such as codliver oil, iron, strychnine and the vegetable bitters should be prescribed. DENGUE. Synonyms. Breakbone Fever; Dandy Fever. Definition. An acute, infectious disease occurring in warm countries, characterized by severe pains in the joints and muscles, fever, and in many instances by an erythematous eruption. .Etiology. This disease occiU"S chiefly in hot climates and during the warmer and more moist seasons of the year; it is common in the East and West Indies but is seldom seen in the United States except along the coast of the Gulf of Mexico. An epidemic occurred in Galveston, Texas, in 1879. One of the affection's distinctive features is its rapidity of diffusion and its proneness during epidemics to attack nearly all persons exposed. While probably due to infection with a micro-organism, the specific cause of the dis- 44 . THE INFECTIOUS DISEASES. ease has not yet been definitely isolated. It is probably not transmitted through contact with patients or by means of fomites, the Aost approved theory of its means of transmission being that certain gnats or mosquitoes may carry the infection from one person to another. Pathology. Little is known of the post mortem changes occurring in this disease, deaths being very rare. Symptoms. The onset of the disease is sudden, without prodromata and after an incubation period of from two to five days. The invasion is marked by a chill followed by a rise in temperature, headache, the ordinary symptoms of beginning febrile disease and severe pains in the muscles, bones and joints. The latter become hot, painful, red, tender and sometimes swollen. It is this joint involvement which gives the affection the name "dandy fever," the gait being so modified that it is supposed to simulate that of a dandy. The rise in temperature is rapid, its maximum being from 103° F. to 106° or 107° F. (39.5° to 41° or 41.5° C). In two or three days, usually in two, the fever falls rapidly by crisis, with diaphoresis, diarrhoea, diiiresis and epistaxis. With the initial rise in temperature an erythematous rash appears which disappears synchronously with the fever. With the fall in temperature the patient feels much improved although weak; the pains are diminished but to some extent persist. After an afebrile period of from two to four days the temperature rises again with a return of the severe pains. The temperatiire is usually less high than in the preceding paroxysm but the pains may be more marked. With the fever a roseolous eruption appears, first upon the backs and palms of the hands and spreads thence over the entire body. The macules are dark red, circular and about the size of a pea; they may be elevated and are likely to be particularly in evidence about the joints. The spots may coalesce. As the eruption fades, which takes place first upon the hands and arms, then upon the body and finally upon the legs, there is a fine desquamation. The entire duration cf the disease is about seven or eight days, at the end of this time the rash has usually faded and rapid convales- cence ensues. In certain instances, however, this may be protracted and the patient meanwhile suffers from vague pains in the joints and feet and mental and bodily weakness. Lymph gland enlargement may be observed and the eruption may persist for several weeks after apparent recovery has taken place. Delirium some- times accompanies the fever and muscular atrophy has been noted consequent upon an attack. Complications are rare but relapses are not infrequent. In epidemics the diagnosis of the disease is not difficult, isolated instances, however, may be confounded with acute articular rheumatism. Dengue is almost never fatal in patients of moderate power of resistance. Death may occur as a result of other infections such as pneumonia, to which MALARIAL FEVERS. ^ 45 the patient is predisposed on account of the weakening effect of the primary disease. Treatment. Isolation, in the Hght of our present knowledge of the prob- able mode of trsSismission of the disease, need not be insisted upon, but the access of mosquitoes to the patient should be prevented. Disinfection, also, would seem to be unnecessary.' Absolute rest in bed is an essential until the termination of the second febrile stage. At the onset the bowels should be opened by means of frac- tional doses of calomel followed by a saline, and throughout the disease the emunctories should be kept active by the means suggested under the section upon the treatment of influenza. The fever seldom needs special treatment on account of its short duration but in instances of hyperpyrexia (105° to 107° F. — ^40.5° to 41.5° C.) cool sponging or one or two tub baths may be employed. These should be given according to the methods set down for use in enteric fever. The pains may be controlled by the employment of the means indicated in those of influenza, together with the salicylates and aspirin 15 to 20 grains (i.o to 1.33) every two or three hours until the desired effect has been pro- duced. Tincture of gelsemium is said to relieve the pain and to lessen the cardiac excitability; 8 drops (0.52) may be given every three or four hours until the pain is relieved or until the depression of the pulse rate and the incidence of ptosis indicates that the physiological limit has been reached. Opium is seldom necessary for the pain. Excessive nervous symptoms may be controlled by means of the bromides. In a word the treatment of this disease is entirely symptomatic, no specific having yet been discovered. The diet during the fever should be wholly fluid. During convalescence tonics should be prescribed and strength-giving foods given in digestible form. MALARIAL FEVERS. Synonyms. Chills and Fever; Fever and Ague; Paludism; Paludal Fever; Swamp Fever. Definition. Malarial fever is an infectious disease occurring in several types: a. intermittent, in which the febrile paroxysm is quotidian, tertian or quartan; h. continuous with remissions; c. pernicious; d. chronic malarial cachexia. .Etiology. This disease is less common in the very young and in aged persons than in young and middle-aged adults; it occurs more frequently in the white than in the negro race and is most prevalent in low lands especially in damp and swampy districts along the sea coast. It is more frequently 46 THE INFECTIOUS DISEASES. observed in the tropics and the warmer portions of the temperate zones. In the latter the affection is rare in the spring, most of the cases occurring in the late summer and autumn. In the tropics it is most common in the months corresponding to the spring and fall. The specific cause of the malarial infections is a micro-organism, the hcsmo- cytozooUf hcsmatozodn or Plasmodium malaricB. The hczmatozobn malaria is a parasitic body developing within organism of all the varieties of anopheles — the common mosquito — and transmitted to man through the sting of this insect. The parasite circulates in the blood of man, the intermediate host, and occurs in three forms, each causing a definite and different type of malaria. The hsematozoon of tertian fever when seen soon after a chill is a small, hyaline body, rounded or irregular in shape, and is seen within the substance of a red blood cell. Its life cycle is of about 48 hours duration, and consists of the following process: It first increases in size, exhibits amoeboid move- ment and fine granules of pigment develop within it, while the red blood cell becomes larger and paler in color. The pigment gradually assembles itself at the center of the organism and in about 48 hours segmentation takes place. This process consists of the division of the original body which now fills nearly the whole of the red cell into 15 or 20 spores, resembling the original hyaline body. These are set free in the blood, each in its turn, to prey upon a red blood corpuscle. At this time the chill is manifested. Other fully developed organisms may not undergo segmentation. These are larger than those which sporulate and contain pigment granules in active (Brownian) movement. These are a sexually different type of the parasite. In the quotidian type of malarial infection there are two sets of tertian or three sets of quartan organisms in the blood which sporulate upon different days caus- ing a chill every 24 hours. The quartan variety of the hsematozoon in its earliest form closely resem- bles the tertian type but as it develops the amoeboid movement is more sluggish and the grains of pigment are coarser and the Brownian movement is less active. It increases gradually in size, the pigment is seen at its periphery and on the third day its division into radially arranged segments, 6 to 12 in number, is noted. After a 72 hour interval of development sporulation takes place. Here as in the tertian type fully developed bodies may be observed which do not break up. These also represent a sexually different form, the gametocytes. The (Bstivo -autumnal organism is smaller than the preceding forms and contains less pigment. Its full size may be less than half that of a red blood cell. Early in the disease only small hyahne bodies containing, it may be, a grain or two of pigment are to be found in the peripheral circulation. The more mature forms are usually found in the blood of the viscera, particularly MALARIAL FEVERS. 47 the spleen, and the bone-marrow, and the corpuscles containing them may be distorted or crenated and are of brassy color. The characteristic forms of the aestivo-autumnal type of the parasite which are crescent-shaped, ovoid or spherical, are seldom seen until the infection has been present for a week or more. These contain near their centers groups of coarsely granular pigment. The crescentic and ovoid bodies do not sporu- late and represent the gametocytes. The sexual forms of each type of the organism, entering the stomach of the mosquito when an infected individual is bitten, are fertilized there and after developing, the spores which result may be transmitted through the insect's bite to a human host and then undergo a further cycle of development. Pathology. In acute infections there is a diminution of the number of red cells and haemoglobin in the blood as a result of the disintegration of the former due to the development of the organism. The spleen is enlarged and may rupture, especially if subjected to traumatism. The parasites are present in the blood. In pernicious malaria there is marked anaemia, the red cells are distorted and degenerated and contain the parasite within their substance. These are also found in the marrow and this structure and the spleen may be pig- mented and the seat of a marked phagocytosis. The spleen may be the seat of moderate enlargement only and is usually dark in color and soft in consistency if the disease is the result of a recent infection. The liver is the seat of acute degeneration (cloudy swelling). If cerebral symptoms are marked the brain is congested and the blood in its capillaries contains numerous haematozoa, with severe intestinal symptoms the parasites may be numerous in the capil- laries of the intestinal tract. In malarial cachexia the anaemia is pronounced, the spleen is much enlarged, weighing at times 8 or lo pounds, its capsule is thickened, it is slate colored on section and contains pigment. Its connective tissue framework is in a state of hyperplasia. A like condition obtains in the liver. Melanin may be deposited in the connective tissue beneath hepatic capsule. The kidneys may be swollen, contain pigment and in some instances may be the seat of an acute or chronic nephritis. The peritonaeum and the gastro-intestinal mucous membrane may be slate color due to the deposition of pigment. Symptoms. The symptoms of the paroxysms of quotidian, tertian or quar- tan malaria are practically identical in their clinical manifestation; they occur, however, at difierent intervals depending upon the time of sporulation of the causative organism. In tertian infection the chill occurs every other day, in quotidian, daily and in quartan, every 72 hours. The incubation period of malaria is variable; it may be as short as 24 hours or as long as several months; the average being from one to two weeks, prob- ably depending upon the amount of infectious matter in the system. 48 THE INPECTIOUS DISEASES. The paroxysm may be preceded by prodromal symptoms such as indefinite malaise, yawning, headache or nausea. Prodromata may be wholly absent. The paroxysm consists of three stages, the chill, the fever and the sweat. The chill lasts from i- to 2 hours; it usually manifests itself late in the morn- ing and almost never at night. Its onset is usually gradual beginning with chilly feelings of increasing intensity until the body shivers with intense cold and the teeth chatter. Even hot water bottles and numerous blankets will not keep the patient comfortable; the face is pinched and pale; the lips are blue, and the patient is apparently very cold yet at the same time the body temperature is elevated even to 105° or 106° F. (4o.5°-4i.i.°C.). There is severe frontal headache and nausea and vomiting may be present. The pulse is rapid, tense and small. The urine is pale, increased in amount and of low specific gravity but before this stage it may have been dark colored and DAY OF DISEASE 1 2 i 4 1 5 ^ n n n n n n n p n n n n n n -42° HOUR Sm A P A P A p ; p A M A p s 5 A p p s p p p M p A P p p A P M P A P M 107' , _ 1 _ _ [ _ _ _, _ _ _ _ _ _ _ _ - 106° — ^ — — -^ — — — — {— -^ 1 — — ' — — — — — — — — - ^ — — -41° H W g : "a 105° - - 1 104' -- - — - - ■ - - — ^ H — - - - - p — - - L - - - ^ .^> c 1 103' -- 1— - - - -^ - - - - - - — - - - - - - -40 % : c a 102° ■■to"? -- y- - -j-^ - — 1— p- — - J - — — - -^ - - - 3 % ini° -- - 1- - uJ - — - - — - - - - r^ — ^ - ~ - - - : n C5 fe 100 -38^ 99 J- J- \ ■ 1— - L - - - — - _ — - _ - - — 1— _ - — - 98 zir /-t — /- - — - — i— — — - - J — -^ - - — - -37 E 97 — _ _ _ _ _ _ -^ _ _ _ -^ _ 96' — — — — — — ' — — — — — — — — — — — — — — — - -36 1 — L J — 1 L L 1 — L. L L. 1— L I— 1— 1 — 1 — I— 1 — 1 i^ I — LJ Fig. 5. — Clinical chart of tertian malarial fever. heavy. At the end of the stage of chill the febrile stage begins. This is char- acterized by flushing of the face, a hot and dry skin, coated tongue, great thirst, severe headache and pain in the back and limbs; the pulse is full, bounding and rapid and active delirium may be present. The temperatvire may be but little higher than during the cold stage and at times the maximum may be reached at the termination of the chill. The stage of fever lasts from 30 minutes to four or five hours, and is at the end of this time followed by the stage of sweating. All the symptoms subside and there is profuse perspiration beginning on the face and gradually involving the skin of the whole body and the patient falls asleep to awake later feeling MALARIAL FEVERS. 49 perfectly well. This stage lasts ^ to 2 or 3 hours. The sweating may at times be very slight. The duration of the whole paroxysm is from 8 to 12 hours, but may be shorter. Splenic enlargement may appear and disappear synchronously with the paroxysm but in long continued infections this organ usually becomes permanently increased in size. The intervals between the paroxysms differ with the type of the infection. Thus in simple tertian fever (infection with one set of tertian organisms) the chill recurs at 48 hour intervals. If two sets of this organism, sporulating on alternate days, are present the paroxysm appears every 24 hours. When a simple set of quartan organisms is present the seizure takes place every 72 hoiurs, if two groups, maturing on different days, are present, the patient will have two paroxysms on successive days, then a day free from chill occurs and the round is then successively repeated. If three sets of quartan parasites are present a chill will occur on every day. The chills may appear at nearly the same hour upon different days or they may anticipate — that is each will occur an hour or so earlier than its predecessor; again the seizures may be retarded, appearing successively at a later hour. Without treatment the paroxysms may cease after several have occurred or they may disappear after two or three weeks. In these events they are, however, very likely to recur. If the disease continues the chronic form of malaria, followed by cachexia (q.v.) supervenes. ^stivo -autumnal malaria, after a period of incubation similar to that of the preceding types, usually begins with a chill which is more frequently preceded by prodromata than is that of the intermittent types of the disease. There are malaise, general pains and nausea often with vomiting of bile. The chill may not be well marked and is followed by a regularly intermittent fever; the intermissions are longer than those of the tertian type, or the par- oxysms may be anticipated or retarded, rendering the fever continuous with exacerbations. This form of remittent fever markedly resembles enteric fever, the patient appears prostrated, the pulse is rapid and full and the temperature rises, with daily remissions, to 102° to 104° F. (38.9°-4o° C); initial bronchitis may be present, jaundice may be observed and there is acute splenic enlargement. Nervous symptoms may be noted. The infection varies in severity; it may ameh orate after from 7 to 10 days, there may be irregular remissions and exacerbations. In the severe forms the infection may become of the pernicious type. Here the resemblance to enteric fever is especially marked. The tongue is thickly coated, the facies closely resembles that of enteric fever, and the fact that the two affections frequently occur in the autumn renders the differential diagnosis particularly difficult. Blood examination and the test of quinine treatment are aids in the distinction between the two infections. 50 THE INFECTIOUS DISEASES. Pernicious malarial fever is a result of infection with the haematozoon of sestivo-autumnal malaria and occurs in three forms. a. The comatose form may or may not begin with a chill but in its severest type this manifestation is usually well-marked (the congestive chill) and accompanpng it delirium, or more often, coma, is rapidly developed. The skin is hat and dry and the temperature ranges from 104° to 106° F. (40° to 41.1° C). The course lasts from 12 to 24 hours and may be followed by a second attack. The coma is a result of the accumulation of the parasites in the vessels of the brain and may prove fatal. h. The algid or asthenic form is characterized at its onset by marked prostration and vomiting; collapse may follow and though the patient may complain of chilly sensations no real chill may be present. The surface is cold and the temperature normal or subnormal. The pulse is small, rapid and feeble and the respiration shallow. Marked choleraic diarrhoea and urine diminished, sometimes to suppression, may be noted. These symptoms may continue, slight rises of temperature occurring from time to time, for a few days, at the end of which time death may occur from prostration and the severity of the infection. c. The hcemorrhagic form. This type includes black-water fever and malarial haemoglobinuria. This is the result of the malarial toxin although it has been attributed to the use of large doses of quinine; the administration of this drug may however aggravate the haemoglobinuria. Black- water fever occurs in the Southern states, in Central America, in Italy and in Africa. The condition is met most frequently in patients who have had frequent attacks of malaria and whose condition approaches that of the cachectic form of the disease. The haemoglobinuria is usually not accompanied by active malarial symptoms although preceding its appearance a febrile move- ment may have been present for a few days. The cause of the haemoglo- binuria is certainly malaria but whether this manifestation is the result of infection by a distinct type of parasite is unknown. The exciting cause of the paroxysm has also never been ascertained. Malarial cachexia may result from long-continued exposure to and repeated attacks of any of the types of this disease. Its most prominent symptoms are anaemia and splenic enlargement (ague-cake). The anaemia is character- ized by a sallow skin with sometimes an added subicteroid tinge, coated tongue, disordered digestion and constipation, palpitation and dyspnoea, oedema and coldness of the extremities. The temperature may be subnormal with irregular ascents to 102° to 103° F. (38.9° to 39.5° C). Haemorrhages into the retina, from the stomach and other structures may be observed. The examination of the blood reveals the presence of a typical secondary anaemia and, it may be, the presence of malarial organisms, usually crescentic in form. MALARIAL FEVERS. 5 1 The edge of the spleen may extend as low as the crest of the ilium and the consistence of the organ is hard and firm. Complications referable to the nervous system, such as paraplegia, resulting from a peripheral neuritis or deranged circulation in the cord, hemiplegia, acute ataxia and symptoms suggestive of disseminated sclerosis may occur. Areas of cutaneous gangrene and testicular inflammation have been noted. The diagnosis of malarial fever is in most cases easily verified by means of examination of the blood, although special training is necessary in order to become expert in the detection of the more unusual forms of the parasite. Fiu"ther aids in differential diagnosis are absence of Widal reaction and of leucocytosis and the test of treatment by quinine. The prognosis in simple intermittent fever is favorable. Under proper treatment it is easily curable and in certain instances spontaneous recovery takes place. Continued exposm"e or insufl&cient treatment may result in chronic malaria. The sestivo-autumnal type can usually be controlled by proper treatment but may merge into the pernicious or chronic types. Pernicious malaria may result in death but recovery from malarial cachexia is the rule. Treatment. The prevention of this disease consists in the employment of means to exterminate mosquitoes, of screens to prevent ingress of infective insects to dwellings and in treatment of patients suffering from the disease as well as protecting them from possible mosquito bites, lest the infection be thus transmitted. In malarial regions all exposiire to infection, especially after nightfall, is to be avoided. Prophylactic doses of quinine — two to three grains (0.13 to 0.20) — three times a day should be taken by individuals coming to malarial districts. During the chill, endeavors should be made by means of blankets and hot-water bottles and the administration of hot drinks to keep the patient warm. The headache may be relieved by hot or cold applications. Spong- ing with cold water may be practised diu-ing the febrile stage and the thirst may be mitigated by frequent drinks of cold water or lemonade. Dm"ing the stage of sweating the patient may be made more comfortable by wiping his skin with hot flannel. The treatment of intermittent fever consists primarily in the administration of quinine. This drug being absorbed into the blood exerts there a directly poisonous influence upon the parasites present in the same medium. The latter are most susceptible to the effect of the quinine when free in the blood stream, that is, at the termination of the process of sporulation, consequently the drug should be so administered that it shall have been absorbed in time to be present while segmentation is taking place. In order that quinine shall be quickly and in sufficient quantity absorbed measures should always be taken to render the gastro-intestinal tract — if the drug is to be given by mouth 52 TELE INFECTIOUS DISEASES. — as active in performing this function as possible, consequently it is wise to clear the intestine, before the administration of the quinine, by means of fractional doses of calomel to be followed by a saline. Then, in order that the blood shall be impregnated with the drug for an hour or thereabouts before sporulation takes place, it should, when given by mouth, be admin- istered lour to six hours before the expected paroxysm. The quantity nec- essary varies with the severity of the infection and the absorptive power of the gastro-intestinal tract. In the less severe types of the disease 15 to 20 grains (i.o to 1.33) are often sufficient while in other instances three or four times this amount may be necessary. For several days following, the patient should receive 10 grains (0.66) or more of quinine three times a day, when the dosage may be reduced to five grains (0.33) three times a day. On the seventh day following the last paroxysm an amount commensurate to that administered at the beginning of the treatment should be given and this procediu"e should be continued every seventh day for about two months. During the first two or three days of the treatment the action of the quinine will be enhanced by confinii3g the patient to bed. After this time he may be allowed up. The drug may be given in solution, in pill form or in capsules. The solution has the disadvantage of an extremely bitter taste and the advantage of being most readily absorbed. Freshly-made pills or soft gelatin capsules con- taining the powdered drug are also to be recommended, particularly if their administration is followed by five to eight drops (0.33 to 0.5) of dilute hydro- chloric acid to facilitate dissolution. Compressed tablets and stale pills of quinine are very likely to pass through the body undissolved. To patients who cannot take the drug by mouth it may be given hypodermatically in the form of the dehydrochloride or of quinine and urea hydrochloride. Either of these may be taken in doses of 10 to 20 grains (0.66 to 1.33) every two or three hours. The following formulae are useful: I^. Quininae sulphatis, gr. xv (i.o); acidi tartarici, gr. vii ss (0.5); aquae destillatae, ni cl (lo.o). I^. Quininae hydrochloridi, gr. Ixxv (5.0); aquae destillatae, 5ii ss (lo.o). I^. Quininae hydrobromidi, gr. xxx (2.0); aquae destiUatae, ttl xc (6.0). Quinine hydrobromate may also be given subcutaneously. The drug may likewise be administered in enemata or suppositories, the rectal dosage being at least twice that appropriate by mouth. Substitutes for quinine spring up from time to time and of these quinidine sulphate and cinchonine sulphate, especially the latter, may be mentioned. The doses of each of these are about A greater than that of quinine sulphate. If in long-continued infections quinine fails to exert its usual influence arsenic may be substituted. It may be given in the form of the liquor potassii arsenitis beginning with doses of five drops (0.33) three times a day or as arsenic trioxide, beginning dose ^V <^^ ^ grain (0.003) three times a day. These MALARIAL FEVERS. 53 doses should be gradually increased until the physiological effect is evidenced by oedema under the eyes or gastro-intestinal disturbance. Methylthionine hydrochloride sometimes succeeds when quinine is not well borne or is contraindicated, as in pregnancy or hsemoglobinuria. Its action is supposed to be exerted upon the parasite in the blood, just as is that of the latter drug. It should be given in capsules containing two to three grains (0.13 to 0.20) each, of which three per day may be taken. The patient should always be warned that the urine becomes blue while this drug is administered. Mstivo-autumnal fever should be treated along lines identical with those described above. The patient is, however, much more ill and needs careful nursing. In the forms resembling enteric fever he should be kept in bed and receive fluid diet and stimulants, especially strychnine, as indicated. If vomiting is a feature of the infection it is Hkely to interfere with the admin- istration of quinine by mouth, consequently hypodermatic injections as described above may become necessary. Enemata of quinine dissolved in starch water are also useful. The vomiting should be treated sympto- matically, the bowels kept active and the hepatic torpor combated by means of calomel. Rectal feeding may be necessary. Pernicious malarial fever demands the most active and energetic treatment. The patient should be kept in bed and thoroughtly cinchonized as quickly as possible by means of hypodermatic injections of large doses. An even more rapid method is that by intravenous injection of the drug. The following solution may be employed: I^. Quininae hydrochloridi, gr. XV (i.o); sodii chloridi, gr. i (0.65); aquas destillatae, 5ii ss (10. o). The cerebral symptoms may be relieved by the bromides or by opium, if necessary, and stimulation by means of strychnine or alcohol may be indi- cated. The bowels should be kept open; the chills may be relieved by ex- ternal warmth and the excessive fever by cool sponging. In giving hypodermatic injections of quinine a long needle inserted deeply into the muscular tissues of the back or buttocks, should be used. Abscesses are very prone to follow and in order that they may be prevented, in so far as may be possible, the strictest aseptic technique should be employed. Malarial Cachexia. Here quinine is also indicated although not neces- sarily in large doses, Warburg's tincture containing 10 grains (0.66) of quinine to the ounce, often acts well in doses of ^ an ounce (15.0) three times a day. Cinchonidine sulphate in doses of 10 to 15 grains (0.66 to i.o) three times a day is also useful. It is in this form of malarial infection that arsenic is particularly indicated, it may be given alone in the form of liquor potassii arsenitis or in combination with iron and quinine. The following formulas are suggested: I^. Quininae sulphatis, 5ii (8.0); ferri et potassii tartratis, 5ss (15.0); arseni trioxidi, gr. i (0.065); ^-quae destillatae q. s. ad §iv (120.0). Misce et signa, one teaspoonful after each meal. I^. Arseni trioxidi, gr, ^V 54 THE INFECTIOUS DISEASES. (0.003); massse ferri carbonatis, gr. v (0.33). Misce. Sig. Take one such pill after each meal. Arsenic may also be given hypodermatically as follows : I^. Sodii arsen- atis, gr. xV (0.006); aquas destillatse q. s.; or, I^ sodii arsenatis, gr. xV (0.006); sodii phosphatis, gr. ^\ (0.003); ^o^i' sulphatis, gr. xV (0.006); aquae destil- latae q. -e.; or, R ferri et ammonii citratis, gr. i ss (o.i); sodii arsenatis, gr. To (0.006); strychninae sulphatis, gr, -jV (0.002); aquae destillatae q. s. Of these one injection may be given daily. Sodium cacodylate J to 2^ grains (0.03 to 0.15) daily may prove useful. In treating this form of malaria either with or without iron the bowels should be kept regular; a course of fractional doses of calomel may be indicated from time to time in order to keep the Hver active and at intervals mild laxative pills may be employed. The treatment otherwise than that discussed above consists in the employ- ment of all measures, dietetic, hygienic and hydrotherapeutic, to improve the patient's general condition, and removal to a different climate, a moun- tainous district if possible. The Treatment oj Malarial Hcematuria. Here imless active parasites are present in the blood it is wise to omit quinine but should they be foimd this drug is strongly indicated. In the milder forms five grains (0.33) three times a day will cause this symptom to cease. Even when no plasmodia are present certain vmters advocate small doses of quinine beginning with one grain (0.065) ^^^ watching the effect on the hsmoglobiniu-ia. Methylthionine hydrochloride gr. ii to iii (0.13 to 0.2) three times a day may be given as also may sodium hyposulphite in doses of 20 grains to i drachm (1.33 to 4.0) three or four times a day. Otherwise the treatment of haemoglobinuria is symptomatic. The organs of elimination, the skin, kidneys and bowels, should be kept active by means of diaphoretics such as pilocarpine ^ to ^ of a grain (0.008 to o.oii) given hypodermatically and with caution, and by hot packs, by high rectal irrigations of hot saline, hypodermoclysis or intravenous infusion. Stimulant diuretics are to be avoided; cardiac stimulation by means of strychnine and the diffusible stimulants is often necessary. NASHA FEVER. Synonyms. Nasa Fever; Nakra Fever. Definition. An acute infectious febrile disease characterized by nasal congestion and localized swelling of the septum nasi. .etiology. This affection occurs in certain districts of India. Adults are most commonly affected, the disease being rare in children and old persons. It is observed chiefly in summer and is predisposed to by lack of proper nourishment, unhealthy mode of life and unsanitary conditions. Its specific cause is not known although it has been considered a form of malarial infec- CHOLERA. 55 tion. The facts that quinine does not influence its course and that the haem- atozoon of malaria is not constantly found are not in accordance with this theory of its causation. Symptoms. The characteristic manifestations of this disease are hyper- aemia of the nasal mucous membrane and swelling of the septum in particular. It is ushered in by malaise, prostration, and general pains in the head, body and limbs. The fever is seldom high and there may be a general eruption of small rose-red spots. The febrile movement persists for from three to five days when the temperature gradually falls and the other symptoms subside. A fatal issue, preceded by sudden amelioration of the nasal manifestations and coma, has been observed in rare instances. Immunity is not conferred by an attack. Treatment consists in employment of the means indicated to control like symptoms occurring in other infectious fevers. Puncture of the septal tumor is said to be followed by an amelioration of all the symptoms. CHOLERA. Synonyms. Cholera Asiatica; Cholera Algida; Epidemic Cholera; Cholera Maligna. Definition. An acute infectious disease caused by a specific m'cro-organ- ism and characterized by emesis, violent purging, abdominal cramps and collapse. .etiology. This disease for many years has been endemic in India and from time to time becomes epidemic. Epidemics have also occurred in other parts of Asia, in Egypt and in Europe whence it was first brought to America in 1832. Since that time the disease has visited this country at intervals, the last time being in 1892 at the time of a general Asiatic and EiU"opean epidemic, when a few cases were reported in New York City. The disease is met in all ages and both sexes, but children and old persons seem most prone to acquire the infection. Cholera occurs more frequently in low lying districts near the sea coast than in higher inland regions, it is more common in warm countries and prevails during the summer months in the temperate zones. The contagium is usually killed by the incidence of frost. The infection is predisposed to by over-population, unsanitary surroundings, bad personal hygiene, intemperance and any influence which tends to reduce the resisting power of the human body. The specific cause of Asiatic cholera is the comma bacUlus of Koch which was discovered in 1884. It is found in the intestines of all persons suffering from the disease, is usually accompanied by the colon bacillus and often by the streptococcus. It is given off from the body in the dejecta. Rarely is 56 THE INFECTIOUS DISEASES. it found in the vomitus. The disease is the result of the growth and propaga- tion of the bacillus in the body. Mode of Infection. The bacillus of cholera is taken into the gastro- intestinal tract in drinking water or upon food. The disease is not contracted by association with patients although by handling the patient's discharges the hands may become contaminated and in this way the contagium may be transferred to the mouth. Vessels washed in contaminated water, vegetables washed or watered with water containing the spirillum, or food upon which flies, which have previously come in contact with infectious matter, have alighted may transmit the disease. The spirilla are quickly killed by drying, consequently it is hardly probable that they maybe taken into the system upon the inspired air; they are capable, however, of living upon bread, meat and other foodstuffs for from six to eight days. The severity of the infection depends upon the amount of the contagious matter taken into the system and upon the resistance of the individual. It is known that the gastric juice is decidedly inimical to the spirillum and individual immunity has been observed, virulent cultures having been isolated from the stools of healthy persons. In direct opposition to Koch's theory of the propagation of cholera is that of Pettenkoffer who holds that the micro-organism of the disease develops in the soil-water of the East during the warm months and rises thence as a miasm into the air. He asserts that conditions favoring its development are a low-ground water, associated with porosity, moisture and organic con- tamination, particularly sewage. It is not certain that one attack of the disease confers immunity. Pathology. On gross inspection the body is usually much emaciated, the skin over the nondependent parts is grayish in color while that over the dependent portions of the body is livid or mottled. Post mortem rise in temperatxire may occur and while rigor mortis is an early manifestation contractions of the muscles of the jaws, the eyes, or of the limbs may be observed. The subcutaneous tissue when cut is dry, owing to the fact that the body liquids have been drained away, and the blood is thick and dark. The peritonaeum is viscid, the intestines are congested but not distended. The stomach may contain a turbid liquid resembling, rice- water; its mucous membrane is congested and its vessels are distended, the epithelium may be eroded or intact. The lining of the small intestine is usually congested and the cavity of the bowel contains turbid serum (rice-water material); in the later stages the hypergemia is more apparent and the solitary and agminated follicles may be swollen; rarely they may be ulcerated. Ecchy- moses and denudation of the mucous membrane may be observed, the latter probably having taken place after death. Patches of false membrane may be found in the intestine in cases of prolonged course. The comma bacillus is found in the contents of the bowel and in its mucous membrane, CHOLERA. 57 A condition of acute parenchymatous degeneration (cloudy swelling) obtains in the liver and kidneys, the former may also show areas of fatty degeneration and the latter coagulation necrosis with desquamation of the epithelial lining of the uriniferous tubules. The spleen is not enlarged and may be decreased in size. The heart is dry and flaccid. The left auricle and ventricle are empty while the right are filled with dark liquid blood. The lungs may be shrunken and bloodless except at the bases posteriorly where they are likely to be the seat of passive congestion. Symptoms. The incubation period is from two to five days after which the invasion of the disease occurs. The symptoms may be grouped in three stages which are more or less distinct. a. The stage of preliminary diarrhoea. This stage may be sudden in its onset or preceded by abdominal pain, malaise, headache and emesis. The diarrhoea is painless, the stools are frequent, fluid, yellowish or of "rice- water " type and alkaline. They contain the comma bacillus and other micro-organisms; there is usually no rise in temperature. This stage lasts from a few hours to a week or more or may be absent. h. The stage oj collapse is characterized by a profuse " rice-water " diarrhoea, the movements being very frequent, and apparently forcibly expelled. Parox- ysmal pain and tenesmus may be present but the patient is more often dis- tressed with painful muscular cramps in the limbs and abdominal wall. Thirst is marked and emesis is profuse, fluid resembling the stools being vomited incessantly and in great quantity. The patient rapidly becomes exhausted, and often sinks into a condition of collapse with sunken eyes, shrunken feat- ures, palhd face, cold and clammy extremities. The surface temperature may sink 4° or 5° F. ( 2° to 2.5° C.) below normal while the thermometer indicates a rectal temperature of 103° to 104° F. (39.5° to 40° C). The pulse becomes rapid, feeble and perhaps imperceptible at the wrist, the heart sounds are markedly weakened. Respiration continues until death super- venes in a condition of coma. At times the patient may remain conscious until the very end. The continued depletion of the patient during this stage results in great diminution of the secretions, particularly the urine and saliva; the sweat glands and, in nursing women, the secretion of milk remain unaf- fected. Microscopical examination of the stools reveals the presence of mucus, epithelial cells, numerous bacteria, together with the comma bacillus and at times blood cells. Chemically the dejecta contain albumin, and the salts of the blood, particularly sodium chloride. Cholera sicca is the term applied to this disease when vomiting and diar- rhoea are absent. The usual duration of the stage of collapse is from twelve to twenty-four hours although it may last but three or four hours. 58 THE INFECTIOUS DISEASES. c. The stage of reaction if the patient survives, sets in at the termination of the stage of collapse and is characterized by a reappearance of the secretions, of bodily warmth and of normal facial expression. The skin may retain its mot- tled appearance for some days or an erythema may appear. The symptoms gradually ameliorate, the heart action becoming stronger, the vomiting and purging gradually diminish and the patient either may recover, there may be a recurrence of the diarrhoea and collapse followed by death, or he may pass into a state termed cholera-typhoid which is characterized by cerebral symptoms, heart weakness and dry tongue. From this he may recover or death may take place in coma which is attributed to uraemic poisoning. Mild cases of cholera are often seen during epidemics which are termed cholerine. In such there are diarrhoea, vomiting and abdominal cramps, but the collapse is not well marked. Malignant cases may also be observed in which death takes place before the appearance of the purging and emesis or in which the patient dies early in the disease, comatose and in a profoundly toxjemic state. Such complications and sequels as nephritis, diphtheritic inflammations of the mucous membranes, and conditions due to septic poisoning, such as parotitis, erysipelas and multiple abscesses may occur. Pleurisy, bronchitis and pneumonia have been observed. In the differentiation of Asiatic cholera from other conditions likely to be confounded with it the chief points to be kept in mind are the history of association with other cases, the presence of " rice-water " stools, the presence of painful cramps in the extremities, the occurrence of cyanosis, collapse and suppression of the secretions, especially the urine, and lastly the presence of the comma bacillus in the dejecta. A preponderance of these symptoms is not likely to occur in any disease except true cholera and, of course, the pres- ence of the spirilla is pathognomonic. The mortality varies in different epidemics from 30 to 80 percent. The disease is more likely to prove fatal in the debilitated and intemperate than in those of better power of resistance. Patients with marked and early collapse seldom recover. The prevention of this disease consists in the prompt isolation of all patients afflicted with the disease and the thorough disinfection of all dejecta and the utensils, bed and personal linen of the sufferer. The methods applicable in enteric fever (see p. 9) will be found efficacious in this disease. During epidemics all water and milk used for any purpose should be boiled and it is even unwise to eat uncooked fruit or vegetables. The disease is as slightly contagious as is enteric fever and consequently if proper precautions are taken, those associating with patients are not likely to become infected. The digestion should be kept in perfect order and any disturbance, partic- CHOLERA. 59 ularly if associated with diarrhoea, promptly treated; here opium, lead acetate, small doses of sulphiiric acid and the salts of bismuth, particularly those which exert an antiseptic action upon the digestive tract such as the sub- gallate, the naphtholate and tetraiodophenolphthaleinate are indicated. The protective inoculation against cholera by means of Haffkine's virus has proved effective in the hands of its originator and its employment produces no evil after-effects. Other experimenters are said to have elaborated anti- toxic sera. Since, however, we have simpler means, namely, through disinfection, sanitation and efi&cient quarantine, by which the disease may be prevented, we may remain content imtil further research has succeeded in establishing an anticholera inoculation which shall be certainly protective. Treatment. The patient should be immediately isolated and put to bed. During the first stage of the disease treatment should be directed at the diar- rhoea, at the destruction of the bacilli within the intestinal tract and at the neutralization of their toxins. Of the drugs most commonly used to check the diarrhoea opiiim and sulphuric acid may be mentioned. It is probable that the latter is to be preferred, while opium is to be reserved to relieve the pain; for this pmrpose it should be given hypodermatically in the form of morphine. A full dose, gr. i to ^ (0.016 to 0.032), may be given at first, to be followed by smaller doses as indicated. Sulphuric acid has a destructive effect upon the comma bacillus and may be given in the form of the dilute acid, 10 to 15 drops (0.66 to I. o), every two or three hours. The acid may be given alone or with the camphorated tincture of opium. Hydrochloric and nitrohydrochloric acids are also useful. Excellent results have been attained from the use of phenyl salicylate in cholera; it may be given in doses of gr. v to xv (0.33 to i.o) every two or three hovurs alone or combined with considerable doses of one of the bismuth salts, either the naphtholate or the iodophenolphthaleinate, these last being among the most effective intestinal antiseptics at our disposal. Calomel has also given good results not only in controlling the vomiting but since a portion of this drug is changed in the digestive tract into mercury bichloride it has an antiseptic effect in addition. It may be given in dosage of from five to seven grains (0.33 to 0.5) at the onset of the disease and continued in smaller doses — ^ to f of a grain (0.02 to 0.05) — every two or three hours during the first and second stages of the affection. If severe vomiting is present we may attempt its control by lavage of the stomach and small doses of cocaine — | to ^ a grain (0.016 to 0.032). When this symptom is very marked we should administer all medication hypo- dermatically. In the control of the diarrhoea external appHcations are often useful; either mild mustard pastes or turpentine stupes may be employed. For the heart weakness the administration of alcohol and strychnine or of 6o THE INFECTIOUS DISEASES. camphor, dissolved in aether or sterile oil, i grain (0.065) ^very six or eight hours, is indicated. During the second stage the abdominal cramps may be relieved by hypo- dermatic injections of morphine and the body heat should be maintained in this as well as in the algid stage by means of hot water bottles and, if sweating is a prominent symptom, by the subcutaneous administration of yJto o^ ^ grain (0.0006) of atropine sulphate which may check this distressing manifestation. The continuous depletion of the system by the serous diarrhoea results in marked thirst and serious diminution in the watery elements of the tissues. The thirst may be relieved by allowing small but frequent draughts of water, either plain water, barley water or carbonated water being permissible, and by intestinal irrigations of hot normal sahne solution. Water may be sup- plied to the tissues and the organism stimulated by means of hypodermato- clysis or intravenous injection of considerable quantities of normal saHne. As much as two quarts (2 Utres) may be given under the skin every four or six hours. It is often wise to begin the hypodermatoclysis in the early stages and to continue it at intervals throughout the disease. During the algid stage the bodily heat may be kept up by immersing the patient in a warm bath. The patient may receive for hypodermatoclysis, instead of normal saline solution, an artificial serum composed of one drachm (4.0) of sodium chloride and 45 grains (3.0) of sodium carbonate to the quart (litre) of sterile water. This should be injected at a temperature of 104° F. (40° C.) by means of a fountain syringe or irrigating glass to the tube of which a long needle of mod- erate calibre is attached. The solution should be put under the skin of the buttocks, thighs or back; it is well to avoid the tissues of the neck lest oedema of the glottis be induced. The injection treatment, also recommended, has been followed by excellent results and consists in irrigating the large intestine, through a soft rubber rectal tube passed as high as possible, with an infusion of chamomile flowers, 2000 parts, gum arable, 30 parts, tannic acid, 10 parts and laudanum, 2 parts. According to the originator of this treatment the tannic acid not only exerts its astringent action but also inhibits the growth of the comma bacillus and has a neutralizing effect upon its toxins. The solution is passed in under gentle pressure, the bag containing it not being ele- vated more than 18 inches or two feet above the patient who lies upon the left side with the buttocks slightly raised. The fluid should be retained as long as possible and it is said that under favorable conditions it may pass the ileo- caecal valve and come in contact with the lining of the small intestine. The injection may be given four times a day and in severe infections may be administered after each movement of the bowels. If the patient is in a state of actual or threatened collapse the solution should be hot — 105° F. (40.5° C.) — but should there be tendency to hyperpyrexia it may be cool. Thetem- DYSENTERY. 6l perature of the fluid in its receptacle if it is to be given hot should be 112° to 116° F. (44.5° to 46.5° C.) since by the time it has reached the body much of its heat will have been lost in its slow passage through the tube. The tendency to urinary suppression is also lessened by the hot irrigations and may be still further combated by means of hot appUcations over the lumbar region. During the stage of reaction the substitution for the tannic acid mixture of saHne solution (sodium chloride, 10 to 15 percent.) is advisable and when the tissues seem still to be in need of water, as evidenced by thirst and relaxa- tion of the skin, the hypodermatoclysis should be continued at increasing intervals. Stimulants may also be necessary. When convalescence has become established the patient should be still kept at rest and fed with the greatest caution lest the diarrhoea reciu-. The food should be given at fre- quent intervals but in very small amounts and must be of the most non-irri- tating character. Peptonized milk is the first nourishment and may be followed by other peptonized foods. Later more liberal feeding may be permitted and tonics should be judiciously administered. Complications should receive appropriate treatment. Dead cholera bacilli in anticholera vaccination have been employed with the result of apparently certain immunization and the Japanese have an antitoxin which is said to be curative when properly administered, unless the patient is in extremis. DYSENTERY. Synonym. Bloody Flux. The term dysentery is applied to a group of infectious inflammatory intestinal affections characterized by ulceration of the intestinal mucous membrane and frequent dejections, associated with pain and often containing mucus and blood. In chronic forms of dysentery constipation may alternate with the diarrhoea. The conditions to be included under the term dysentery may be classified as follows: a, Catarrhal or sporadic dysentery; b, tropical or epidemic dysentery; c, amoebic dysentery; d, diphtheritic dysentery. .etiology. Aside from the specific causes of these different types of the disease certain predisposing astiological factors are common to all forms. Dysentery is especially a disease of warm climates, although its epidemic and other varieties have been observed in northern latitudes. Season also has a distinct influence upon the occurrence of dysentery, the disease being most prevalent during the warm months of the summer and autumn. Damp low-lying regions near the sea shore suffer more frequently than highland and inland districts. Unhygienic conditions of life, unsanitary surroundings 62 THE INFECTIOUS DISEASES. and over-crowding predispose to the incidence of the disease as is evidenced by the epidemics which occur from time to time in army camps, jails, hospitals and the like. Dysentery affects all ages, both sexes and all races. Barring the proneness of infants to dysenteric disturbances the disease is most commonly seen in young adults. It is predisposed to by all disorders of the intestinal tract and by errors in diet, particularly the eating of unripe or over-ripe fruit. Catarrhal Dysentery. Synonym. Sporadic Dysentery. .Etiology. This form of dysenter}^ is met as a complication of the various acute infectious diseases as well as of chronic wasting diseases such as tuber- culosis. It is predisposed to by the ingestion of irritating and improper food and is the type of dysentery met so frequently in children dmringthe summer months. Here it is usually a primar}' disease and it may occur as such in adults. Its specific cause is in all probability the result of the presence and growth in the intestine of the Shiga bacillus or analogous micro-organisms of which several varieties may be present in the same case. Pathology. The morbid changes depend upon the severity of the infec- tion and may consist merely of an increased production of mucus, exfoliation of the epithelial cells lining the large intestine, exudation of serum and dia- pedesis of white blood cells. In more marked infections there is swelling of the soUtary follicles which is foUowed by necrosis and ulceration; haemor- rhages from the mucous membrane may occur and this structure may be the seat of a purulent inflammation. Symptoms. The onset of the disease may be preceded by such prodromata as malaise, abdominal pain, nausea and moderate diarrhoea, or it maybe sudden and marked by a chill followed by a slight or moderate rise in temperature which seldom is higher than 103° to 104° F. (39.5° to 40° C). The t}^ical symptoms are cramp-like pains in the abdomen accompanied by movements from the bowels accompanied by tenesmus. At first these number not more than five to six per day, are copious and consist of faecal matter; soon they become much increased in number, even to 100 or more per day, are small, mucoid and at times bloody; they are accompanied by pain and tenesmus. Microscopic examination of the stools reveals the presence of mucus, red blood and pus cells, epithelial cells which may have undergone partial fatty degeneration and the bacteria of putrefaction. After a week or ten days the stools become less frequent, contain less mucus and blood and are greenish, due to the presence of bile. Other symptoms manifested in this disease are a coated tongue, at first DYSENTERY. 63 moist, later dry, loss of appetite, rarely vomiting, and marked thirst. The patient rapidly becomes emaciated and a condition of collapse with small weak pulse and moist clammy skin may be observed. Occasionally delirium followed by coma and death may be met. The usual coxirse is one week to ten days when the stools begin to approach the normal in number and character, but at times the disease will resist treat- ment for a long period or even become chronic. Death occurs in rare instances from exhaustion. The diagnosis is to be based upon the character of the stools and the intes- tinal symptoms. In protracted cases rectal examination should always be made in order to exclude malignant tumor. Tropical Dysentery. Synonyms. Epidemic Dysentery; Bacillary Dysentery. Definition. A specific inflammation affecting the colon and sometimes the small intestine and characterized by the exudation of a false membrane which may be cast off, leaving ulcerative surfaces behind. .etiology. This affection is a common disease of tropical and temperate cHmates and especially prone to appear where large numbers of persons are gathered under unsanitary surroimdings as in army camps, ships and hos- pitals. It often appears in epidemics. Its specific cause is the bacillus dysenteruB discovered by Shiga dtiring an epidemic in Japan. Other observers have confirmed his observations in the Philippine Islands and in other coun- tries. This micro-organism is not found in the normal intestine but may persist in this situation after an attack of the disease which may account for the dissemination of the infection in regions where it has been prevalent. It has appeared in the United States since the return of our soldiers from China and from the West Indies. Its mode of transmission is by means of drinking water or other contaminated ingesta. Pathology. The changes observed depend upon the severity of the infection. In mild forms the mucous lining of the intestine is inflamed, swoUen and covered with a croupous exudate which is easily detachable and is composed of necrotic epithelium. In the more severe grades this exudate involves all the coats of the intestine and appears as a grayish or brownish mass of granular surface which may cover the entire lining of the colon or may affect localized areas only. Portions of this pseudo-membrane may be sloughed away, ulcers, varying in extent, being left behind. A follicular form of inflammation may occur without membrane formation in which the intestinal lining is at first swollen and congested, the follicles, especially those of the caecum, being inflamed and ulcerated. These ulcers may extend to the muscular coat; their edges are ragged and overhanging. Cicatrization may 64 THE INFECTIOUS DISEASES. take place, and ulcerations in all stages may be observed at the same time. In other instances a gangrenous process may follow the diphtheritic inflam- mation. Here the serous coat is affected and adhesions are common; the wall of the gut is easily torn, is necrotic and dark olive green in color with here and there areas which are quite black. Its hnmg is the seat of diffuse puru- lent in^tration with localized areas of necrosis and gangrene. Portions of the mucosa may not be involved in the above described t)'pes of inflam- mation but are the seat of simple catarrhal changes. Symptoms. The onset is usually sudden and may be characterized by a chill. The temperature rises rapidly — 102° to 103° F. (39° to 39.5° C.) — the prostration is marked and cerebral symptoms, even delirium, may be present. The temperature is irregular with remissions from time to time, the piflse is rapid and soon becomes feeble; irregularity of force and frequency may be noted. There is severe abdominal pain and the stools are frequent, small, dark ir color, fcetid and contain caucus and blood. Pieces of pseudo-membrane may be cast off, varying from a small shred to a tube cast of the gut of considerable size. Tenesmus is Hkely to be a distressing symptom and the abdomen may be distended and tender. In persistent cases the stools are likely to become serous and more profuse. Such dejecta are markedly albuminous, and may be reddish, due to the presence of blood. The patient becomes rapidly weak and emaciated and suffers from thirst; the mouth is dn^ and the tongue foul and coated. In severe infections delirium may be followed by coma. Milder subacute types of the disease may occur in which the symptoms are not marked and the stools as few as five or six per day. The diagnosis may be made upon the rapid development of intestinal and constitutional symptoms, and the appearance of bits of membrane in the dejecta. It is assured by the isolation of Shiga's bacillus from the stools and by obtaining a positive agglutination reaction with pure cultvires of this bacillus when mixed with the blood-serum of the patient. The prognosis in this type of dysentery is distinctly unfavorable, recover}^ may, however, occur or the disease may become clironic. Complications such as localized peritonitis, intestinal rupture with subse- quent general peritoneeal infection may be observed. Hepatic abscess is less frequent than in amoebic dysenter}\ Pleurisy, pericarditis and endocar- ditis are infrequent complications. Amoebic Dysentery. Definition. An inflammation of the large intestine characterized by the formation of ulcers and due to the amceha coli. .Etiology. This disease is most common in tropical countries but has DYSENTERY. 65 also been observed in the southern United States and more infrequently in those farther north. It mayocciir at any age but is most common diiring the third decade of life and seems to affect males more frequently than females. Its specific cause is the amceba coli which is found in the stools, the intestinal ulcerations and in the pus from liver abscesses which commonly complicate the disease. This organism is from 15 to 20 microns in diameter, spheroidal in form and, when living, actively motile. It is composed of two portions, an outer, the ectosarc, and an inner, the endoscarc. It moves by propelling the former, after which the endosarc follows by flowing into the pseudopodia thus extruded. The amoeba is phagocytic taking into its substance red blood cells and other bodies occurring in the intestine. It- is said that the virulence of this micro-organism is much enhanced by the presence of other pathogenic bacteria. Its mode of transmission is usually by means of drinking water or vtpon other ingesta contaminated with infective water and consequently the disease, of which it is the cause, may be in great measure prevented by proper attention to water supply and by thorough disinfection of the discharges of affected individuals. Pathology. The intestinal changes are confined almost wholly to the large intestine and are but seldom found in the ileum. The ulceration involves first the submucosa of the gut but spreads thence to the mucosa. The muscularis is rarely and the peritonaeal coat stiU more seldom, afi'ected. The first changes noted are a number of areas of congestion in the submucous coat; these are followed by necrosis of this and a sloughing process which involves the mucous coat as well and leaves behind ulcers of varying size and depth. The peritonasal coat rarely shares in the inflammation and perforation is a rare occurrence. Pus is present in surprisingly small amount considering the extent and type of the process and extensive necrosis of the submucosa may be observed with no or only slight involve- ment of the mucosa, the inflammation dissecting its way downward and laterally rather than toward the lumen of the intestine. The ulcers may be circiflar or ovoid, with ragged floors and overhanging edges and may involve nearly the whole of the colonic lining including that of the appendix. In them the amoebae are present; these may also be foimd in the lymph spaces and more rarely in the neighboring blood-vessels. As the ulcers heal their bases become covered with fibrous tissue which may later contract and cause strictures or even sacs in which the amoebafc may remain after the patient seems to have recovered. Thickenings and adhesions of the colonic wall may be observed. The hepatic lesions are probably the result of the entrance of the parasites into the portal capillaries and are of two types: First, multiple circum- scribed areas of necrosis, and second, abscesses, single or multiple. The 5 66 THE INFECTIOUS DISEASES. former lesions are thought to be due to the action of the products of the growth of the parasite, the latter, if recent, contain within their cavities, which are large if single, small if multiple, necrotic matter of semifluid consistency and reddish — or greenish — ^yellow color. On close inspection this is seen to be composed of a spongy net-work of tissue in the interstices of which a viscid fluid isi confined. The walls of the recent abscesses are ragged and necrotic while those of long standing are lined by firm, dense fibrous tissue. Micro- scopic examination of the contents of the abscess reveals the presence of necrotic liver ceUs and amoebae. True pus is not present unless mixed infec- tion has taken place. Such pyogenic bacteria as staphylococci, streptococci, colon bacilli, etc., have been found. Large single abscesses are usually near the upper or lower surfaces of the right lobe while the smaU multiple abscesses are scattered through the organ and may be at no great distance from its surface. Hepatic abscesses may rupture, depending upon their site, into any of the surrounding organs or through the abdominal wall. They may perforate the diaphragm and biu-st into the lung, whence their contents may be coughed up. Associated lesions which may be observed are nephritis and cerebral conges- tion with or without capillary haemorrhages. Symptoms. In cases of acute onset the symptoms are practically those of dysentery due to the baciUus of Shiga (see p. 64). The temperature is seldom high but the patient is greatly prostrated and becomes rapidly and to a marked degree emaciated. Intestinal haemorrhage or perforation may occur. While recovery usuaUy takes place in two or three months, in severe grades of the infection death may take place within a week or ten days or, the disease becoming chronic, the patient continues to suffer from alternating diarrhoea and constipation, exacerbations occmrring from time to time during which the pain and temperatiu^e recur and diarrhoea with the passage of mucus and blood makes its appearance. Between the exacerbations the patient enjoys periods of improvement but a recurrence of the symptoms may be brought about by errors in diet or exposure; while often enough the patient's nutrition remains good, in other instances emaciation may be marked. In another chronic type of the disease the ulceration persists and with it the diarrhoea; the emaciation is progressive and death from exhaustion super- venes within a few months. The complication to be particularly anticipated is liver abscess, the presence of which is evidenced by an increase in the area of liver dulness, pain, leuco- cytosis and a temperature of septic type accompanied by chills and sweating. Other possible complications are peritonitis, intestinal haemorrhage or per- foration, pylephlebitis, pleurisy, pericarditis, endocarditis and arthritis. Malaria and typhoid fever have been observed in co-existence with this disease. DYSENTERY. 67 The diagnosis of this affection is to be based upon the finding of the amoebae in the patient's dejecta. They should be searched for upon a warmed stage and a positive diagnosis should not be made unless amoeboid movement is observed. The prognosis of amoebic dysentery in epidemics and without proper treat- ment is unfavorable; in sporadic cases the mortality is low. Recurrences are prone to occur and in the patients in whom the disease is complicated by hepatic abscess the chances of recovery are greatly diminished. Diphtheritic Dysentery. This form of dysentery occurs secondary to the acute infectious diseases* pneumonia, enteric fever, etc., and to certain chronic affections such as endo- carditis, nephritis and pulmonary tuberculosis. Pathology. While termed diphtheritic this condition is not a result of Klebs-Loffler infection. It is characterized by the appearance of a pseudo- membranous exudate of yellowish or grayish color upon the mucous lining of the intestine and by necrotic ulcerative areas. The supporting connective tissue of the colonic glands is inflamed and infiltrated with fibrin and pus ceUs. The process may involve the muscular and peritonaeal coats as weU. The inflammation may be confined to the rectum or the whole colon may be involved, its entire surface being covered with the exudate or merely scattered areas of pseudo-membrane being present. In markedly severe instances the necrotic patches may slough leaving ulcers behind which either cicatrize or remain active for long periods. Symptoms. The onset of this disease is gradual being characterized by the appearance of slight or moderate diarrhoea, the stools being fluid, not often accompanied by pain or tenesmus and seldom more than from three to five daily. In mild cases the passage of mucus and blood rarely is observed but in the severer types of the disease these with shreds of membrane may appear in the dejecta. The affection is usually subacute or chronic in its course and is associated with emaciation. Death may take place from asthe- nia. The Treatment of Dysentery. Under this caption the means applicable to the treatment of all types of the affection will be first discussed, to be followed by a description of those especially indicated in the different forms of the disease. General Considerations. In all forms of dysentery the prophylaxis consists in boiling all possibly contaminated drinking water, disinfecting and des- troying the patient's dejecta and in taking all the other precautions laid down in the section upon the prevention of enteric fever (p. 9). Much work 68 THE INFECTIOUS DISEASES. has been carried on recently along the lines of preventive inociilation against bacillary dysentery and it is quite probable that we may in the not far distant future have at our disposal an effective immunizing serum against Shiga bacillus infection. At thf onset of any of the varieties of dysentery the patient should be imme- diately put to bed and if the catarrhal type is the one in hand a pm"ge of castor oil, one ounce (30.0) with 20 grains (1.33) of sodium bicarbonate should be given. The pains and tenesmus may be controlled by the application of turpentine stupes or mild sinapisms to the abdomen and by the administration of Dover's powder by mouth. In instances where these means fail morphine may be given hypodermatically. The feeding of the patient offers difl&culties, for we have a distiurbed diges- tive tract and one which must be irritated as little as possible, and at the same time we have to combat a disease, one of the most prominent characteristics of which is loss of strength and emaciation. Milk has its disadvantages since the curds which are formed in the stomach may be impossible of digestion by an alimentary tract the powers of which are impaired; the curds also are excellent culture media for the growth of the micro-organisms which are present in the intestine. Curd formation may be prevented by taking the milk in small amounts and diluted with lime water or vichy or barley water, or in the form of kumyss or zoolak. Peptonized milk may also be tried, soups and broths may be permitted. When milk is not well borne easily digestible semi-soHds, which may be partly predigested by means of pancreatin or diastase, such as soft boiled eggs, meat jellies, milk toast, junket, etc., are allowable. The diet in the protracted forms of diphtheritic or amoebic dysentery may be more liberal. While milk plays an important part here such nourishing and easily digestible solids as raw oysters, cereals, poultry and fish may be given in small quantities and tentatively. As the patient recovers a still more liberal dietary may be gradually permitted. Various forms of drug treatment may be employed in catarrhal and bacillary dysentery; the so-called saline treatment is indicated particularly in sthenic cases with high fever and in many instances achieves excellent results. Instead of the initial dose of castor oil, a purgative dose of magnesium sulphate or sodium and potassium tartrate is given and the intestine thoroughly evacu- ated. Then, upon the theory that intestinal micro-organisms cannot exist or at least are inhibited in their growth by an acid medium, aromatic sul- phuric acid is given in 20 drop (1.33) doses three times a day. By this means, not only are the intestinal bacteria retarded in their development, but the astringent action of the acid is also exerted. The ipecac treatment may be employed in all forms of dysentery and is DYSENTERY. 69 to be carried out as follows: The drug is administered upon the empty stomach and it may be wise to apply mild coxmterirritation over the stomach in the form of a mild mustard paste or by painting with iodine before giving the ipecac. The amount of this drug which is administered is large and under ordinary circumstances would produce emesis, consequently the patient should not be told of what the medication consists and he should be warned not to vomit if he can avoid it. The size of the dose is in proportion to the severity of the disease and weakness is not a contraindication. Preceding the administration of the ipecac a dose of 10 to 15 drops (0.66 to i.o) of tinc- ture of opium is given and after a quarter of an hour from 15 to 60 grains (1.0 to 4.0) of ipecac, depending upon the age of the patient and the type of the infection, are taken. The drug may be given in pill form or suspended in a little water to which a little peppermint or anise oil has been added. Should emesis be induced the dose should be repeated as soon as the stomach is at rest. The ipecac may be given for considerable periods, the dosage being diminished as the dysentery becomes less marked in severity. Intestinal antiseptics may be employed as advised in the treatment of chronic diarrhoeal conditions (see p. 384), but are usually less effective than the forms of treatment described above. Treatment by means of intestinal irrigations often brings about good results. The apparatus necessary consists of a fountain syringe to which a long rectal tube of soft rubber is attached. When the intestine is very irritable it may be wise to pass a soft catheter beside the tube to carry off the return flow and prevent distention of the bowel. Forcible irrigation is contraindicated, a gentle flow, the receptacle containing the fluid to be used being held at a height not greater than three or four feet above the patient, being preferable. Careful introduction of the tube is necessary and a skilled hand may often succeed in passing the same well beyond the sigmoid flexure. The discom- fort accompanying its passage in instances of severe tenesmus may be obviated by the insertion of a cocaine — gr. J to J (0.016 to 0.032) — and iodoform — gr. viii (0.5) — suppository shortly before the procedure. The quantity of the irri- gation selected may be from one to two gallons (4 to 8 litres), although irri- gations so large in amount may at first be intolerable to the patient; we may by beginning with small quantities gradually increase until the bowel becomes tolerant and the patient's discomfort endurable. The insertion, previous to the injection, of such a suppository as that given above or the injection of a drachm (4.0) of tincture of opium in a little starch water will often render the subsequent irrigation well borne. The temperature of the irri- gation is an important consideration, cold irrigations being indicated in sthenic cases while, when stimulation is desirable, higher temperatures are advisable. Tepid irrigations are seldom employed. Various solutions have been employed in the different types of dysentery. 7© . THE INFECTIOUS DISEASES. In the simple catarrhal and the diphtheritic forms simple cold water, or hot saline solution may be employed. Here also astringent solutions such as alum (2, percent.), zinc phenolsulphonate (0.25 percent.), silver nitrate (0.25 percent.), tannic acid and salicylic acid (i to 2 percent.), silver-protein (protargol) (0.75 percent.) are of use*. An infusion containing 45 grains (3.0) of ^ ipecac is said to be useful. Those particularly indicated in baciUary dysentery are antiseptics, silver nitrate and protargol in the strengths given above, methylthionine hydrochloride gr. x (0.66) to a quart (i litre) of saturated solution of boric acid, potassium permanganate (0.025 percent.). In amoebic dysentery an approved irrigation is of quinine sulphate, i to 5000, gradu- ally increased to 2 to 1000. Mercury bichloride i to 1000 to i to 6000 may be used. Such irrigations consisting of from two to four quarts (2 to 4 litres) are given twice a day. Recently it has been found that irrigations of copper sulphate solution of a strength of i to 6000 or less are very efl&cient. The irrigations are given twice a day, and the colon having been filled, the fluid is retained for twenty minutes if possible. A preliminary cleansing of the gut by means of the injection of sterile water is advisable. This water should be allowed to drain away before the medicated irrigation is given. Enemata of ice water are also useful in this type of the disease. Hydrogen dioxide, both in amoebic and bacillary dysenter}', may be injected per rectum as a parasiticide. Cases of tropical dysentery are reported as being favor9,bly influenced by drinking sulphur waters and sulphur in connection with pulvis ipecacuanhae et opii has been suggested for internal administration; 15 or 20 grains (i.o to 1.33) of the former and five grains (0.33) of the latter may be given every four hours. In this form of dysentery excellent results are said to follow the administration of the fluid extract of cortex granati and of aplopap- pus Balayhuen, a South American drug and one used there in dysentery. In dysentery of the chronic type pure olive oil may be tried. It is said to act as a cholagogue, and to decrease the number of bowel movements and the tendency to intestinal fermentation and putrefaction. Much research has been carried out in the attempt to elaborate an anti- dysenteric serum and while in some instances favorable reports have been made of the results of these endeavors, as yet we have no specific serum which may be relied upon. Before concluding it is weU to mention the surgical management of chronic dysenteric conditions. This consists in the formation of an artificial anus through which the bowel may be irrigated. It has been suggested that the appendix, being opened and fastened to the edges of a colostomy wound, may be used in this way. When rectal ulcers exist in subacute or chronic cases they may be opened under anaesthesia, scraped and touched with caustic. They then should be irrigated with warm normal saline solution and when EPIDEMIC GANGRENOUS PROCTITIS. 7 1 healed the employment of irrigations of silver nitrate, i to 500 to i to 250, is advised. EPIDEMIC GANGRENOUS PROCTITIS. Definition. An acute infectious disease characterized by rapidly pro- gressing ulceration of the rectum resulting, in certain instances, in prolapse and gangrene. .etiology. This affection occurs in certain parts of Central and South America, the Philippines and in islands of the Malay Archipelago. Children are more frequently attacked than adults and in Northern South America the latter are not affected. The disease is favored by unsanitary conditions and malnutrition, and marked humidity is probably necessar}^ to its occiurence. It has been attributed to the eating of unripe maize but since the affection has been reported in regions where this cereal is unknown this cannot be held responsible for all cases. The essential factor in the aetiology of epidemic gangrenous proctitis is probably a micro-organism, although possibly not a specific one, since by some it is not regarded as a distinct disease but merely a dysentery of severe type, the lesions of which are, for some unknown reason, confined to the colon. Pathology. The typical lesions of this disease consist of deep ulcera- tions of the rectal mucous membrane occurring low in the viscus between the two sphincters or higher than this point, even involving the lining of the sigmoid fiexure, and covered with a pseudo-membranous exudation. In the severest forms of the affection there is rectal prolapse with gangrene of the extruded portion. Symptoms. The invasion of the disease is characterized by burning and pruritus of the anal region followed by symptoms resembling those of dysentery. The dejecta are faecal at first and ven,^ foul, later they are mixed with mucus and finally consist merely of blood and mucus which nms slug- gishly but constantly from the anus. Tenesmus is present, progressive weakness even to coUapse is manifested and there are pronounced cerebral symptoms — delirium or coma. Death in convulsions may supervene, or, the patient surviving, rectal prolapse takes place, the prolapsed portion of the gut soon sloughing. The differential diagnosis from dysentery may be made by means of proc- toscopic examination. The prognosis of the disease is distinctly unfavorable but even the most severe cases sometimes recover. After sloughing of the prolapsed rectum recovery has been observed, the process being analogous to that which takes place in a sloughing intussusception which heals spon- taneously. Treatment. Taking into consideration that this affection is probably 72 THE INFECTIOUS DISEASES. due to an infectious process localized in the rectum, the indication for treat- ment would seem clear, namely, to render this viscus as antiseptically clean as possible. For this purpose injections of merciuy bichloride solution (i to 10,000 to I to 6000), of hydrogen dioxide, of weak creolin solution, of silver viteUin (20 percent.), etc., may be employed. The prolapsed rectum should not be reduced but should be cleansed and kept dusted with bismuth subgallate (dermatol), thymol iodide (aristol) or other similar powder. Sur- gical procedures are indicated when gangrene takes place. HILL DIARRHOEA. Definition. An acute diarrhoeal disease characterized by whitish stools occurring in the morning and a tendency to abdominal tympanites. ^Etiology. This disease is seen in the mountainous regions of British India in persons who are accustomed to residence in the tropics but have gone from lowland to highland districts. Marked humidity and a high altitude seen to be the chief predisposing factors in its occurrence. Its specific cause has not been determined. Pathology. The pathogenesis of this disease is probably based upon a transient disorder or cessation of the hepatic and pancreatic functions which may be the result of the effort of an impaired digestion to accommodate itself to unusual meteorologic conditions. By certain observers it is considered to be induced by the effect of the unusual cold and dampness of the early morning of tropical mountainous climates upon the atonic colon which is likely to be met in those who have lived in hot countries for considerable periods of time. Symptoms. The disease is evidenced by disordered digestive function and the appearance of a morning diarrhoea. The stools increase progressively in number until there are 8 or 10 daily, the first appearing about daybreak, the last about noon or shortly before this time. The dejections are colorless, of large size, pasty or frothy and of sickish odor. Pain is not marked though there may be slight discomfort referred to the region of the colon. Abdom- inal cramps and tenesmus are conspicuously absent. Abdominal distention is a prominent symptom and there is manifest digestive disturbance charac- terized particularly by discomfort after meals. This disease is analogous to sprue but differs from the latter in its tendency to recovery after a few weeks. Certain cases may progress and terminate in true psilosis, while others persist until the patient returns to a lower altitude. Treatment consists in combating the tendency to digestive disorder by means of a diet of milk and other easily digestible fluids and by keeping the patient in bed until the noon hour. Cholagogues, especially calomel in smaU doses, are indicated and the administration of pilocarpine hydrochloride, SPRUE. 73 ^ to J of a grain (0.008 to 0.022), is suggested with a view to increasing the pancreatic secretion. Artificial digestive ferments particularly pancreon and pancreatin may- prove useful. Cases which are uncontrollable by ordinary means must be sent to low-lying districts. SPRUE. Synonym. Psilosis. Definition. A disease of tropical coimtries characterized by a catarrhal inflammation of the entire digestive tract which results finally in glandular atrophy and which is evidenced clinically by sore mouth, diarrhoea and dis- tention of the intestines with gas. .Etiology. This disease is common to all tropical climates and prevails particularly in India, Southern China and the Malayan Archipelago Author- ities differ as to whether sprue is a specific bacterial infection or originates secondarily to the diarrhoeal and other wasting diseases, malaria, etc., which are common in the tropics. The fact that no bacterial cause for the disease has yet been isolated is against the former h^'pothesis. Various micro- organisms and intestinal parasites have been considered as causes of the affec- tion but their occurrence is probably a coincidence or they are present as a result of preceding morbid conditions. The strongyloides intestinalis, the amoeba coh and several varieties of bacilli intermediate between the colon bacillus and the bacillus of enteric fever are frequently found. Predisposing factors to the incidence of sprue are fatigue and over-exertion, pygemic con- ditions, the puerperal state, nephritis, and in fact any influence which tends to vitiate the bodily power of resistance. The affection usually shows itself during tropical residence but may not occm* until the patient has retmrned to temperate regions, having remained inactive in the system for years. Pathology. The changes found after death from sprue consist of atrophy of the mucous membrane and glandular structures of the small intestine. The latter may be entirely destroyed but while the intestinal wall is greatly thinned the peritonaeal coat is unaffected. The agminated glands may be swollen or ulcerated and dysenteric ulcerations may be present in the large intestine. The mesenteric and subcutaneous fatty tissue has wholly disappeared. The parenchyma of the liver, pancreas and kidneys may be the seat of an inflammatory process or of localized fatty degeneration. The mucous membrane of the mouth is eroded, ulcerated and cracked. Symptoms. The typical manifestations of sprue are sore mouth, irreg- ular diarrhoea and tympanites. The tongue is seldom coated, it is yellowish in color, pointed and shrunken and tiny aphthous ulcers are often present at its edge and upon its ventral surface. These lesions may also be observed 74 THE ENFECTIOUS DISEASES. upon the hard and soft palate. The dorsum of the tongue is dry and shining^ or it may be the seat of very shallow erosions which may unite to result in a serpigenous formation. Fissures may be present and the patient complains of buccal soreness which is increased upon taking salty or highly seasoned food. Pain on swallowing may be noted, showing that the oesophagus is probably in a condition analogous to that of the tongue. Emaciation is marked and the abdomen is tensely distended, and tympanitic. Eructation is frequent and either gas or watery fluid may make its appear- ance in the throat as a result of this symptom. The appetite may be excessive or entirely lost. Nausea and vomiting uninfluenced by eating may occur. Gastric discomfort and pain often are associated with the flatulence. The diarrhoea is a characteristic manifestation, the movements varying from one to a dozen in the 24 hours. They are large, acid, foetid, white and frothy, resembling whitewash, and usually unaccompanied by pain. Micro- scopical examination reveals bits of the mucous lining of the gut, various micro-organisms and perhaps a small number of red blood-corpuscles. The patient becomes rapidly weak and emaciated as a result of the im- pairment of assimilation due to the interference with the action of the intes- tine and the inability to retain food. The skin is sallow and yellowish and secondary anaemia is marked, the leucocytes are not increased in number. Attacks of tetany have been noted. The course of the disease is chronic with no tendency toward spontaneous recovery, although temporary improvement may be observed from time to time. The patient may recover unless the mucous lining of the intestine is so atrophied as to render sufl&cient assimila- tion impossible. The affection usually lasts for a year or two but a much more protracted course is not rare. Treatment is principally dietetic. The patient should be kept in bed and fed upon frequently repeated small quantities of milk. As rapidly as possible the amount of milk should be increased. Whether the patient is receiving too much is indicated by its appearance undigested in the stools and increase in the soreness of the mouth. In favorable cases after a month or more the buccal symptoms and the diarrhoea will begin to disappear. Successes have been reported to have followed a diet entirely of meat or meat juice, and certain observers consider the use of minced meat, five ounces (160.0) three times a day as important. Antiscorbutic treatment has been advised, and a fruit diet, particularly a regimen of berries, is said to have pro- duced rather remarkable cm^es. Strawberries are reputed to have achieved cure in obstinate cases. In the control of the diarrhoea the intestinal antiseptics, particularly the salts of bismuth, the naphtholate and the tetraiodophenolphthaleinate, may be employed and when convalescence has become established general tonic treatment by means of iron, arsenic and strychnine is indicated. THE PLAGUE. 75 THE PLAGUE. Synonyms. Bubonic Plague; Black Death; Malignant Adenitis; The Pest. Definition. An epidemic contagious febrile disease characterized by- swelling and inflammation of the lymph glands and haemorrhages into the skin and mucous membranes, .etiology. The disease is endemic in India and from time to time epi- demics have appeared in various European countries. Cases have been brought to New York and instances of the affection have been observed amongst the Chinese in San Francisco. The plague is most common during the hot months and is seldom seen in individuals beyond middle life. The chief predisposing factor is lack of proper hygiene, the infection being usually met in crowded and filthy quarters and amongst the poor and ill-nourished. The specific cause of the affection is the bacillus pestis which was discovered in 1894 by Yersin and Kitasato. Transmission and Modes of Infection. The contagium of bubonic plague may enter the body through the respiratory or digestive tracts or through abrasions of the skin and is found in the blood of patients and in the pus from the suppurating glands. It is given off in the faeces, urine and sputum and contaminates clothing, bed linen, apartments and the like. It may be carried by fleas and other insects and by rats, mice, dogs, etc. Pathology. The skin and the digestive tract are the seat of punctate extravasations of blood; these are also found upon the serous membranes and upon the capsules of the viscera. The latter and the central nervous system are congested. The spleen is enlarged. In the bubonic type of the disease the lymph glands, particularly those of the axillas and groins are swollen and inflamed and often undergo haemorrhage, suppuration and necrosis. The periglandular tissue may be involved in similar changes. In these glands the bacillus pestis is found and, after suppuration has taken place, with it other pathogenic bacteria are associated. The lymph system is affected in all types of the disease but in the bubonic form a particular set of glands will be chiefly involved. In the pneumonic variety the bronchial lymph nodes are especially affected and areas of broncho-pneumonia exist in the lungs. Here the bacilli are found in the sputum. Symptoms. The disease occurs in two main types, i. pestis minor and 2. pestis major. The latter is met in three varieties: a. The bubonic form. b. The septicaemic form. c. The pneumonic form. Pestis minor, abortive or ambulant plague is seen usually just before or at the termination of an epidemic. The patient is seldom very ill but is a great danger to the community since his excreta contain the contagium. The 76 THE INFECTIOUS DISEASES. attack lasts several days and is characterized by mild fever and swelling and tenderness of the inguinal glands. Suppuration may occur. Pestis Major. The incubation period is from three to seven days; during the day or two before the onset of the disease the patient may complain of indefinite malaise, dizziness and general pains. The invasion, which may be without prodromata, is marked by a chill or chiUy feelings followed by a rapid rise in temperature to 104° to 106° F. (40° to 41.1° C), rapid, and sometimes weak, pulse. Nervous symptoms and prostration are marked and the patient may die in collapse. Should he survive, about the third to the fifth day the glandular swellings appear, the inguinal lymph nodes being affected in the majority of cases. These become red and tender and may resolve, suppu- rate or become gangrenous. Petechial haemorrhages take place into the skin and there may be bleeding from the various mucous membranes, gastric, intestinal, pulmonary, etc. In the septicemic type of the infection the bacilli are found in the blood stream, the patient is profoundly poisoned and is likely to die before the glandular swelling takes place. The typhoid condition is rapidly developed and hjEmorrhages are common. The pneumonic form of the disease is sudden in onset with a chiU, rise in temperature, cough and pain in the chest resembling those of lobar pneumonia. Physical signs of pulmonary consolidation may be obtained, the sputum is mucoid and contains blood and the bacillus pestis in large numbers. This form of plague is very fatal, the patient seldom surviving more than three days. The diagnosis may be made upon the appearance of the glandular tumors and upon the occmrrence of the bacillus in the excreta and blood. The prognosis is markedly unfavorable; from 70 to 90 percent, of those afflicted usually perish. The septicaemic and pneumonic varieties are espe- cially fatal. Suppuration of the buboes is a favorable sign while the occur- rence of haemorrhages is the contrary. Treatment. Prophylaxis consists in the establishment of proper sanitary conditions, the extermination of rats, isolation of patients, careful disinfection of their excretions, of bed clothing, apartments, etc., and cremation of the dead. Much can be done toward immunization since the work of Haffkine and Yersin in the elaboration of protective sera. Of Haffkine's serum the dose is about 38 minims (2.5) and by its use, according to reports, the death rate may be markedly diminished and epidemics controlled. The treatment of the attack is to a great extent symptomatic. At the onset the bowels should be opened by means of fractional doses of calomel followed by a saline. The fever may be controlled by cool sponge baths. The coal tar antipyretics should not be given on account of their depressing effect upon the heart. For the nervous symptoms, the bromides may be CLIMATIC BUBO. 77 administered but for these and the pain the hypodermatic exhibition of mor- phine often becomes necessary. For the tendency to heart weakness and collapse stimulants such as ammonia, alcohol, strychnine and camphor dis- solved in aether or sterile olive oil are indicated. The glandular swellings may be treated by means of cold applications, or poulticed. When the pres- ence of pus is manifest they should be promptly incised and drained. The injection into the buboes of mercury bichloride has been employed with good results. Phenol is recommended and has given excellent results. It is given in doses of 12 grains (0.8) every two hours (144 grains — 9.6 daily) and when taken well diluted causes no disturbance except carboluria. Much research has been conducted in the hope of producing an effective antiplague serum and at least two antitoxins have been elaborated which are useful. That of Yersin seems to be considered more effective than that of Haffkine. The former is considered by certain observers to be of great value. Its action is said to be bactericidal, as evidenced by the degenera- tion induced in the bacilli, and antitoxic as well. In order to achieve the best results the serum should be given in large doses early in the disease, both intravenously and under the skin of the lymphatic area which drains toward the bubo. In mild instances of the disease the latter method will Of ten suffice but in marked infections the combined method is necessary, the beginning dose being about 5 to 10 drachms (150.0 to 300.0), the intravenous dose varying with the severity of the intoxication. No evil results are reported as due to this treatment. CLIMATIC BUBO. Synonyms. Tropical Bubo; Tropical Adenitis. This affection consists of a non-venereal subacute inflammation of the inguinal glands associated with a remittent fever lasting several weeks. It is observed on the tropical coasts of Asia and Africa, in the Philippines and the Malayan Archipelago and in the West Indies. It is prone to affect persons living in close association amid unhealthy surroundings and is met in epidemics. Its chief importance consists in the fact that it may be mistaken for pestis minor from which it is bacteriologically entirely distinct. Its aetiology is not definitely known but it has been consid- ered to be a bacterial infection which effects an entrance by means of abra- sions upon the legs or about the genitalia or by means of the stings of insects. It has also been considered as occiuring secondarily to dysentery and chronic malaria. Symptoms. These consist of unilateral or bilateral inflammation of the inguinal glands or those about the saphenous opening, preceded by a chill, 78 THE INFECTIOUS DISEASES. general pains and malaise. A remittent fever follows. The glands increase in size for from three to four weeks when the fever subsides by lysis. The glandular tumors remain for several months and slowly resolve. In a small percentage of cases the tissues about the glands become involved and sup- pmation takes place, the constitutional symptoms under such conditions are marked. If not opened the abscesses tend to spread and finally bu}"st discharging pus. The discharge continues for varying periods, finally ceasing and leaving behind sluggish painful ulcers. Treatment. This is entirely symptomatic and svurgical. Until sup- puration occurs the buboes should receive inunctions of unguentum Crede, lo percent, ichthyol or compound iodine ointment. If they subside without pus formation, in their declining stages inunctions of unguentum hydrargyri and snug bandaging are indicated. As soon as the presence of pus is apparent, free incision, drainage and dressing with antiseptics are necessary. The ulcers which foUow suppmration should be treated in accordance with surgical principles. It is said that calomel dusted over their surfaces will relieve the pain. DIPHTHERIA. Synonyms. Membranous Croup; Angina Malignum; Putrid Sore Throat. Definition. An acute infectious febrile disease characterized by inflam- mation and the formation of a false membrane in the upper air passages, particularly in the pharynx. The specific disease, diphtheria, is the result of infection with the Klebs-Loffler bacillus. To the affections of similar clinical appearance, but of usually milder course, which are not due to this bacillus the terms diphtheroid and pseudo-diphtheria are applied. Diph- theria has been known since the time of Galen and from time to time has occurred epidemically. Its specific nature, however, was not distinctly proven until the discovery of the bacillus diphtherice. .etiology. The disease occurs chiefly in children and is rare after the age of 1 6 years. It is seldom seen in very young infants especially in those who are breast fed. It is predisposed to by the presence of nasal or pharyngeal catarrh, a poorly cared for mouth and teeth, adenoids and enlarged tonsils, and is most prevalent in the cold and damp months. It appears rather amongst unsanitary surroundings than in healthy districts although severe epidemics have been observed in the country. Bad drainage and emanations of sewer- gas have never been proven to have any direct influence upon the incidence of the disease and when the infection occurs where these factors are present, save in so far as residence in places exposed to their influence is likely to depreciate the general health and lessen the powers of resistance, they are not causative. DIPHTHERIA. 79 The specific cause of diphtheria is the Klebs-Loffler bacillus, a non-motile, short, slightly bent bacterium with rounded ends. This organism may be found in the false membranes of the disease and in its growth produces a poisonous substance which is responsible for the constitutional symptoms. With the diphtheria baciUus other pathologic bacteria are often associated which may be held responsible for the purulent inflammations which frequently com- plicate the disease. Of these the streptococcus pyogenes is the most important. It is an interesting fact that the diphtheria bacillus may be found in the mouths of healthy persons in whom it causes no symptoms. This fact may be due to a lack of virulence on the part of these bacilli, a natural immunity or suffi- cient power of resistance upon the part of the individual to render them inert. The contagium is transmitted upon the air or by means of ingested sub- stances and may be received from the membranous exudate or nasal or pharyn- geal secretions of patients either actively ill or convalescent from the disease or from persons who have come in contact with sufferers. The disease is markedly contagious for the distance of a few feet but fortunately its con- tagium is not very diffusible, consequently it is quite possible to confine it to a single room. The contagious material is resistant and of considerable viability and may repaain upon clothing, etc., for a number of months. Previously it has been believed that diphtheria might be conveyed to man by means of contagion from cats, calves and fowls which were affected by a disease of identical causation, but it has been proven that the diphtheria of these animals is a different affection and is not communicable to human beings. Pathology. The characteristic pseudo-membrane of diphtheria may be found in various situations. Of these the throat, including the tonsils, pharynx and larynx, including the epiglottis are most frequently affected. The mem- brane commonly occiurs upon the nasal mucous membrane, in the trachea and in the bronchi. Less frequent situations are the oesophagus, the stomach, the duodenum, the vagina, the vulva, the ear and the conjunctiva. The nasal accessory sinuses may be involved and the process may extend to the middle ear through the Eustachiun tube. The membrane is first yellowish-white in color later becoming grayish. Early in the disease it is firmly attached to the underlying mucous membrane and when detached leaves abrasions, later it is softer and more easily re- moved. In extreme cases the mucosa beneath may be gangrenous. The adjacent lymph glands are enlarged and the salivary glands may be swollen. Similar membranous inflammations may occur in scarlatina, measles, pertussis and enteric fever. These are usually the result of streptococcus infection and are termed diphtheroid. The diphtheritic membrane is the result of a degenerative necrosis of the 8o THE INFECTIOUS DISEASES. mucous membrane. The epithelial cells are infiltrated with fibrin and leucocytes, necrose, and then undergo a hyaline transformation and coagula- tion. To this process the term "coagulation-necrosis" has been applied. The membrane histologically is composed of coagulated fibrin, necrotic tissue and the diphtheria bacilli. The 'heart is frequently the seat of fatty degeneration which may precede a hyaline change in the heart muscle. Endocarditis may be present with vegetations in which the bacilli are found. This latter complication, with pericarditis, is rare. Broncho-pneumonia is often present; the kidneys are the seat of an acute degeneration or a true acute nephritis. The liver and spleen are softened and degenerated (cloudy swelling). Symptoras. The incubation is usually two or three days, rarely as long as a week. The onset is marked by chiUs, or, in children, a convulsion fol- lowed by a rise in temperature; there are headache, bodily pains, nausea, vomiting and prostration, but in the mild types of the disease these symptoms may be very slight. The temperatiue is not a marked feature; it rises to 102° to 104° F. (37.8° to 40° C). The pulse is rapid — 120 to 140 — and is usually small and feeble. Cerebral symptoms are infrequent. In the pharyngeal type there is complaint of sore throat and difficulty in swallowing. The pharynx and tonsils are inflamed and swoUen and upon the latter there are yellowish spots which gradually enlarge, becoming grayish in color, until by the third or foixrth day the tonsils are entirely covered and the piUars of the fauces and the soft palate may be involved to such an extent that the opening of the pharynx may be wholly occluded. The cervical glands are swoUen. In the ordinary case the patient is not markedly poisoned and the symptoms soon abate. In about a week or ten days the glandular swellings have disappeared with the false membrane, leaving the pharynx clean, the temperature falls and the patient is convalescent. In nasal diphtheria the onset is marked by the usual constitutional mani- festations and an increased nasal discharge which irritates and often exco- riates the upper lip. The glands beneath the angle of the mandible are swoUen and indiu-ated. This enlargement is characteristic and probably due to the fact that the nasal mucosa is particularly rich in lymphatics. Many cases of nasal diphtheria are of severe type with marked constitutional symp- toms and antral, aiual or ocular complications are frequent. A peculiar form is sometimes met in which constitutional manifestations are absent; the nostrils are occluded by typical membranes in which the bacilli are present but the infection is characterized by a benign course. Laryngeal diphtheria or membranous croup is characterized by a laryngeal cough at the onset and by the gradual development of obstruction. The latter may, however, appear suddenly at night. The respiration is rapid DIPHTHERIA. 8 1 and difficult, the expiration particularly being interfered with, the abdomen and lower thorax are retracted in inspiration and the mucous membranes and extremities become cyanotic from lack of oxygen. The patient becomes restless and may fall into a semi-coma and die of asphyxia. In milder instances the paroxysm may last but a short time and the patient will gradually become quiet. The attack is, however, likely to be repeated during the following night. At times relief will foUow the coughing up of the membrane, in part or as a whole. The constitutional symptoms are often not marked but when there is an accompanying pharyngeal membrane the opposite is usually the case. Membranous croup occurs in two varieties, the clinical appearances and symptoms of which are so similar as to prevent their differentiation except by bacteriological examination. Cultures alone will determine whether the affection is due to the streptococcus or to the diphtheria bacillus. Diphtheria in other parts is rather infrequent but the inflammation may affect the conjunctiva, either primarily or by extension through the lacry- mal duct, the skin, especially about the lips and nostrils and the external auditory meatus by extension from the middle ear. The genitals may be affected, whence the inflammation may spread to the surrounding skin and diphtheritic inflammations may occur in open wounds which have been infected by the bacillus. The symptoms oj constitutional infection in mild cases are not marked. In more severe instances, three or four days after the onset the patient's con- dition becomes one of great weakness, the heart action is feeble and cerebral symptoms are present. At this time there is great danger of death from paralysis of the heart. In other cases the constitutional symptoms are prom- inent from the beginning, the temperature is high and the evidence of toxaemia pronounced. As a rule the constitutional symptoms are directly proportional to the local involvement. A marked leucocytosis is usually present in diphtheria even of mild type and albuminuria occurs in nearly aU severe cases. Complications and Sequelae. The slight albuminuria which is so commonly seen is not to be attributed to nephritis but the appearance of blood and epithelial casts and the occurrence of diminution of the urine indicate that serious kidney involvement is present. Oedema is less frequent than in scarlatina and while the nephritis of diphtheria usually terminates in recovery it may cause death. Bronchitis and broncho- pneumonia are important and serious complications. Pericarditis and endocarditis are rare. The heart is often irregular and an apical systolic murmur is present in a large majority of cases. Heart weakness, evidenced by rapid and galloping rhythm and by sudden diminution in the pulse rate, is a serious manifestation. The cardiac symptoms usually appear from the 6 82 THE INFECTIOUS DISEASES. loth to the 2oth day of the disease but fatal acute dilatation may occur in convalescence, even as late as the seventh week. Minor complications such as nasal or pharyngeal haemorrhage, various skin eruptions and jaundice are not uncommon. Paralysis ig a most important sequel and is a result of neuritis due to the toxins of the disease. It may appear as early as the seventh day or not until convalescence and as frequently follows mild as severe cases. It occurs in lo percent, to 20 percent, of cases and is more frequent in adults than in children. The palate is most often affected and involvement of this struc- ture is evidenced by nasal voice and the regiirgitation of food through the nostrils. The phar}'nx is anaesthetic. Involvement of the muscles of deglu- tition is also frequent and various ocular palsies are not rare and neuritis of the extremities may occur resulting in permanent disability. Recovery usually takes place from these paralyses within a few weeks. Multiple neuritis may be observed which may rarely involve the innervation of the heart and the respiratory muscles, in which event the patient's condition is dangerous. The diagnosis can be assured only by bacteriological examination of the false membrane; fortunately this is not a difficult procedure, and where there is no health department affording facilities for laboratory diagnosis, it may be carried out by the practitioner. For a description of the technique the reader is referred to any good work upon clinical diagnosis. The prognosis since the introduction of the antitoxin treatment has been rendered vastly more favorable than previous to this event. By this remark- able therapeutic advance the mortality from diphtheria has been reduced from 30 percent, to 50 percent, to from 10 percent, to 15 percent. The prog- nosis is excellent in the usual case. Complications and laryngeal involve- ment render it less good. Sudden heart failure, paralyses and uraemia may result fatally. Prevention. Prophylaxis in diphtheria has been fiu-ther developed and is more successful than in any other infectious disease save smallpox. The following condensation of the rules concerning the disease laid down by the New York Health Department covers the subject of prevention very thoroughly. If possible one person should take entire charge of the patient and no one else except the physician should be allowed in the sick-room. The nurse should hold no communication with the rest of the family, who should not receive or make visits during the illness. Discharges from nose and mouth must be received on cloths which should be immediately immersed in carbolic acid solution (six ounces of pure carbolic acid added to one gallon of hot water and diluted with an equal quantity of water). All handkerchiefs, towels, bed linen, clothing, etc., that have come in contact with the patient, after use must be at once immersed without removal from the room in the DIPHTHERIA. 83 above solution. These should be soaked for two or three hours and then boiled in water for one hour. The greatest _ care should be taken in making applications to the throat and nose lest the discharges be coughed into the face or upon the clothing of the attendant. A pane of glass held between the patient and the physician will effectually prevent this accident. The hands of the attendant should always be disinfected by washing in the carbolic solution and in soapsuds after making applications and before eating. Siufaces of any kind soiled by discharges should be immediately flooded with carbolic solution. All utensils used by the patient must be kept for his use alone and not removed from the room, but must be washed in the carbolic solution and in hot soapsuds. After use the soapsuds should be thrown in the water-closet and the vessel which contained it washed in the carbolic solution. The sick-room should be thoroughly aired two or three times a day and swept frequently after scattering wet sawdust or tea leaves on the floor to prevent the dust from rising. After sweeping, the room should be dusted with damp cloths. The sweepings should be burned and the cloths soaked in the carbolic solution. ^Vhen the disease is recognized shortly after the beginning of the illness all hangings and unnecessary furniture should be removed from the sick-room. After recovery, the patient's body and hair should be washed with hot soap- suds, he should be dressed in clean clothes, which have not been in the room during the illness, and taken from the apartment. The quarantine should last as long as the diphtheria bacilli are found upon the mucous membranes; they may persist for six or eight weeks. The nurse and physician should wear, while in the sick-room, a gown which covers the clothing completely. This should be kept just outside the apart- ment and sterilized directly after use. If the patient, while the throat is being examined, should cough in the examiner's face, the latter should wash the face and hair in soap and water followed by i to 1000 mercury bichloride solution. The hands must always be sterilized upon leaving the sick-room. The niurse should spray or gargle her throat several times a day with mild antiseptic, such as Dobell's solution. It is strongly advisable that the nurse and members of the family, if they have been exposed, should receive an immunizing dose (100 units for a child under the age of one month to 800 units for an adult) of antitoxin and at the first sign of sore throat a full dose must be given. The effect of an immunizing dose lasts about four weeks and at the close of this period a second dose should be given if there is continued exposure. After removal of the patient the room and its contents should be properly disinfected and aired. 84 THE INFECTIOUS DISEASES. Treatment. The patient should be immediately isolated, especially if the disease is complicated by pneumonia, in an apartment which should be kept cool (65° F, — 18.5° C.) and freely ventilated. If practicable, in hospitals it is always better to assign each patient a separate room than to collect the sufferers in a ward. From the onset of the disease until all possible danger of heart failure is past the patient should be kept in bed. At the beginning of the treatment the bowels should be freely opened by means of fractional doses of calomel to be followed by a saline and regvilar daily movements should be obtained throughout the coiirse of the disease. The treatment of diphtheria by antitoxin is attended with such good results and has so few disadvantages and dangers that it should always be employed. All patients in whom the symptoms and clinical appearances resemble those of diphtheria should receive the treatment without waiting 24 hours or more to learn the result of a bacteriological examination. By enforcing this rule we may give antitoxin in many cases in which it is unnecessary but it is better to do this than to allow one patient who is suffering from true diphtheria to wait even a few ho\irs. The antitoxin of any reputable producer may be used and the technique of its administration is simple. An ordinary hypodermatic syringe may be used or the injection outfit provided by the maker of the serum. The needle should be sterihzed and the skin of the selected site, which is usually the thigh, buttock or side of the chest, bathed with soap and hot water, washed with alcohol and i to 5000 mercury bichloride solution. The serum should then be slowly injected, the needle withdrawn and the puncture covered with a bit of sterile gauze held in place by adhesive plaster. The quantity of the antitoxin administered depends upon the severity of the infection and the age of the patient. After the first injection the dosage should be regulated by the effect produced and is limited by this consideration alone. The most concentrated serum obtainable should be used so that the bulk of the dose should be as small as possible. In mild cases one dose of 2000 to 3000 units is often sufficient, a unit being the amount required to neutralize the amount of diphtheria toxin necessary to kill 100 small guinea pigs; 5000 units is a proper initial dose for a child of two years with a severe infection. All cases with laryngeal involvement should receive a dose at least as large. Late in the disease when the condition is profoundly toxic 10,000 units may be given and repeated until the condition is ameliorated. Too great insistence cannot be laid upon the importance of giving large doses in severe infections for it is possible by this means to save seemingly hopeless cases. The treatment is harmless and amounts of over 100,000 units have been given. The favorable action of the antitoxin is evidenced as a rule within 24 hours and often within less time. The membrane ceases to spread and becomes more soft and more easily detachable. The surrounding and underlying DIPHTHERIA. 85 mucous membrane rapidly assumes a normal appearance. In nasal and laryngeal diphtheria the amelioration of the local inflammation is quite as evident. The glandular swellings diminish and at the same time the consti- tutional symptoms clear, the temperature falling, the heart action becoming stronger and the prostration less marked. It is important to keep in mind the fact that the antitoxin in order to exert its best effect must be given early. One should not wait for an assured bac- teriological diagnosis but the treatment should be instituted as soon as the patient is seen. The serum is impotent to check such complications as septic infection, nephritis and broncho-pneumonia. Unfavorable Effects of Antitoxin. Authentic cases of sudden death have never been reported and the consensus of opinion is that the treatment is harmless. Various skin eruptions, especially lu-ticaria may foUow injection and cases of arthritis and abscess have been reported. The latter are not often seen and considering the advantages of the antitoxin treatment are wholly negligible. Local treatment has become less important since the introduction of anti- toxin but still holds a considerable place in the management of diphtheria. The object sought is cleanliness rather than the destruction of the baciUi. In many cases it is difl&cult of accomplishment owing to the objections of the patient. If the child is prone to struggle it is better not to employ force, and in such instances the local treatment may be omitted. The most approved method is to irrigate the nose and pharynx with mild solutions such as normal sodium chloride or weak boric acid as hot as the patient will bear, by means of a fountain syringe or rubber hand syringe to which a soft rubber catheter is attached. The child should lie on his side with the head slightly lower than the rest of the body so that the irrigation can readily flow from the mouth into a convenient receptacle. In severe cases such irrigations should be given every two or three hours. Nasal syringing is necessary in cases with nasal discharge and in patients with pronounced symptoms and evident marked nasal involvement is abso- lutely necessary. If there is epistaxis the irrigations should be temporarily omitted and sprays of suprarenal extract, 10 percent, calcium chloride solution or of weak alum solution may be employed. In mild cases when practicable mild antiseptic alkaline sprays should be used both upon the nose and pharynx. Dobell's solution or diluted liquor antisepticus (U.S. P.) are applicable for this purpose. Direct applications to the site of the inflammation are used less now than form- erly but many physicians approve them. The patient should be warmly wrapped and held by the nurse, the mouth being held open by a cork between the teeth or by a mouth gag while the application is made by means of a cotton swab or a brush. Various solutions may be employed, that originated by 86 THE INFECTIOUS DISEASES. Loffler being one of the most efficient. It consists of lo parts of menthol, 26 parts of toluol, liquor ferri sesquichlorati 4 parts and absolute alcohol 60 parts. Other solutions which may be used are 10 percent, lactic acid; one part of mercury bichloride to 1000 parts normal sodium chloride; mercury bichloride one part, tartaric acid five parts, water 1000 parts; phenol three parts, rectified oil of turpentine 40 parts, absolute alcohol 60 parts; hydrogen dioxide solution, etc. Such applications may be made to the inflamed sur- face ever}^ three to six hours. Insufflations of various powders such as bismuth subgallate, thymol iodide (aristol), nosophen, one part iodoform to five parts sodium bicarbonate may be given, but the treatment can be carried out very satisfactorily without them. External apphcations to the throat in the form of poultices are not indi- cated. Ice bags, however, may lessen both the pharyngeal inflammation and the tendency to enlargement of the cervical and submaxillary glands. Sucking bits of ice often makes the patient more comfortable and may influence the pharyngeal inflammation. In glandular enlargement and tendency to cervical suppuration inunctions of unguentum Crede and injections of antistrep- tococcus serum are valuable since suppuration in diphtheria is considered to be due to mixed infection with pyogenic micro-organisms. In the early stages and especially in laryngeal diphtheria, steam inhalations by means of a croup kettle, the spout of which is introduced under a tent of blankets constructed over the child's crib, are indicated. The steam may be that from plain water, lime water, 2 J percent, lactic acid solution, 3 percent, phenol solution, one drachm of eucah^tol or benzoinol to a pint of water, etc. In lar}-ngeal diphtheria with obstruction and pronounced dyspnoea emetics should be given. Here syrup of ipecac may be administered in teaspoonful doses to a child of three years every 15 to 30 minutes until emesis is induced, or a teaspoonful of the following formula may be given in the same way. I^ pulveris ipecacuanhae, gr. xxii ss (1.5); antimonii et potassii tartratis, gr. i (0.065); syrupi scillEe, 5i (30.0); aquee destillatas, 5iv (15.0). Lar}-ngeal obstruction which does not yield quickly to this form of treat- ment necessitates immediate intubation or tracheotomy. The internal administration of drugs with the hope of influencing the course of the disease is considered by many authorities quite useless while among the more conservative the old idea still prevails and drug medication is prescribed as before the introduction of antitoxin. Mercury bichloride is given to adults in doses of ^ig- to J^- ^^ ^ grain (0.0012 to 0.005) every two hours with potassium chlorate and tincture of iron chloride in the hope of causing the membrane to loosen. For children the dosage should be some- what lower. Toxic effects are not likely to occur since digestive disturb- ances usually appear before any harm is done. Calomel is also given with DIPHTHERIA. 87 the same object in view, in fractional doses, ^ to ^ of a grain (o.oii to 0.008) every' hour, until free diarrhoea is induced. The saturated solution of potassium chlorate was for long the classical mouth wash in diphtheria and is still prescribed by some but it is in no way preferable to the solutions previously suggested. Gargling with potassium chlorate solution is inferior to irrigating and spraying, for it is almost impossible to bring the gargle into contact with the seat of the inflammation if it is behind the piUars of the fauces. Iron and quinine may be given through the course of the disease in the hope of supporting the patient's strength. Stimulation becomes necessary as soon as the toxaemia is evidenced by the general condition and by tendency to heart weakness. In mild cases stimu- lants may be unnecessary but alcohol will be required in most cases sooner or later. The need of its exhibition is shown by marked constitutional symp- toms and feebleness of the pulse. The dosage should be regulated by the patient's condition and either brandy or whiskey, diluted with water, may be given. Half a drachm (2.0) every three hours is a proper amount for a child of five years. This quantity may be increased as necessary. Strychnine is valuable and digitalis may be given in small doses if there is low arterial tension combined with cardiac weakness. Sudden heart weakness necessitates the administration of stimulants hypodermatically and here we may give camphor dissolved in aether or in sterile oil. H}'podermatic injections of morphine in appropriate doses are said to be our best means of combating the cardiac paralysis which is so much to be dreaded in diphtheria. When there is evidence of obstruction to respiration, due to excessive forma- tion of membrane in the larynx, intubation or tracheotomy becomes neces- sar}'. The former procedure possesses the following advantages: It is safe, rapid and without danger, is free from shock, needs no anaesthesia, no wound is made, the patients make no objection and the air taken into the lungs is warmed and filtered by its passage through the upper air passages. Intuba- tion relieves the mechanical obstruction and the indication for its performance is dyspncea which necessitates relief. Cyanosis is not a safe guide. When there is evident effort in respiration as shown by the action of the abdominal, thoracic and cervical muscles, weak heart action and coldness of the extremi- ties, constitutional depression and evidence of marked toxaemia, intubation should be performed at once. It is far better to intubate too early than to wait until too late. In a few instances the laryngeal membrane may be pushed into the trachea by the introduction of the tube but if the latter is withdrawn immediately the former will be coughed up; if this does not take place tracheotomy must be done at once. The operation of intubation is not difficult and a moderate amount of practice upon the cadaver or upon dogs wiU render the physician proficient. 0'Dw>-er's original tube is best but while he was accustomed to intubate with the patient in the erect position, the 88 THE mrECTious diseases. horizontal is preferable especially if there is tendency to marked prostration or cardiac weakness. Diphtheritic paralysis should be treated by rest in bed and, if persistent, by means of strychnine, electricity, massage and hydrotherapeutic measures. During convalescence the patient should be kept in bed until all danger of heart failure is past, this complication being prone to occur for some time after the acuity of the disease is over. The diet should be fluid and it is very important that the patient should get sufiicient nourishment. If nursing, the child should not be allowed the breast but should be fed upon milk withdrawn by means of the breast pump. For older children dilute cow's milk, if necessary peptonized, should be the chief food. If is often necessary, in order that the child shall receive plenty of food especially in the later stages of the disease, when the appetite is insuffi- cient and there is pain and difficulty in swallowing, to feed the patient by means of the stomach or nasal tube. The latter is especially to be employed in children who object to the former and in those who have been subjected to intubation or tracheotomy. The food should be predigested in so far as is possible. The operation is performed with the patient upon his back and the stomach should be washed before each feeding. Medicines may also be administered by means of the tube. Each feeding should be of considerable size for of necessity the operation cannot be performed at frequent intervals. The quarantine should be continued until cultures from the throat show the presence of no diphtheria bacilli. The treatment of diphtheroid injections (pseudo-diphtheria) is the same as for true diphtheria, save that antitoxin is not indicated. Antistreptococcus serum may be given in its stead. MUMPS. Synonym. Epidemic Parotitis. Definition. An acute infectious disease characterized by inflammation of one or both parotid glands, sometimes extending to the submaxillary glands and rarely to the testicles, ovaries and mammary glands. .etiology. This disease is most common in childhood and youth and is most likely to occur in the spring and fall. The infection is uncommon in young infants and in adults and attacks boys more frequently than girls. Sporadic cases are generally present in cities and epidemics occur at intervals. The disease is communicable from person to person but the specific cause of the contagion is not known; one attack usually confers immunity. Pathology. The morbid anatomy of this disease consists of a congestion and oedema of the salivary glands with swelling of the walls of their ducts resulting in obstruction of their lumen. Symptoms. The incubation period is from two to three weeks. Pro- MUMPS. 89 dromal symptoms are rare and in mild, cases the initial symptoms are referable to the affected gland. In the severer types there may be such symptoms at the invasion of the infection as headache, general bodily pains, loss of appetite, vomiting and a rise of temperature, in mild instances rarely above 101° F. (38.3° C), but in the severe forms the fever may reach 103° to 104° F. (39.6° to 40° C). The first local symptom is usually pain below and in front of the ear, pain in swallowing is often present and swelling soon becomes apparent in both parotid glands simultaneously or more often in one, the other becoming involved two or three days later or not at all. The swelling is in front of and below the ear and may affect the entire neck in this vicinity. The lobe of the ear is everted and occupies the central part of the tumor. The swelling reaches its greatest size in from two to three days and at this time the pain may be severe and the difi&culty in swallowing marked, opening the mouth and mastication may be well-nigh impossible, the secretion of saliva is dimin- ished, and there may be earache. The disease is usually mild but in rare instances disturbing and even danger- ous symptoms, such as delirium resulting from pressure upon the veins of the neck and consequent cerebral congestion, may occur. Suppuration of the glands is rare. The fever lasts four or five days but the swelling may last a week or more. The opposite side may become involved after the original site of the disease has returned to normal. Complications are rare in young children but in youths orchitis may occur after the inflammation of the parotids has subsided. The body of the testicle is affected rather than the epididymis and both organs may be involved. The onset of this complication is marked by a rise in temperature, the testicle is swollen, painful and tender; the acuity of the inflammation lasts several days but the swelling persists for a few weeks and rarely atrophy may result. Hydrocele of the tunica, oedema of the scrotum and a muco-purulent iu"ethral discharge may accompany the orchitis. Ovaritis, and inflammation of the vulva and of the mammary glands may occur in girls. Still rarer complications are nephritis, otitis media and deafness, pneu- monia, pericarditis, endocarditis, meningitis and facial paralysis. Enlarge- ment of the thyroid gland and symptoms suggestive of pancreatic inflamma- tion have been observed. Following the disease, permanent hypertrophy of the parotid may be noted. The diagnosis is usuaUy easy. Mumps is most likely to be mistaken for acute cervical lymphangitis but may be differentiated by the characteristic shape of the parotid tumor and by the elevation of the lobe of the ear. The prognosis is very favorable, especially in the absence of complications. Treatment. Isolation is necessary in institutions and in families where 9© THE INFECTIOUS DISEASES. there are other children, and the quarantine should be continued for at least three weeks. At the onset of the disease the patient's bowels should be opened and if there is fever he should be put to bed and kept there until all constitutional symptoms have disappeared. Avoidance of exposure will diminish the Hability to complications. The pain in the swollen gland may be diminished by compresses of gauze impregnated with a mixture of fluid extract of belladonna, /i xx (1.33) and an ounce (30.0) of glycerin, with a 5 percent, ointment of ichthyol or a 2 percent, morphine ointment. The compress should be covered with rubber tissue or oil-silk. Cold com- presses may be grateful to the patient but the application of heat is usually preferred. Should the fever give rise to anxiety an ice coil may be applied to the precordium but this will seldom be found necessary. Other symptoms should be treated as they arise. If enlargement and hardness of the parotid persists after the acuity of the infection has subsided inunctions of 6 percent, iodine-vasogen or of a potas- sium iodide ointment are suggested. The orchitis necessitates rest in bed, support of the testicles by means of a bridge across the thighs made of a strip of adhesive plaster and the application of a 10 percent, ointment of ichthyol. The dryness of the mouth should be relieved by washes of dilute liquor antisepticus. The diet should be fluid while the temperature is elevated and even if this symptom is absent it may be impossible for the patient to take solids because of the pain upon mastication and deglutition. WHOOPING COUGH. Synonym. Pertussis. Definition. A specific infectious disease characterized by catarrhal in- flammation of the air passages and by paroxysms of coughing accompanied by long inspirations producing the typical "whoop." -Etiology. This disease is endemic in cities and from time to time epi- demics appear, especially in the winter and spring and often associated with epidemics of measles or scarlatina. Children are most frequently attacked and the most susceptible period is between the first and second dentitions. Niursing infants and adults may, however, contract the infection and in old persons it is likely to be serious. Delicate children and those prone to catar- rhal affections are particularly liable to infection. Whooping cough is most contagious during the catarrhal stage and is generally spread by direct con- tact but schools, dwellings, etc., may be infected. Various observers have described micro-organisms which they consider responsible for the occurrence of the disease but their claims have not as yet been substantiated. WHOOPING COUGH. 9 1 Immunity is usually conferred by one attack, and while certain individuals seem unable to contract the affection it must not be forgotten that the dis- ease may occur in a mild form which may be overlooked. Pathology. There is no constant morbid change associated with whoop- ing cough. Complications are usually responsible for fatalities and here we find the causative lesions such as broncho-pneumonia, bronchitis, collapse of the lung, vesicular and interstitial emphysema and enlargement of the tracheal and bronchial lymph nodes. After death during a paroxysm the brain is found in a state of congestion and punctate or larger haemorrhages may be present. Symptoms. After a period of incubation of from 7 to 10 days the first or catarrhal stage sets in. This is marked by slight rise in temperature, run- ning at the nose, conjunctival injection, sore throat and cough, usually dry, and at times paroxysmal. The characteristic whoop in certain cases may be present from the onset but more commonly after a week or 10 days of atypical cough the tendency to the whoop becomes gradually more and more marked, the spasms more and more frequent and the paroxysmal stage begins. A typical fit of coughing begins in a succession of 15 to 20 short expiratory coughs between which there is no effort at inspiration. The face is flushed and perhaps cyanotic, the eyes are prominent, there is lacrymation and nasal discharge. At the termination of the paroxysm there is a deep inspi- ration accompanied by a whoop. Such a fit of coughing may be immediately succeeded by another, be terminated by the expectoration of more or less mucus or followed by emesis. The paroxysms vary in number from four or five daily, to ten times this number. The patient recognizes the imminence of the coughing fits and endeavors as far as possible to prevent them. Fre- quent vomiting may render the child emaciated as a result of its inability to retain sufficient nourishment. An ulcer due to friction against the lower incisors, may form at the fraenum of the tongue; rupture of a nasal or con- junctival vessel and involuntary urination may occur during a paroxysm. Physical examination of the thorax during the spasm reveals diminished pulmonary resonance during the expiratory coughs and normal resonance during the inspiration. During the whoop there may be absence of the normal vesicular murmur on account of the slowness with which air enters the lungs. Mucous rales may be present. Paroxysms may be induced by emotion, any irritating inhalations and even by deglutition. This stage of the disease lasts from one month to six weeks, increasing in intensity for the first half of this period, then remaining stationary for about a week and then gradually subsiding. The paroxysms are very likely to recur if the patient catches cold or if his digestion becomes disordered. This reappearance of the whoop is not to be considered a true relapse. 92 THE INFECTIOUS DISEASES. The stage of convalescence lasts from three to four weeks but may be much longer than this period. Complications are frequent and sometimes serious. The congestion caused by the paroxysm may cause bleeding from the nose, conjunctiva or even the ears as weU as petechial haemorrhages into the skin, haemoptysis and intestinal haemorrhage. Intracranial extravasations of blood may occur, causing death, various paralyses or convulsions. These haemorrhages are seldom large and their manifestations are rarely permanent. Disturbances of the special senses are sometimes noted. Pulmonary complications are usually responsible when death takes place. Both broncho- and lobar pneumonia ma} be observed. Inflammation of the larger bronchi is the rule and is not especially to be feared; involvement of the small tubes is as serious as broncho-pneumonia. Transient vesicular emphysema is not uncommon, being caused by the severity of the paroxysm; interstitial and even subcutaneous emphysema have been observed. En- largement of the bronchial glands is common. Infants suffering from pertussis in summer are very frequently affected with diarrhoea. Malnutrition may result from the frequent emesis caused by the paroxysms. Albuminuria and glycosuria may occiu* but these conditions are usually only temporary. Overstrain of the heart may result in permanent valvular endocarditis and as sequelae hernia, prolapsus ani and a predisposition to tuberculosis may be mentioned. The diagnosis in typical cases may be easily made; other instances may occur, in which there is no whoop, in which the problem is much more difficult, but a cough occmring chiefly at night, which increases in severity for two or three weeks, is unaccompanied by constitutional symptoms and physical signs and which may manifest itself in paroxysms followed by vomit- ing is probably pertussis. In the presence of epidemics the diagnosis is greatly simplified. An increase in the number of leucocytes particularly of the lymphocytes, is an important feature of this disease. The prognosis is distinctly bad in children under four years of age and in those previously delicate, broncho-pneumonia being responsible for many of the deaths. Treatment. The patient should be kept from association with other children; confinement to a single room is unnecessary, consequently all indi- viduals to whom the infection is prejudicial should be sent away. Particu- larly should all delicate children and those with any tuberculous tendency be kept from exposure. Quarantine is necessary until the paroxysmal stage is past. In the treatment of the disease itself hygienic measures are most impor- tant. WHOOPING COUGH. 93 The patient should, as a rule, be kept in the open air especially during the warm months. Older children may be allowed out of doors on pleasant days even in winter. Delicate children, however, and those in whom there is any tendency to bronchitis should be kept in doors. Special stress should be laid upon the thorough and frequent ventilation of the apartments occu- pied by the patient and frequent, even daily, fumigation by means of a forma- line candle or lamp. The bedding, clothing, etc., should be often changed. In protracted cases a change of climate is indicated and delicate children do better, especially in winter, if they are taken to a warm place. The sea shore and sea voyages are often beneficial. Internal Treatment. Of the almost numberless drugs which have been recommended in whooping cough bromoform is, perhaps, one of the most effectual but must be employed with great caution as cases of poisoning have been reported from its use. It may be administered in the following formula: Bromoform, i part; alcohol, 8 parts; glycerin, 48 parts; compound tincture of cardamom, 8 parts. Each drachm (4.0) contains 3 minims (0.2) of bromoform which may be given to a child of two years, three or four times daily. The mixture should be very carefully compounded and shaken immediately before taking. Bromoform may also be taken dropped upon lumps of sugar. Antipyrine is a useful drug but should not be given if heart or severe pul- monary complications are present. Its dosage for a two year old child is two grains (0.13) 5 or 6 times a day. In cases with particularly marked paroxysms antipyrine may be advantageously combined with sodium bromide or heroine. Quinine has enjoyed much vogue in the treatment of pertussis. Its dosage for a child of two years should be about three grains (0.2) three times a day, and it may be given either as the sulphate or the hydrochloride. It is important that it should be prescribed in palatable form, for instance, in chocolate covered tablets. Its great disadvantage is its liability to distiirb the stomach in infants and young children; this fault may be obviated by giving the drug in enemata or in suppositories. The treatment should begin early and it may be wise to give each dose directly after a fit of coughing since at this time it is less likely to cause gastric disturbance. Aristochine (quinine carbonic ester) has no bitter taste and may be em- ployed instead of quinine. Its dose is i^ to 3 grains (o.i to 0.2) three times a day. Euquinine is another substitute for quinine. In belladonna we have an effectual means of diminishing the number and severity of the paroxysms. The beginning dose should be small and gradually increased until physiological effects are produced. Its action must be care- fully observed for the evidence of toxic symptoms. A two year old child may receive of the fluidextract | to ^ a drop (0.016 to 0.032) every four hotus; atropine in doses of -j-g-jj- of a grain (0.00015) may be substituted. The 94 THE INFECTIOUS DISEASES. above doses may be gradually increased in size or given at gradually dim- inished intervals until their physiological effect as evidenced by an erythema of the skin is noted. Camphor is said to act, not only as a stimulant in the bronchitis and pneu- monia-.of pertussis, but also upon the disease itself. It may be given internally in appropriate doses. The severity of the nocturnal attacks may be lessened by sodium bromide 2 to 4 grains (0.13 to 0.24), or by codeine, sulphonethylmethane or chloral; the latter, however, must be given with care. Certain observers rely chiefly upon paregoric to check the paroxysms. In general it may be said of the drug treatment of whooping cough, that since the disease is self-limited and since in all probability its coiirse cannot be shortened, internal medication, in patients whose paroxysms are neither distressing nor frequent, should be postponed until the cough becomes so marked as to interfere with rest and the bodily functions. When this event takes place medication is indicated. Local treatment by means of sprays, inhalations, insufflations of various powders and by direct applications to the larynx may be prescribed. Sprays and insuffla- tions probably influence the disease but little, but may be useful in allaying the catarrhal symptoms in the upper air passages. As sprays a solution of one of the more soluble quinine salts, Dobell's solution, liquor antisepticus, or a mixture containing menthol 0.3 parts, thymol iodide i part, oil of sweet almonds 25 parts may be used. Insufflations such as the following may be employed: Benzoic acid and bismuth subsalicylate each 10 parts, quinine sulphate 2 parts, or powdered antipyrine and quinine hydrochloride each i part, boric acid 2 parts, bismuth subnitrate 5 parts. Direct applications of 5 pejxent. cocaine solution may be made to the larynx in older children, but with cau- tion. One percent, solutions of phenol or of resorcinol are less dan- gerous. The applications of a i to 2 percent, solution of formalin to the pharynx has been advised. Inhalations to be given by impregnating the air of the apartment with various mixtures or by means of an inhaler are some- times beneficial. By this means we may lessen the irritation of the air passages and combat the tendency to bronchitis. The following formulae are applicable: ^ther, chloroform and creosote equal parts; to be used upon the cotton or sponge of a respirator. Phenol, 3 parts, thymol, 5 parts, alcohol, 50 parts, compound tincture of lavender, 20 parts, water to 1000 parts; to be evaporated over an alcohol lamp. Inhalations of ethyl iodide are said to afford instant relief to the paroxysms and to lessen the severity of the disease. • The spasm of the glottis which may occur when the spasms of coughing are frequent and severe may be relieved by means of laryngeal intubation. The tube may remain in place as long as the paroxysms continue. I CEREBROSPINAL FEVER. 95 For the convulsions a few whiffs of chloroform may be given and as an antispasmodic a plaster of asafoetida applied to the whole chest has been suggested. A 20 percent, solution of cypress oil in alcohol sprinkled upon the patient's pillow, the upper part of the bed and upon the underclothing several times daily is said to benefit the cough. Lewriaux has produced an antitoxic serum by inoculating horses with cultures of a bacillus which he has isolated from cases of whooping cough. In his hands injections of from 75 to 150 minims (5.0 to lo.o) of this serum, especially if given early in the disease, have acted favorably. The tendency to vomiting may be lessened by , applying an abdominal band to which a snugly fitting elastic bandage has been sewn. To young children in whom this symptom is marked a few drops of the camphorated tincture of opium or a half teaspoonful of a mixture of dilute hydrochloric acid 2 parts, simple syrup 200 parts, lemon spirits 2 parts, may be given. The sublingual ulcer should be kept clean by the use of mild antiseptic mouth washes and may be touched from time to time with a 3 percent, solu- tion of silver nitrate. Heart weakness calls for the administration of alcohol and strychnine. The compUcating pneumonia, bronchitis, etc., may be treated as ordinarily. Throughout the disease the bowels should be kept freely open and the patient should be most carefully fed. The regulation of the diet is often a difl&cult matter since vomiting is so likely to occur, but is most important, for digestive disturbances accentuate the severity of the whooping cough and increase the frequency of the paroxysms. Young infants should be given diluted milk which may if necessary be peptonized. Older children should be allowed only fluids, chiefly milk, during the acuity of the disease. It is essential that the patient's nourishment be thoroughly maintained, conse- quently vomited meals should be repeated. During convalescence the administration of tonics, especially codliver oil, the syrup of iron iodide and arsenic, is usually necessary since even if the infec- tion has run a seemingly uncomplicated comrse the patient's system is depre- ciated and his powers of resistance are decreased, owing to the strain to which he has been subjected. CEREBROSPINAL FEVER. Synonyms. Epidemic Cerebrospinal Meningitis; Malignant Purpuric Fever; Petechial Fever; Spotted Fever. Definition. An acute infectious febrile disease occurring sporadically and in epidemics and characterized by inflammation of the membranes of the bnin and spinal cord and frequently by an eruption upon the skin. 96 THE INFECTIOUS DISEASES. Etiology. Epidemics of this disease have occurred from time to time in the United States, the last being in New York City during the winter of 1904-5. The epidemics are usually localized and seem to occur rather more often in the country than in cities and usually in the winter and spring. Unsani- tary co|iditions, fatigue, mental and physical depression and the association of large numbers of persons in small spaces such as army camps and barracks predispose to the occurrence of the disease. The specific cause of epidemic meningitis is the diplococcus intracellular is meningitidis which is found within the bodies of the polynuciear leucocytes of the inflammatory exudate. With this micro-organism other bacteria such as the staphylococcus, the streptococcus, the pneiunococcus, the bacillus coli, etc., may be associated. Cerebrospinal fever is probably not directly contagious in that the infection is transmitted by fomites and the excretions and it is difficult to trace the origin of a certain case to any other, irregular distribution being a character- istic of the affection. The contagium is, however, supposed to be air borne and to reach the meninges through the nose by means of the cribriform plate of the ethmoid bone. Pathology. The sl^in may bear the remains of the petechial or herpetic eruption in certain instances but the changes in the nervous system are more constant. These, however, are very variable in degree and may occur as merely slight congestion or as pronounced hypersemia of the pia-arachnoid with fibrino-purulent deposits especially at the base of the cerebrum, resulting in a coating of the meninges with the exudate. The upper and lateral surfaces of the brain may also be involved in the inflammatory process. The exudate is beneath the pia mater and is likely to be more profuse in the longitudinal fissiires and Sylvian fissures. The substance of the brain may be congested and even softened. In the cases of long standing the meninges are thickened and adherent to the cortex. The ventricles are filled with sero-pus and in prolonged instances of the disease may be greatly distended, their walls being softened, and a condition of hydrocephalus may result. The cranial nerves, especially the optic, the facial and the auditory are often involved. The spinal meninges are involved similarly to those of the brain. The exudate is most profuse upon their dorsal surface and the lower segments are chiefly affected. The spinal and the central canal may both contain pus in considerable amount. The cord itself may be inflamed and the spinal nerve root? may be the seat of a neuritis or compressed by the exudate. Microscopical examination shows the exudate to consist of polynuciear leucocytes enmeshed in fibrin. The meningococci are found both within the leucocytes and amongst the fibrin. The substance of the brain and cord CEREBROSPINAL FEVER. 97 may be infiltrated with pus, the neurogha cells are swoUen and hsemorrhagic foci may be present. The lungs may be the seat of a pneumonia caused by the diplococcus pneu- moniae or by the meningococcus. Pulmonary congestion or plevirisy may be observed. Endocarditis sometimes is noted and the congestion of the various viscera occiuring as a result of an infectious disease is usually present. The spleen may be enlarged. Symptoms. These vary with the type of the disease. The incubation period of the ordinary form is not known. Its onset is usually sudden, although there may be a short prodromal period marked by dizziness, headache and pain in the back. The invasion is often evidenced by a chill and vomiting of the projectile type followed by headache, pain in the back of the neck and in the lumbar region. These may be mild or very severe. The muscles of the neck are stiff and movement causes an increase of the pain. The temperature is not characteristic, it may not exceed 102° F. (38.9° C.) but in marked infections it may reach 104° to 106° F. (40° to 41.1° C.) and may ascend even higher just before death. Remissions are not infrequent. The pulse in adults is at first not very rapid and is of good strength. Later it becomes faster and weaker. In children it is usually rapid from the outset. In certain instances the disease is characterized by a pulse of not over 60 or 70. In the absence of pulmonary complications the respirations are not much accelerated. Cheyne-Stokes respiration is sometimes observed. The symptoms due to the nervous system are marked and of early appear- ance. The skin is hyperaesthetic and the muscular rigidity increases as the disease progresses, spasm of the neck muscles draws the head back and opistho- tonos may be present; clonic spasms may occur especially in children, in whom the onset may be marked by a convulsion. Strabismus, nystagmus and facial contractions are common. As the exudate increases the symptoms of pressure paralysis succeed those of irritation and there are paralyses of the muscles of the face with ptosis, pupillary inequality and rarely paralysis of the muscles of the body and limbs. Of symptoms referable to the special senses photophobia, diplopia and auditory distiirbances, especially intolerance of sound, are often preseni. Delirium is an early symptom and may be violent. The increase in intra- cranial pressure later results n, stupor and finally in coma. The skin manifestations arc mportant although the eruption is by no means constantly present. Herpes labialis is very frequent and herpetic eruptions may appear elsewhere upon the face as well as upon the body and limbs. The characteristic rash of the disease is petechial and often general. The number of spots varies greatl}', in some instances only a few being noted, while in others they are very numerous. They do not disappear on pressure. 7 98 THE INFECTIOUS DISEASES. Other rashes such as erythema, urticaria, ecthyma, erythema nodosum, pemphigus, and spots resembhng those of enteric fever may occur. Cutaneous gangrene has been noted. The tongue is at first moist and coated, later it may become dry; distressing vomitin^ may persist throughout the disease. The bowels are usually con- stipated but at times a diarrhoea may be present at the invasion. The urine is usually scanty, high colored and contains albumin. At times it is increased in quantity and contains glucose as a result of the pressure of the exudate upon the cerebral centers. Leucocytosis is a constant symptom and is often persistent. Kernig's sign is constantly present as in all other conditions in which there is inflammation of the spinal meninges. It is obtained by placing the patient in a sitting position with the thighs flexed at the hips and the legs partly flexed at the knees. The observer then attempts to extend the leg at the knee which will be found impossible on account of the resistance of the flexor muscles. If the thigh is not flexed upon the abdomen the leg can be straightened. This phenomenon is explained upon the ground that in meningeal inflammation the spinal nerve roots become irritable and the flexion of the thighs at the hips when the patient is sitting tends to stretch the lumbar and sacral roots and increase their irritability. Babinski's reflex, a turning up of the toes, especially the great toe, conse- quent upon tickling the sole, is not constant. The course of cerebrospinal fever is very variable; death may occur within a few hours or the disease may be prolonged for months. Fatal cases usually die within the first week. If the patient survives for five or more days im- provement may be expected, the temperature falls, the nervous symptoms gradually clear and convalescence becomes established. This period is usually long. Relapses are not uncommon. The malignant form of the disease is very sudden in its invasion and while there may be only slight rise in temperature the headache and nervous symp- toms are pronounced, collapse with feeble and slow pulse and labored respi- ration ensues to be followed by death, sometimes within 24 hours. A hsemor- rhagic. eruption is usually present. Such cases are often seen at the beginning of an epidemic. A mild form of the disease sometimes occurs in which the presence of an epidemic gives the only clue to diagnosis. The abortive form is evidenced by pronounced and severe symptoms at its onset; these cease suddenly and an early convalescence is established. The intermittent form is characterized by a temperature resembling that of pyaemia which exhibits remissions daily or every other day. The chronic form. This designation is applied to a type of the disease in which the course may be prolonged for several months. The patient suf- CEREBEOSPINAL FEVER. 99 fers from headache, digestive irritability, marked emaciation and exhaustion and remissions of the fever. Complications. Of these pneumonia is one of the most frequent and it may be difficult to determine whether it or the meningeal inflammation is the primary disease. In the presence of an epidemic the problem is more simple than at other times and when the headache, pain and stiffness in the back, and nervous symptoms precede other manifestations the chances are in favor of meningitis. Pleurisy, bronchitis, endocarditis and parotid inflam- mation may occur. Arthritis is a common complication in certain epidem- ics. The affection is usually multiple and the effusion may be either serous or purulent. The sequela of cerebrospinal fever are numerous and "often serious. Those referable to the motor nervous system are facial palsy of varying extent and paralyses of the limbs; these may be permanent but are usually temporary only. Sequelae referable to the organs of special sense are optic neiu"itis resulting in blindness, choroido-intis and keratitis; labyrinthine inflam- mation resulting in deafness, otitis media and its complications. Speech disturbances may occiu: and obstinate headache and muscular pains have been noted. Chronic hydrocephalus, abscess of the brain and mental weakness have deen observed. The diagnosis during epidemics is usually not difficult but the recognition of sporadic cases, especially those of atypical course is sometimes far from easy. The diagnostic symptoms which are present early in the disease are the headache, stiffness, with retraction of the head, of the muscles of the neck and back, tremors and mental distin-bance, especially delirium. Pneu- monia may be mistaken for meningitis but here we have a diminution of the urinary chlorides, an absence of Kernig's sign, a rapid pulse and a preponder- ance of the pulmonary symptoms over those referable to the nervous system. With regard to the general differentiation of this disease, the presence of Kernig's sign is an important point and the result of lumbar puncture should usually confirm or disprove the diagnosis. This operation is simple, harmless and needs no anaesthesia beyond that obtainable by means of the ethyl chloride or aether spray, or at most a few breaths of chloroform. The patient should lie upon the right side with knees drawn up and the left shoulder turned toward the front. An aspirating syringe is used, the needle of which is introduced one centimeter to one side of the median line and midway between the third and fourth or the fourth and fifth lumbar vertebrae below the spinous process, the thumb being placed as a guide between the spinous processes. The needle should be directed sUghtly upward and inward, and at a depth of about two centimeters in infants and from foiur to six in adults, should enter the canal. The syringe now being detached from the needle the fluid is allowed to flow into a sterile test tube. From i| to 4 drachms (6.0 to 16.0) are neces- lOO THE INFECTIOUS DISEASES. sary for chemical, microscopical and bacteriological examination. The fluid in epidemic meningitis is usually turbid and may contain pus or blood; that in tuberculous meningitis is clear in most instances. The meningococcus is often present in the fluid of epidemic meningitis in considerable numbers. The prognosis varies in different epidemics from 20 to 75 percent. The mortality is very high in the prolonged cases, in yoimg children and in the aged. The initial symptoms give no index of the probable subsequent course of the disease and while a mild invasion may be followed by grave symp- toms a severe onset may be succeeded by a rapid amelioration. Convales- cence may be interrupted by recrudescences or relapses. Treatment. Much in the way of prevention may be accomplished by the establishment of proper ventilation, drainage and general sanitation. In private practice the patient should be isolated, in order to secure the nec- essary quiet as weU as to prevent contagion, in a properly ventilated room which need not be darkened since bandaging the eyes accomplishes the same purpose. The old method of treatment by blood-letting is seldom employed at present but the pain may be relieved in robust patients by the application of wet cups to the back of the neck; the use of the ice helmet and of ice bags ap- pHed along the course of the spinal cord is to be recommended, and while blistering is unnecessary, touching the skin of the nape of the neck with the actual cauter}' may be beneficial. Elevating the head of the bed often makes the patient more comfortable. The plan of treatment by means of hot bathing as advocated by Aufrecht is said to accomplish exceedingly good results. A hot bath at 104° F. (40° C), lasting from 15 to 20 minutes is given once or twice daily or even oftener. An ice bag is kept upon the patient's head and stimulants such as alcohol, ammonia, etc., are given as indicated. While the temperature, muscular rigidity and emesis are not markedly influenced by this treatment, it is asserted that bathing after this fashion relieves the pain, lessens the restlessness and delirium and may restore consciousness. Such complications as endocarditis do not necessitate the intermission of this treatment. It may be safely stated with regard to the hot bath method, that it does no harm, may benefit the patient and may exert a favorable influence upon the course of the infection. Lumbar punctiure, with or without the injection of antiseptic fluids, has been employed in treatment as well as in diagnosis, by many cUnicians. The opinions as to its efficacy differ to a marked degree. It may be asserted, however, that, even though the procedure may not be curative, it does relieve the symptoms due to pressiue and is worthy of employment for this reason. The technique of the operation has already been described (p. 99). In instances where marked pressure symptoms are present from 5 to 15 drachms (20.0 to 60.0) may be withdrawn and the procedure repeated if necessary. CEREBROSPINAL FEVER. lOI Where only slight evidence of pressure is manifest not more than 5 to 7J drachms (20.0 to 30.0) should be withdrawn. Of the solutions used for intraspinal injection, following the withdrawal of fluid by lumbar puncture, i percent, lysol is the most common. From two to three drachms (8.0 to 12.0) have been injected with var}dng results in the hands of different clinicians. Mercury oxycyanide solution has also been employed. This form of treatment, while it may do no harm, has, tak- ing everything into consideration, given no very remarkable results. The hot bath treatment and that by lumbar puncture may be employed in connection with one another. The fact that there is a marked antagonism between the meningococcus and the Klebs-Loffler baciUus has suggested the employment of diphtheria antitoxin in the treatment of meningitis but unfortunately the results obtained either by hypodermatic or intraspinal injections of antidiphtheritic serum have not been sufficiently good to establish this treatment upon a firm basis. The subcutaneous injection of mercury bichloride solution along the course of the spinal cord has been recommended by several authors. The adult dose is ^ of a grain (0.0 1) and that for children from yyo to ^s" of a grain (0.0005 to 0.005). The injections are weU borne and may be repeated while the temperature, pain and muscular stiffness persist. Angyan, who has reported at length upon this form of treatment, while not asserting that it influences the length of the disease, considers that by its use the symptoms are favorably affected. With regard to the general management of epidemic cerebrospinal mening- itis and the relief of symptoms the following points may be given. The bowels should be kept freely open throughout the disease by means of calomel given in divided doses, by salines or by enemata. The patient should be allowed plenty of water to drink which will increase the elimination of the toxins through the kidneys. In instances of urinary retention the use of the catheter may become necessary. The nose and throat which are often inflamed should be sprayed and irrigated with mild alkaline solutions and the frequent use of a mouth wash wiU lessen the tendency to dryness of the tongue. In instances where there is dysphagia feeding by means of the stomach or nasal tube or by rectum should be practised. For the vomiting the patient should be given bits of cracked ice to suck, cold should be applied to the epigastrium and feeding should be infrequent until this symptom is under control. In obstinate cases the use of morphine hypodermaticaUy mav become imperative. Vomiting due to pressure upon the medulla may be relieved by lumbar puncture. The nervous symptoms necessitate the employment of various analgesics and sedatives. Cool packs and tepid baths, to which mustard may be added. I02 THE INFECTIOUS DISEASES. often, in the milder cases lessen the tendency to sensory, motor and mental excitability and may induce sleep. Antipyrine is often effectual in checking the headache and general hyperaesthesia and is also useful in lowering the temperature and relieving the mental excitability. While not likely to cause cardiac Repression, the drug should be given with care. Acetphenetidine may also be employed. When these two drugs fail to control the nervous symp- toms we may have recoiirse to codeine or morphine. The bromides likewise may be administered in this connection. For the convulsions chloral should be given per rectum and inhalations of chloroform may be prescribed. Where these fail hypodermatic injections of morphine should be given. In the later stages where cardiac weakness is pronounced free stimulation by means of alcohol, ammonia and, in cases of collapse, by hypodermatic injec- tions of camphor in oil, are indicated. Heart weakness may also be combated by means of high hot saline irrigations given fer rectum and by hypodermato- clysis with normal saline solution. The former procedure has the addi- tional advantage of assisting in the elimination of toxins through the kidneys, it being a vigorous diuretic. Various other drugs have enjoyed, probably undeservedly, a vogue in the treatment of this disease. Among them may be mentioned ergot, quinine, physostigma and belladonna. In chronic cases and in those which are left with meningeal thickenings potassium iodide or the syrup of hydriodic acid should be given with the intent to induce absorption. The complications and sequelae should be treated as when occurring as a result of other causes. The importance of maintaining nutrition cannot be over-rated. During the acute stage the diet should consist of milk, broths, gruels and other fluids; later semi-solids, to be followed by ordinary diet, may be allowed. The use of the stomach tube may be necessary. ERYSIPELAS. Synonym. St. Anthony's Fire. Definition. An acute febrile contagious disease characterized by intense local inflammation of the skin, a remittent temperature and a tendency to spread. etiology. This disease is common, often endemic, and from time to time epidemic. It is most common in the spring months and is very likely to break out in old and improperly kept hospitals and institutions; it may occur, however, under the best sanitary conditions. Poor general condition, alcoholism and chronic diseases predispose to its incidence and certain indi- viduals seem more prone to acquire the infection. One attack does not ERYSIPELAS. I03 confer immunity, on the contrary recurrences are frequent. Women, ^05/- partum, and the subjects of recent surgical operations, even such procedures as cupping, leeching and vaccination, are especially liable to acquire the disease. The contagium, while not very active, may be transmitted by contact with a third person and by fomites, bedding, furniture, etc. While a solution of the continuity of the skin would seem to be a necessary antecedent to infection, idiopathic cases do occur in which no such manifestation is discoverable; in such, however, it is impossible to state that a microscopical lesion has not existed, although the possibihty that the contagium may reach the blood stream by means of the respiratory or the digestive tracts must be considered. The specific cause of erysipelas is a bacterium, the streptococcus erysipelatis, one of the micro-organisms of the streptococcus pyogenes group. Pathology. The inflammatory redness of the skin in erysipelas does not persist post mortem but oedema and abscesses or blebs, if they have occurred, are left behind. Microscopic examination reveals the presence of the streptococci in the lymphatics and lymph spaces at the margin of the inflamed area; they may be demonstrated in the lymph vessels of the structures beyond the affected tissues as well. Associated lesions are metastatic abscesses in the various organs and haemorrhagic infarcts of the lungs, kidneys or spleen. Secondary septic pleurisy, pericarditis or endocarditis may be present. Acute nephritis may be found; meningitis and pneumonia are rare. Symptoms. The variety of erysipelas which usually confronts the physician is that which occurs without previous discoverable lesion and most often involves the head and face. The incubation period is given by various authori- ties as being from i to 14 days. The onset of the disease is usually marked by one or more chills, general malaise and anorexia, followed by a rise of temperature. If the point at which infection has taken place is discoverable it becomes red, a reddened, burning spot appearing usually upon the bridge of the nose or upon the chin. This rapidly increases in size, becoming elevated with a distinctly palpable margin, smooth, brawny, oedematous and hot to the touch. The skin feels tense to the patient and the inflammation spreads rapidly toward the forehead and ears, closing the eyes, thickening the lips and ears and distorting the features. Blebs form upon the ears and eyelids; these contain serum; the neck is rarely involved but the cervical glands are swollen and there is marked leucocytosis. In the severe types deep abscesses may form. The inflammation as it extends gradually diminishes in the parts first affected, lasting about four days in one spot. If its progress becomes limited the temperature falls by crisis and the symptoms disappear. Recur- rences are not rare. With the fever, the pulse is rapid, there are headache and sometimes cerebral symptoms, the constitutional manifestations being due to the toxaemia resulting from the growth of the bacteria in the organism. ;I04 THE INrECTIOUS DISEASES. Severe infections which are not uncommonly met in aged, debilitated and alcoholic patients are characterized by marked prostration, cerebral symp- toms and the appearance of the so-called "typhoid state" in which death may ensue. The mucous membranes of the mouth, pharynx and larynx may be involved by extension from the skin, and laryngeal oedema may occur. Albuminuria is common and haematuria has been observed. Protracted cases may be met in which the inflammation wanders from one part to another, gradually involving the whole body. Complications are not common although such conditions as septic inflam- mations of the pleura, pericardium and endocardium, bronchitis, pneimionia and nephritis do occur. Meningitis is very rare, septicaemia and pyaemia are more often seen. The diagnosis is usually easy, the constitutional and local manifestations being quite characteristic. The prognosis in robust persons is good, the debilitated, those addicted to alcohol, infants with erysipelas due to infection at the imibilicus, and the aged furnishing the great majority of the fatahties. Treatment. Isolation is a necessity, especially in hospitals. Siurgeons and those engaged in obstetrical practice should not attend cases of erysipelas. Frequent baths with boric acid solution (5 percent.) will remove the desqua- mating epidermis and the bed and body linen should be changed at least once daily. The patient should be kept in bed upon a liquid diet and the channels of elimination kept freely opened by means of plenty of fluids to drink and laxatives when necessary. If there is headache and severe general pain such anal- gesics as antipyrine salicylate, gr. x (0.66) or acetphenetidine, gr. x (0.66) may be prescribed. The cerebral symptoms if present may be controlled by cool or tepid sponge baths, by the bromides or by morphine hypodermatically. In feeble patients stimulation by alcohol and strychnine may be employed as indicated. It is doubtful if internal medication can influence the infection in any way but the tincture of iron chloride is prescribed by many in the hope that in some way it exerts a specific action. A drachm (4.0) every three hours may be given but a smaller dose — 10 drops (0.66) — will probably do the work quite as well. Injections of antiseptic solutions into the skin just beyond the margin of the inflammatory area have been practised and seem to have a rational basis for their employment. Two percent, phenol solution or 1-4000 mercury bichloride solution may be used. Of local applications that most popular at present is an ointment or solu- tion of ichthyol of xo percent, strength, applied upon gauze and renewed ACUTE ARTICULAR RHEUMATISM. 10$ several times daily. An ointment containing i part of phenol, lo parts of ichthyol and 20 parts of lanoline is also recommended. Moist dressings of I percent, phenol, i to 1000 mercury bichloride, equal parts of ichthyol, glycerine and water, i to 1000 potassium permanganate and dusting with equal parts of bismuth benzoate and starch have been suggested. In the umbilical infection of the newborn, ichthyol in 10 percent, solution or ointment or an ointment of -gV part of mercury bichloride, 10 parts of cerate of lead subacetate and 40 parts of vaseline may be applied. The use of Crede's ointment shotdd be accompanied by good results. It should be well rubbed into the skin just beyond the inflammation. The suggestion to lightly scarify the part before applying moist antiseptic dressings would seem reasonable since by this means the germicide is able to come into closer contact with the infective micro-organisms in the tissues. Various observers have employed injections of antistreptococcus serum; the results reported have in many instances been favorable and it is quite possible that further experimentation with this treatment may establish it as a routine method. This form of treatment does not seem to shorten the disease but the injection of 5 drachms (20.0) of the serum in one or two doses is said to lessen the severity of the symptoms and to cause a disappearance of the albuminiuria. The diet during the febrile stage should be of fluids only and as highly nutritious as possible in order to maintain the patient's strength and powers of resistance. During convalescence the dietary should stiU be carefufly regulated and the administration of tonics, such as strychnine, iron and quinine is strongly indicated. ACUTE ARTICULAR RHEUMATISM. Synonyms. Rheumatic Fever; Inflammatory Rheumatism; Acute Rheu- matism. Definition. An acute infectious febrile disease characterized by inflam- mation of one or more of the joints. -Etiology. The disease is most common during the cold and damp months and in young adults, especially those of low vitality and whose occupa- tions expose them to the inclemencies of weather. Extremes of cold are less likely to predispose to the disease than a moderately low temperature accom- panied by moisture. An hereditary tendency to the disease has been noted. It is probable that the infection is the result of specific bacterial intoxi- cation, although thus far no causative germ has been isolated. Various observers have, however, cultivated from the inflammatory exudates of rheu- matic patients different micro-organisms which are capable of causing arthritis Io6 THE INFECTIOUS DISEASES. and endocarditis in lower animals. Several distinct species of bacteria have been isolated from rheumatic exudates which goes to show, as suggested by Flexner and Barker, that perhaps acute articular rheumatism may be the re- sult of infection of the blood by any one of several species of pathogenic micro- organisms at a time when circumstances are such as not to favor the develop- ment of general septicaemia but are favorable to the propagation of inflam- matory conditions of one or more of the serous membranes. Various forms of arthritis simulate acute articular rheumatism, such as those complicating other acute infectious diseases, notably scarlatina, and the arthritis due to the gonococcus. These are not true rheumatisms but inflammations of the synovial membranes due to other causes. Pathology. The affected joint is swollen, hot, sometimes red, and is bathed in acid perspiration. Its synovial lining is congested and swollen. The joint cavity is sometimes distended by fluid. This is usually serous but may be turbid, or rarely puru- lent. The cartilages within the joint and covering the articular surfaces may be eroded. Symptoms. The onset of the disease is usually rapid, one or more joints becoming, even within a few hom"s, swollen, painful, tender, reddened and bathed in perspiration. Less frequently there is a short period of invasion during which the patient has indefinite pains in bones and joints. The onset is rarely marked by a chill, but is usually followed by a rise in temperature. The regular course of the infection lasts about six weeks but with proper treatment we are usually able to shorten the acute stage to six or seven days. With the inception of the disease there is often nausea and vomiting. The temperature rises to io2°-io4° F. (38.9° to 40° C). The pulse is accelerated (95-100), the urine is scanty, high colored and acid with a copious sediment of urates; it may contain albumin; the bowels are usually constipated. The febrile movement continues while the joints are acutely inflamed but usually is of remittent type. The skin is usually bathed in an acid perspiration and it may be the seat of various eruptions. These may be erythemata, diffuse papular, tubercular or marginate, urticaria, or a true purpura with haemorrhagic spots of varying size. Sloughing may follow these last and with them there may be haemor- rhages from the various mucous membranes and hsematuria. This condition is demonstrated peliosis rheumatica and is of doubtful rheumatic origin. Nodules of various sizes up to that of a pea have been observed in certain cases in the tendons and muscle sheaths of the extremities, limbs and even over the ver- tebrae. These are a feature of the declining stage of the disease; they are more usually seen in children and remain from several days to several weeks. The pain is usually very severe, any movement increases it and even the ACUTE ARTICULAR RHEUMATISM. 107 weight of the bed clothing may cause extreme discomfort. The patient finds that the pain is less when the joints are held in a position of mid-flexion. Usually more than one jojnt is inflamed and those most often attacked are the knee, ankle, wrist, elbow, shoulder and hip, in the order named. The joints of the fingers are not however exempt. Rarely is a single joint affected, though this may occur. The inflammation has a tendency to involve succes- sively one joint after another, the symptoms in one being to some extent relieved as another is attacked. At times the process will recur in a joint which has partially returned to normal. A patient who has once suffered from rheumatic fever is prone to recur- DAY OF, OlSEASi 1 2 3 4 5 6 7 8 9 10 11 12 13 14 13 16 17 18 19 20 21 E42° —40°^- HOUR ML 106° ioa° 0104' k A p 4= ^ M M K 1 E E M A M E p M j p E p A M p 5 A M S P i M E = E p >t p - - p E _ i p E = ^102 g 101' g 100 S J9 98' 97° 96° — 3 z E E E 1 z 1 a ^ A — 2 E ? = 1 - I E E 1 1 § S s r ^ I E —39 g - ^' d38°"' 5-37° A d A d = = ^ = - - z z z = z - - = z E E E E E E E E Fig. 6. — Clinical chart of acute articular rheumatism. rences of the disease at intervals of from one to several years, and it is these successive attacks which are likely to result in serious complications, more especiaUy in the heart. Hyperpyrexia. In certain cases the temperature may rise to a very high level even to 110° F. (43.3° C). Such a condition is a very serious one and generally results in death unless the temperature can be quickly reduced. With this excessive temperature are other symptoms of marked constitutional disturbance such as headache, delirium, unconsciousness and heart failure. Complications. These affect the serous membranes and the endocardium and are the result of the lodgment of the infectious material in the blood in these situations. The pleura, the pericardium and more rarely the peri- tonaeum are the membranes involved and their inflammations are amenable Io8 THE INFECTIOUS DISEASES. to antirheumatic treatment. In rheumatic pleurisy physical signs are con- spicuously absent, an important point in differential diagnosis. Endocarditis is a frequent and most dreaded complication, its usual seat is in the left side of the heart and it is less likely to attack the aortic than the mitral valve. The heart should be the subject of very frequent examination since in even mild rheumatic infections it may become the seat of valvular disease of severe type. The percentage of heart complications in this disease is stated by some authorities to be as high as sixty percent. The onset may be gradual and difficult of diagnosis, while dyspnoea and palpitation may appear as features of a rheumatic attack with merely a functional cardiac disorder. The endocarditis is more frequently seen in youthful patients and is usually of the vegetative type. The heart may regain its normal condition but most of the cases of chronic endocarditis seen in practice are the result of rheumatic infection. Infective or malignant endocarditis may occur, but inflammations of the myocardium are believed to be rare. In consideration of the sequelae of acute rheumatism, chorea, exophthalmic goitre and acute nephritis and the permanent joint changes similar to those of chronic articular rheumatism and arthritis deformans should be men- tioned. The prognosis. Recovery is usual in non-complicated cases. The dura- tion of the disease untreated is about i6 days but with proper treatment this may be much shortened. In many cases the infection leaves the patient with a permanently impaired heart. Rarely the patient passes on to the condition known as chronic rheumatism. Death, when it takes place, is usually the result of hyperpyrexia or cardiac complications. Prophylaxis. Persons subject to the disease should avoid excessive mus- cular exertion and especially exposure to cold and wet. Their clothing should be warm, preferably of woolen next to the skin in winter and of linen during the hot months. Too much carbohydrate food and malt beverages should be avoided, and the liver and bowels should be kept active. Daily baths, cold, preferably, if well borne, should be taken in order to keep the skin active and healthy. Out-door life and proper exercise are important. Treatment. The patient should be kept in bed, upon a soft mattress and covered with blankets, not sheets. Calomel followed by a saline should be administered and the bowels should be kept freely open during the whole course of the disease. Medicinal Treatment. The salicylates are an exact chemical limitant of the action of the causative bacteria, but the problem is to administer these in sufficient dosage to accomplish our object without injury to the heart, stomach or kidneys. Salicylic acid and sodium salicylate, especially the former, are ACUTE ARTICULAR RHEUMATISM. I09 very likely to disturb the stomach, and being eliminated through the kidneys these organs are likely to receive harm. The acid in large doses diminishes the contractile povi^er of involuntary muscle fibre and consequently its adniin- istration may result in acute cardiac dilatation. The ideal drug would be an organic combination of the salicyl radical which would pass through the stomach unchanged to be spilt up in the intestines. Sixty to eighty grains (4.0 to 5.33) per day of the salicyl radical are necessary to cause a disappearance of the symptoms within a week and so great a quantity is likely to be harmful and certainly is objectionable to the patient. The problem being to bring the salicylate into direct contact with the joint in as great a quantity as possible and to prevent its getting into the circulation, the following ointment is prescribed : I^ acidi salicylatis, olei terebinthinse, adipis lanae hydrosi, of each one drachm (4.0), unguenti, q.s. ad one ounce (30.0) . Sig. Rub one drachm (4.0) thoroughly into the diseased joint twice a day. The fact that a curative quantity of the salicyl radical is absorbed may be proven by finding salicyluric acid in the urine within 20 minutes after an inunction.* The acutely painful and tender joint of beginning acute rheumatism may cause the patient to rebel against this form of treatment but the administration of salophen (two drachms — 8.0 — in divided doses during 24 hours) or antipyrine salicylate in like quantity will ease the pain so that the inunctions may be employed. During the administration of salicylic acid in any form the urine should be examined daily and the quantity, specific gravity, and presence or absence of albumin or casts noted. It should be remembered that salicyluric acid reduces Fehling's solution, consequently such a reaction should not be mis- understood. The above treatment usually results in the disappearance of the acute symptoms of the disease within a week. In hospital practice the use of sodium salicylate — grains xx (1.33) — and sodium or potassium bicarbonate — ^grains x (0.66) — every four hours will be found to be attended with excellent results but in privtae practice such dosage is objectionable for obvious reasons. The alkali may be diminished when the reaction of the urine becomes alkaline. With this form of treatment it is very necessary that the bowels be kept freely open, that water be drunk copiously and that the condition of heart and kidneys be carefuly watched. When the acute symptoms of the disease have abated the dosage should be diminished. Certain authorities advocate the use of salicin, phenyl salicylate (salol) or methyl salicylate (oil of wintergreen) but these drugs seem to have no advantage over those above mentioned. Certain feeble and anaemic patients are not benefited by the alkalies or ♦Test for salicyluric acid: To a test tube of urine add 10 drops of the tincture of ferric chloride and in the presence of salicyluric acid a port wine color will result. no THE INFECTIOUS DISEASES. salicylates and in these iron, codliver oil, potassium iodide and other tonics and alteratives are indicated. In gouty patients an attack of acute rheumatism seems to be best treated by a combination of colchicum and the salicylates. When the salicylates are too disturbing to the stomach they may be given per rectum in dosage of 20 to 40 grains (1.33 to 2.66) in solution every four or six hours. If larger doses are injected it is wise to add a few drops of tincture of opium. Acetyl-salicylic acid (aspirin) is recommended as a substitute for the more commonly used salicylates, chiefly because is passes unchanged through the stomach, consequently not disturbing this organ, and is split up in the bowel; its taste is less unpleasant and it is less likely to cause tinnitus. Its dosage is from ten to fifteen grains (0.66 to i.o) in powder or capsule every three or four homrs. It may be said in conclusion that while various other drugs have their advocates the general consensus of opinion is that in salicylic acid and sodium salicylate we have the most eflScacious treatment for acute rheumatism. Disadvantages they have it is true, such as their tendency to disturb the stomach, heart and kidneys and to produce tinnitus aurium, which may be relieved by sodium bromide, or even deafness, and while their use does not prevent relapse, possibly because their administration is not long enough continued, nor heart complications, it does relieve the pain quickly and effectively, enables the patient to sleep and causes the fever to fall within a few days. With regard to hyperpyrexia, energetic cold bathing — 70° F. (21.1° C.) — or cold packs are the only means of treatment which have given good results. While the patient is being moved to undergo either of these procedures mor- phine may be given hypodermatically to control the pain and strychnine or alcohol may be used to counteract any tendency toward collapse. The treatment of other complications, pericarditis, endocarditis, etc., will be dealt with in the sections upon these diseases. While the febrile movement and the other acute symptoms persist the diet should be of milk, soups and semi-solids. A retiu-n to ordinary diet should not be allowed for at least a week after the subsidence of the joint symptoms. Menzer has prepared a serum from streptococci from the tonsils of rheu- matic patients and has used it in more than 30 cases with the following results : The treatment caused no pain or other local reaction as a rule. A general reaction, chilliness, fever, and skin eruptions, often resulted. The dose used was from i^ to 5 ounces (50.0 to 150.0). He believes that in acute cases the course of the disease was shortened, and he particularly states that the treatment seemed definitely to prevent severe endocarditis. Local applications of various kinds may relieve the joint pain and swelling. SEPTICEMIA AND PYEMIA. Ill The affected parts should be swathed in cotton covered by oiled silk which will protect from traumatism and maintain an even temperature. Often immobilization by means of splints and the use of sand bags and pillows will add to the comfort of the patient. It is to be remembered in the application of splints, etc., that mid-flexion is the proper position in which to place the joint. Blisters of cantharides may relieve the pain in the acute stage and are often useful later in the disease. Care should be taken lest their action be carried too far. Injections of lo to 15 drops (0.66 to i.o) of i percent, solution of phenol beneath the skin of the joint are advocated. These may be repeated once or twice daily and are said to relieve the pain to a considerable extent. Painting with tincture of iodine or applications of iodine ointment are likely to accomplish little, but a 10 to 20 percent, ointment of ichthyol in lanolin is highly recommended. If wet dressings are applied the temperature should be warm. Among the most efficacious of these is Fuller's lotion (sodium carbonate 6 parts; laudanum 80 parts; glycerine 16 parts; water 72 parts), equal parts of guaiacol and glycerin; fluid extract of belladonna 20 drops (1.33) to the ounce (30.0) of glycerin; and oil of wintergreen. These should be applied upon gauze compresses and renewed twice daily. After the acute stage is over the joints will be much benefited by properly applied massage and passive motion; warm and steam baths and galvanic electricity will also be found useful. SEPTICAEMIA AND PYEMIA. Synonym. Bacteriaemia. Definition. Septicaemia and pyaemia are febrile diseases caused by the existence in the blood of pathogenic micro-organisms and characterized by recurring chills and irregular rises and falls of temperature. From these affections sapraemia or toxaemia are to be differentiated, the latter being the result of the local development of bacteria and the taking up by the blood of the toxic products of their growth. The distinguishing mark of pyaemia is the occurrence in the various tissues and organs of metastatic pus foci; in septicaemia this manifestation does not take place. .Etiology. Surgical septicaemia is usually considered to be a result of infection by pyogenic micro-organisms, particularly staphylococci and strep- tococci, while to the physician the term septicaemia signifies a condition caused by the presence of any variety of pathogenic micro-organism in the blood and tissues while a demonstrable focus of infection may or may not be present. The basis of pyaemia is analogous to that of septicaemia with the added factors of thrombosis and embolism. To these latter the occurrence of the metastatic abscesses is due. For instance a septic phlebitis may occur with the formation of an infective thrombus from which bits of infectious matter 112 THE INFECTIOUS DISEASES. may become detached and may be borne as emboli by the blood current until their final lodgment in a vessel the lumen of which is too narrow for their passage. Here such infectious particles become stationary and set up inflam- mator}' processes which soon become abscesses. An example of this often occurs in infective or malignant endocarditis in which bits of the valvular vegetations may become detached and carried as emboli by the circulation, imtil lodging in some perhaps remote part of the body they result in abscesses. Emboh from septic processes in the periphery and in the bone-marrow are most Hkely to lodge in the lungs, those from the tissues drained by the portal system in the liver, those from the female organs of generation in the pelvic tissues, those from the left side of the heart and those whose size permits of passage from the right side of the heart through the pulmonary circulation to the left heart, in the brain, kidneys or spleen. Of the more common varieties of septicaemia puerperal infection due to retained secundines, lacerated cervix or perinaeum, scarlatinal or erysipelas infection and the process which may result in severe forms of enteric fever, gonorrhoea, diphtheria and other acute infectious diseases, should be men- tioned. Symptoms. Before the appearance of constitutional symptoms, those of the primary local lesion, if such is present, will be noticed. The onset of the septicemia or pyaemia is usually marked by a severe chill during which the temperature may rise to 103° to 105° F. (39.4° to 40.5° C). Following this manifestation there is profuse sweating succeeding which the temperature may rise again. Chills, rises of temperature and sweats succeed one another at intervals of one or two days, a general tendency of the fever to be higher at night being not unusual. The patient is prostrated, thirsty, suffers from anorexia and nausea, and perhaps vomits. Flesh is rapidly lost, exhaustion becomes profound and a condition of semi-coma may supervene; transient erythematous eruptions may appear. Local symptoms are frequent in pyaemia and are due to the lodgment of the septic emboli. In the lungs these cause pain, rapid respiration and cough; in the liver, pain with tenderness, enlargement of the organ and jaundice; in the subcutaneous tissues, pain, tenderness and swelling, followed by abscess formation; in the joints, the usual signs of inflammation and the presence of intraarticular effusion; in the kidneys, albumin or blood in the urine. Emboli lodging in the brain, unless they shut off the blood supply of portions of this organ essential to the performance of the body functions, are not likely to be suspected. Emboli of the spleen cause pain in the side, tenderness and splenic enlargement, while metastatic abscesses of the pancreas are evidenced by deep pain and tenderness in the region of that organ. The diagnosis of septicaemia and pyaemia usually offers little difficulty when a primary focus is present. When this aid is absent blood examination SEPTICEMIA AND PYEMIA. II 3 will reveal a considerable leucocytosis and cultures may show the presence of the causative micro-organism. Enteric fever may be differentiated by means of the Widal reaction and malaria by examination of the blood and by the test of quinine treatment. Gonorrhoea and prostatic abscess as well as tuberculous nephritis and pyelitis due to the presence of calculi may be factors in causation. In malignant endocarditis a murmur is usually present but both this condition and acute osteo-myelitis may be unsuspected. The prognosis is always serious in pysemic conditions. Puerperal septi- cemia is the least grave type of the affection if proper treatment is instituted. Chronic cases may last for months with irregular temperature and gradually increasing anaemia and emaciation until death supervenes. Treatment. Much may be done in the way of prevention of puerperal septicaemia by proper cleansing of the patient's genital tract, the physician's hands and instruments, the complete removal of the contents of the uterus and proper after-treatment of cervical, vaginal and perinaeal lacerations. Crede recommends the sterilization of the patient's genitals after partiurition by first removing all clots, etc., and then inserting a vaginal suppository con- sisting of I J grains (o.i) each of powdered talc and collargol and 30 grains (2.0) of cocoa butter; the vagina is then packed loosely with sterile gauze which later with the introduction of another suppository may be renewed. If infection takes place douches of i to 2000 to i to 5000 collargol solution are given and if there is any retention of placenta or membranes these should be removed by operation. In advanced infection the intravenous injection of 2 to 2^ drachms (8.0 to lo.o) of collargol solution is advised. This last pro- cediu-e may also be employed in septicaemia and pyaemia of other forms. The early treatment of septicaemic and pyaemic states by surgical means is most important. The primary focus should be rendered thoroughly clean by means of antiseptics, the curette or even the actual cautery. All collections of pus which can be reached should be opened and drained and even ampu- tation of a limb may be necessary. Subcutaneous injections of antiseptics into the tissues may be given just as has been recommended in erysipelas (p. 104). The bowels, kidneys and skin should be kept active in order that the poisons may be eliminated in so far as is possible and this may be furthered by the administrations of high rectal irrigations of hot saline solution given two or three times daily and two to four gallons (8 to 16 litres) at a time. The temperature may be relieved by sponging with cool water and quinine sulphate may be given in doses of 15 to 30 grains (i.o to 2.0) daily. If the coal tar antipyretics are employed much caution is necessary because of their depressing effect. The sweating may be controlled by -yV of ^ grain (0.006) of morphine with yto ^^ ^ grain (0.0006) of atropine, by agaricin one to two grains (0.065 to 0.13), or dilute sulphuric acid 15 to 30 drops (i.o to 2.0). 114 THE INFECTIOUS DISEASES. Tincture of iodine 20 to 25 drops (1.33 to 1.66) daily in divided doses, given in syrup or rice-water is recommended and inunctions of Crede's oint- ment may be employed. Intravenous injections of coilargol solution as advised above may be tried. Stimulation by means of alcohol and strych- nine is always necessary and in the later stages h}'podermoclyses of hot norma] saline solution may become necessary. Treatment by means of antistreptococcus serum should never be omitted especially in severe cases; 5 to 7 J drachms (20.0 to 30.0) may be injected every six to eight hours, the doses being diminished as improvement is mani- fested. The diet throughout should be of the most nutritious and easily digestible character and of plentiful amount. HYDROPHOBIA. Synonyms. Rabies; Lyssa. Definition. An acute specific infectious disease to which all warm-blooded animals are subject. It is communicable to man by inoculation and is characterized by tonic spasms usually beginning at the larynx. .Etiology. The dog is particularly prone to this disease and when the affection occurs in man it is usually through the bite of this animal. Hydro- phobia is also seen in wolves, cats, skunks and even cows and may be inocu- lated into rabbits, horses and other domestic animals. While undoubtedly the result of infection with a micro-organism the specific cause of the disease has not been isolated. The toxic substance exists in the central nervous system and in certain secretions, particularly the saliva, by means of which it is usually transmitted. By no means all the individuals bitten by rabid dogs suffer from hydropho- bia. Horseley gives the figures as 15 percent., while the mortality among those bitten by wolves is much larger, being from 40 to 80 percent. Children more frequently suffer from the disease than adults and bites upon the face and hands, probably because these parts are more often unprotected by clothing which may wipe off the saliva before the teeth of the animal reach the tissues, are more likely to be followed by hydrophobia than those upon other parts. Punctured wounds are considered especially likely to be serious. It is certain that many cases reported as hydrophobia are in reality not this disease at all and some go so far as to assert their skepticism as to its existence as a nosological entity. Pathology. The characteristic morbid changes present in hydrophobia are microscopical and are, so far as is known, confined to the nervous system, the rabic virus likewise is present in the brain, cord and peripheral nerves but is not found in other organs and tissues. The pathological conditions HYDROPHOBIA. II5 consist of a dilatation of the vessels of the brain, medulla and upper cord and a collection of leucocytes in the perivascular sheaths and about the nerve cells, particularly those of the motor ganglia. Van Gehuchten andNelis have described certain alterations in the peripheral ganglia of the cerebro- spinal and sympathetic systems consisting of a proliferation of the normal cellular elements which tends later to destruction and a replacement by round cells. Analogous changes are observed in certain other diseases as botulis- mus and diphtheria. In 1903 Negri described as constantly present in the nerve cells of rabetic animals, certain bodies, which he believed to be protozoa, and which varied in size and shape according to their position in the cell. They are found espe- cially in the cells of the hippocampus major and have been observed also in the cells of the pons, in Purkinje's cells and in those of a number of other situations. A number of different opinions exists as to the character of these bodies and also as to their diagnostic value. Inasmuch as there are no pathological appearances which are universally admitted to be characteristic of the disease the diagnosis must remain uncer- tain. Many instances of tetanus, septicaemia and tuberculous meningitis have been reported as hydrophobia. Of fifteen consecutive deaths ascribed to hydrophobia and so recorded by the New York City Board of Health not one, after careful investigations could fairly be ascribed to this cause. Symptoms. The period of incubation is from six weeks to two months although rarely, symptoms have been reported as appearing within two weeks after the infection, and incubations of a year or more have been observed. The symptoms of the attack may be divided into three stages. Of these the first or premonitory stage is characterized by local manifestations about the bite, such as pain, tenderness and redness. The patient's mentality is depressed, he suffers from headache, anorexia and insomnia; he is feverish and perhaps melancholic and anxious. Any sudden noise or flash of light is startling. The voice is hoarse, the larynx may be congested and there may be dysphagia. The spasmodic stage follows the stage of premonition after about 24 hours. The patient is most excitable, restless and hyper esthetic. Any peripheral irritation, even a sound or draught of air brings on a pronounced reflex spasm. This affects chiefly the muscles of the throat and larynx and is particularly likely to be induced by the act of swallowing. The spasm is painful and is accompanied by marked dyspnoea. The fact that the spasm is so closely associated with the act of deglutition causes the dread of water. The saliva is usually increased and cannot be swallowed without causing a paroxysm. Maniacal excitement may accompany the spasm and restraint may be neces- sary, but in the intervals the patient is quiet, his mentality is normal and he appears anxious lest he do harm during the seizures. Il6 THE INFECTIOUS DISEASES. The temperature is elevated — ^from ioi° to 103° F. (38.5° to 39.6° C.) — and the pulse is accelerated. This stage lasts from one to three days and is succeeded by The paralytic stage. This is characterized by exhaustion upon the part of the patient; he becomes quiet and gradually comatose. The cardiac action becomes weaker and weaker and death supervenes in syncope. The diagnosis is not particularly difl&cult, the history and the length of the incubation period being important differential points. Pseudo-hydrophobia or lyssophobia may closely simulate true rabies. This condition is likely to follow, particularly in neurotic individuals, the bite of an animal and it may even be characterized by paroxysms very like those of hydrophobia. The patient's symptoms usually ameliorate upon treat- ment although their duration is longer than in true rabies. The disease does not progress nor is there a rise of temperature. The diagnosis of hydrophobia may be assured by inoculating rabbits or guinea pigs with bits of the medulla of the supposedly rabid animal; the animals, if true rabies is present, will within 15 to 20 days develop the paralytic type of the disease. It is advisable, how- ever, to inoculate a second series of animals, since various drugs such as strych- nine and atropine are capable of producing symptoms identical with those of dumb rabies. The changes in the peripheral ganglia of the cerebrospinal and sympathetic nervous systems of the affected animal are also character- istic. These may be examined and the diagnosis determined within a few hours after the animal's death; he must, however, die a natural death and not be killed. The ganghon of the vagus nerve is usually examined and shows a proliferation and finally destruction of the normal cells and a replace- ment by round cells. It must be remembered that Marinesco has shown that identical changes occur in sausage poisoning (infection with the bacillus hotulismus) and analogous ones are met in tetanus and diphtheria. Supposedly rabid animals should not be kiUed unless absolutely necessary, but should be confined in order to ascertain if they are certainly affected with the disease. The prognosis in fully developed cases is distinctly bad, the patient dying usually in from two to six days. Cauterization of the bite and the Pasteur treatment when undertaken in time are very effectual. Treatment. Prevention of rabies is easily accomplished by the syste- matic muzzling of all dogs. The bite having been inflicted should be at once sucked, preferably by the patient himself, and the mouth immediately washed. Cauterization with a red hot iron, the Paquelin or the galvano-cautery should be practised as soon as possible. Failing these means stick silver nitrate, pure phenol or potassium hydrate should be employed; the wound should not be allowed to heal. I HYDROPHOBIA. 117 The Pasteur treatment is a method of prevention based upon incompleted experiments made by the distinguished French scientist whose name is imme- diately suggested by the word hydrophobia. It is founded upon his discovery that the poison of this disease has its seat in the nervous system, especially in the brain, medulla and cord. By inoculation of virus from the nervous tissues of rabid animals through a series of 50 rabbits a virus is produced which acts after an incubation period of 7 days. This is termed "fixed virus." The spinal cords of the last rabbits of such series contain this virus in great intensity but its potency is quickly reduced by exposure of the cords to (Jry air, consequently they are dried in sterile glass vessels with potassium hydrate. In dogs inoculated with an emulsion made from fragments of medulla of diminished virulence and then with preparations of cord of higher potency immunity from inoculation by fresh cord substance is reduced. Working on this basis Pasteur inocvdated human subjects, who had been bitten, with emulsion of two weeks old cords and on each successive day to the number of 12 gave other inoculations until those but one day old were used. By this treatment he succeeded in rendering the individual immune. At present the method employed in most Pasteur institutes consists in giving inoculations from cords of increasing virulence in rather more rapid successions. Below is given a tabulated statement of the results of this treatment at the institute in Paris. Year. Persons Treated. Deaths. Percent, of Mortality. 1886 2,671 1,770 1,622 1,830 1,540 1.559 1,790 1,648 1.387 1,520 1,308 1.521 1.465 1,614 1,420* 1.321 1,105 25 14 9 7 5 4 4 6 7 5 4 6 3 4 4* 5 2 1887 0.94 0.79 0-55 0.38 1888 i88q i8qo i8qi 0.32 0.25 i8q2 180^ 0.36 0.50 i8q4 1895 1896 °-i6 1897 0.30 1898 0-39 1800 0.25 0.35* 0.38 <:..l8 iqoo IQOI igo2 During 1902, one thousand, one hundred and six persons were treated, of whom three died from hydrophobia. Inasmuch as in one instance the disease * Corrected to 1,420, 5, and 0.35 respectively. Il8 THE INFECTIOUS DISEASES. declared itself before the end of treatment, this is excluded from both " persons treated" and "deaths." The time necessary for the treatment is 15 days, two inoculations being given daily in ordinary cases. In those whose treatment has been instituted late or in whom the wounds are upon the face or head four to six inoculations per da)> may be given. The following is a condensation of the instructions published by the insti- tute at New York, for the benefit of those bitten by supposedly rabid animals. Cauterization should be practised as soon after the bite as possible. Late cauterization is without benefit and possesses the disadvantage of inducing a false sense of security. The bite should be treated in other respects just like any infected wound. The patient should be immediately sent to the institute, since each day of delay renders the prognosis less favorable. The inoculation is harmless and it is better to inoculate before learning the result of the biological diagnosis even though we treat those who do not possess the disease. The inoculation has the advantage of conferring immunity which persists for several years. The dog or other animal should be confined and kept under observation until it dies or recovers, and notes of its condition and progress should be sent to the institute. If it is impossible to keep the animal alive it should be kiUed, its head should be severed with a sterile knife, a portion of the medulla removed, and placed in a sterile bottle containing a previously boiled mixture of equal parts of glycerine and water. This bottle should be sealed and sent to the institute for examination and inoculation. A report upon the stomach contents of the animal should also be forwarded to the institute. After the onset of the symptoms they should be controlled in so far as possible. The patient shovild be placed in a darkened and quiet room in charge of two attendants. While the milder sedatives such as the bromides and chloral may be effectual at first in overcoming the nervous irritability, it is wiser to employ inhalations of chloroform and hypodermatic injections of morphine from the beginning. The difficulty in swallowing may be relieved by the local use of cocaine but it is often necessary to administer both food and drink by means of the rectal tube. TETANUS. Synonyms. Lockjaw; Trismus. Definition. An acute infectious disease characterized by repeated tonic muscular spasms of increasing intensity. .Etiology. Tetanus occurs in human beings and in lower animals and is the result of the growth within the organism of a specific micro-organism, the bacillus of tetanus. This bacillus is found in the soil, especially in tropical TETANUS. 119 countries, in the intestines of ruminant animals and in their excreta, in the fluids of putrefying wounds and in pus. Its portal of entry is usually by means of a wound, especially one of the hand or foot and a punctured or contused wound rather than one due to incision. While idiopathic tetanus may occur, in most cases a thorough search will reveal a slight loss of continuity of the skin which has afiforded entry to the bacillus. Tetanus may occur as a result of umbilical infection in the newborn and before the introduction of antiseptic dressings was a frequent cause of death of negro infants in the West Indies. The wound of the blank cartridge of the Fourth of July toy pistol frequently results in tetanus, not, however, from any infective character of the charge of the weapon. The disease is predisposed to by exposure to cold and wet and while it affects all ages and both sexes is more common in males. Epidemics have been occasionally met. The symptoms are not the result of the presence of the bacilli in the blood, for these remain and develop at the site of the wound; the toxins produced by their growth are responsible for the constitutional manifestations. Some years ago a large number of cases was reported as being caused by injection of diphtheria antitoxin but investigation proved that these were due to antitoxin from one source only, and that the substance had not been prepared under proper precautions. Pathology. There are no characteristic morbid changes in this disease. The wound is in no way typical and while granular degeneration of the nerve cells, inflammatory conditions of the nerves, and congestion, extrava- sations and exudates of various parts have been found, these are neither con- stant nor essential. Symptoms. The usual incubation period is al^out 10 days. The onset of the disease may be marked by a chill or chilly sensations but this is not the rule, the initial symptoms being stiffness of the neck and jaw; mastication is difficult but not painful. The muscles of the abdomen, back and limbs become gradually stiff and the body becomes so inflexible that it may be raised as if made of a single piece of wood (orthotonos). In marked instances it may be impossible to force the jaws apart. Risus sardonicus may be present as evidenced by a drawing out of the corners of the mouth and eleva- tion of the eyebrows; paralysis of the muscles of the face, dysphagia with laryngeal and oesophageal spasm may be noted; this is the so-called head tetanus of Rose and usually is the result of a w6und of the head with injury to the fifth nerve. Paroxysms may be induced by a touch, a breath of air or any alight noise; during these the muscles of the trunk contract, producing arching of the back so that the body is supported by the head and heels {opisthotonos), or the body may be bent forward in the position of emprosthotonos or side- I20 THE INFECTIOUS DISEASES. ways in the posture of pleurosthotonos. The tongue may be bitten in spasms of the jaw or in marked instances the chest may be so compressed by mus- cular contraction as to cause severe pain and rapid respiration. The opening of the larynx may be contracted producing a condition of asphyxia. Extreme pain is an accompaniment of the paroxysm and the body may be bathed in perspir^ion. Between the attacks, which occur at intervals varying from a few minutes to several hours, the patient may be able to walk about but the relaxation is not complete. Usually the temperature is only slightly above normal but may rise to io6° F. (41.1° C.) or to 110° F. (43.4° C.) or even higher just before death which may occiur during a paroxysm from asphyxia or cardiac failure, or from exhaustion. The pulse and respiration are, as a rule, accelerated. The mind remains clear. Constipation is frequent and often serious since attempts at relief are likely to induce the paroxysm. The diagnosis particularly in traumatic tetanus is usually not difl&cult; trismus occurs in tetanus but not in hydrophobia, and in str}'chnine poisoning in the intervals of the paroxysms there is no rigidity and the convulsive attacks affect the limbs more than in tetanus. Bacteriological tests may be employed to assure the diagnosis. The prognosis in traumatic tetanus is bad, the mortality being about 80 percent, as against less than 50 percent, in the idiopathic form. Death usually takes place within six days after the onset; patients sm-viving longer than this period are likely to recover. The disease is especially fatal in children. A prolonged incubation period is a favorable sign as are also a localization of the spasms in the face and neck and an absence of elevation of temperature. Treatment consists first in thorough cleansing and cauterization of the woimd. Particularly should all bits of wadding, powder, etc., be removed from blank cartridge wounds; the actual cautery, phenol or silver nitrate should then be used and the wound dressed antiseptically. Dusting the wound with powdered tetanus antitoxin has been suggested, and a prophy- lactic injection of at least 5000 units of antitoxin should be given The patient shovild be placed in a darkened room, as far removed from irritant influences as possible; he should receive no visitors, one attendant being sufficient, and the strictest quiet should be enjoined. While the resiilts obtainable from antitoxin treatment are not all that could be hoped, injections should in all cases be instituted. It has been shown that the route of the tetanus toxin to the nerve centers is along the motor nerves and less directly through the blood and lymphatics, and since only that portion of the toxin which is in the blood and tissues outside the nerves can be reached, the antitoxin should be injected directly into the veins and into the tissues about the focus of infection. The diagnosis having been made by TETANUS. 121 means of bacteriological tests, injections shoiild be immediately begun and continued daily for at least two weeks from the date of the injmy. The injections should be into the median basilic vein and each dose should consist of from 2^ to 5 drachms (lo.o to 20.0). It is better to give too large doses than too small. Intraneural injections, the motor nerves supplying the injected region having been exposed as near the spinal cord as possible, of from 5 to 20 minims (0.33 to 1.33) are advised in connection with the above treatment. The cauda equina may also be injected by means of lumbar punc- ture, certainty that the injection has been given directly into its nerves being e\'idenced by twitchings. In urgent cases the injections may be given directly into the cord itself at the level of the sixth or seventh cervical segment, the risk of injury being less than that of the spread of the infection. After these more drastic measures attention should be given to the local lesion and the surrounding tissues should be fully injected with the antitoxin. The entire process described above may be repeated daily until there is subsidence of the symptoms. Anaesthesia is of covirse necessary in this treatment. Sub- dural injections of antitoxin by means of trephining have been practised but these would seem in no way superior to the less difl&cult injections into the tissues, veins, nerves and cord. Excellent results have been reported from the employment of subcutaneous injections of an emulsion of rabbit's brain, the basis of the treatment being the fact that the tendency of tetanus toxin is to become incorporated and fixed in the nerve structures. At least one case has been cured, after the antitoxin treatment had seemed to fail, by the removal of cerebrospinal fluid by means of lumbar puncture and injecting into the subarachnoid space 45 minims (3.0) of a solution containing i^ grains (o.i) of eucaine, J of a grain (0.022) of morphine and three grains (0.2) of sodium chloride. An amelioration was immediately noted and the process was repeated several times, the patient ultimately recovering. Very recently treatment by means of the injection of a solution of magnesium sulphate into the spinal canal by means of lumbar puncture has been sug- gested and the few results so far reported seem to justify the method; 25 and 12^ percent, solutions have been employed, the amount injected being about 15 minims (i.o) for every 25 pounds of the patient's weight. Repeated injec- tions may be given and the treatment is said to restrain the conviilsions and relieve the pain, thus preserving the patient's strength and preventing excessive metabolism and heat production; in addition the spasm of the muscles of the jaw is lessened, thereby permitting the administration of food by mouth. The action of the salt is continued for a considerable period without depressing the heart and no ill-effects are likely to be produced save an inhibition of the action of the bladder, rendering catheterization necessary. It is possible that the drug exerts some chemical action upon the toxins of the disease 122 THE INFECTIOUS DISEASES. but more probably its effect is purely symptomatic. This form of treat- ment may be employed to advantage in connection with that by means of tetanus antitoxin. Treatment by means of the repeated hypodermatic injection of two percent, phenol is said to act favorably upon the nervous system and, to a certain extent, to neutralize the effect of the toxin of the disease. Amputation of the wounded limb has its advocates. With regard to the treatment of the paroxysms it may be said that they are best controlled by chloroform inhalations but they may be avoided or at least decreased in intensity by the use of various hypnotics. Of these mor- phine given hypodermatically is the most efficient and the patient may be kept under its influeTice. Hydrated chloral given together with the bromides may prove effective; physostigma — \ to ^ a grain (0.0165 to 0.033) — given every three to six hours and curare — gV of a grain (0.0026) — administered hypoder- matically, the dose being gradually but with caution increased, may benefit the condition. The resulting stiffness frequently observed during convalescence may be markedly relieved by the tincture of conium in doses gradually increased until its physiological effects are noted. Stimulation is necessary when the heart and circulation become depressed and warm baths may aid in relaxing the spastic condition and are grateful to the sufferer. The nourishment should be maintained at the highest possible level since it is said that tetanus antitoxin does not exert its best influence in conditions of impoverished nutrition. The diet, however, must of necessity be chiefly of fluids and feeding by the nasal tube or per rectum becomes imperative when deglutition becomes difficult or impossible. ANTHRAX. Synonyms. Malignant Pustule; Wool Sorter's Disease; Splenic Fever; Splenic Apoplexy. Definition. An infectious disease of animals, particularly cattle and sheep, and transmissible to man. .Etiology. This disease in animals is widespread but less common in America than in Europe and Asia. In man it occurs as a result of infection through the skin, lungs or digestive tract and is most often seen in those who work about animals or animal products, such as shepherds, hostlers, tanners, butchers, etc. The contagium is transferred to man by means of the hides, flesh, blood and secretions of affected animals and while the possibility of contracting the infection through an intact skin or mucous membrane is to be considered it is probable that a solution of continuity of the integu- ment is necessary for a successful inoculation. ANTHRAX. 123 The specific cause of anthrax is a cyHndrical bacillus of great vitality and the largest of the pathogenic bacteria. It is termed the bacillus anthracis and exists in great numbers in the blood and tissues of the infected subject. While the bacilli themselves may be easily destroyed their spores are very resistant to disinfecting agents. Animals acquire the disease through abra- sions such as insect bites, etc., by feeding upon the flesh of other animals dead from the infection and by grazing over fields where the bacilli are present, for these have been found upon the herbage over the buried bodies of animals which have died of anthrax. Symptoms. The incubation of anthrax is usually about one week and for convenience in description the disease may be considered as occurring in two forms, the external and the internal. External Anthrax, a. Malignant pustule occurs as a result of inocu- lation and most often begins upon the exposed surfaces of the face, hands or arms. The first symptom is pain, itching or burning in character, at the site of inoculation. Soon a reddened spot appears which quickly becomes papular and then vesicular, the vesicle containing clear or bloody serum. The surrounding tissues become indurated and, the original vesicle bursting, other vesicles develop about the indurated area. The induration extends and becomes darkened at its center, a brown eschar usually appearing within 36 hoiu-s. The neighboring tissues are oedematous and, the infection spreading along the lymphatic channels, these become reddened, swollen and tender and the adjacent lymph ganglia are enlarged. There is accompanying constitutional disturbance, the temperature and pulse rate being elevated and other symptoms of an acute infection being present. Later the temperature may fall below normal and in fatal cases death supervenes after from three to five days. In favorable cases with mild constitutional symptoms the vesicles may scab and with the induration gradu- ally disappear or the eschar may slough away leaving the wound to heal. h. Malignant anthrax cedema usually begins in the eyelid, spreading thence to the face; it also may occur in the hands or arms; papules and vesicles do not appear but there is marked oedema which may go on to gangrene. The constitutional symptoms may precede the local manifestations and are usually of severe type. Recovery from this form of the disease is practically unknown. A marked characteristic of both forms of the infection is the absence of mental anxiety, the mind often remaining wholly unaffected. Internal anthrax also occurs in two forms, a. Intestinal anthrax or mycosis intestinalis results from the ingestion of the meat or milk of infected animals or from the transference of the contagium of external anthrax to the digestive tract. There is likely to be a chill at the onset which is succeeded by the symptoms of intense intoxication such as vomiting, diarrhoea with bloody stools, general pains, fever and abdominal tenderness. In the severe 124 • THE INFECTIOUS DISEASES. cases the respiration is difficiilt, cyanosis and pronounced mental symptoms are present and there may be extravasations of blood from the mucous membranes or petechial haemorrhages into the skin. There is splenic en- largement, the blood is dark, remains uncoagulated for a considerable period post mortem and in the later stages of the disease may contain the bacillus anthracis. Convulsions may be observed shortly before death. b. Wool sorter's disease is seen amongst those who work in wool or hides, especially those imported from South America or Russia, and is the result of the inhalation or of swallowing the contagium. There is seldom an external lesion and the onset of the infection is usually abrupt with a chill, high temperature, general pains and prostration. The heart action is rapid and feeble and there is dyspnoea and thoracic pain. Cough with accompanying physical signs of bronchitis is not infrequent. Death may occur in collapse within 24 hours or the disease may be prolonged with vomiting, diarrhoea and marked cerebral syniptoms. In such cases the capillaries of the brain have been found to contain the bacillus anthracis in enormous numbers. Rag picker's disease is the name given to a pulmonary and pleural anthrax infection which is accompanied by a general intoxication. The diagnosis of anthrax of the external form may be made from the local appearances and from the history. Bacteriological examination of the con- tents of the vesicle may reveal the presence of the specific micro-organiam. Inoculation experiments are also useful. Internal anthrax is less simple of diagnosis but may be suggested by a history of exposure. The prognosis is distinctly bad, particularly in the internal types. Treatment. Much may be done in the way of prevention by the disin- fection of hides, wool, rags, etc., by means of steam under pressure. Hides, unfortunately, are damaged by this process. All animals dead from the disease should be burned, not buried, grazing over infected pastvires should be prohibited and the thorough disinfection of infected buildings is of much importance. The site of the lesion in external anthrax should be excised if possible or if not deep crucial incisions are to be made and followed by cauterization with the thermo-cautery, phenol or a solution of potassium hydrate. The wound should then be dressed with a strong solution of phenol or powdered with pure mercury bichloride. General or local anaesthesia may be necessary. Injections beneath the skin of the siurrounding parts may be effectual in preventing the spread of the infection. Such solutions as ^ percent, phenol; two to five percent, tincture of iodine; iodine one part, potassium iodide two parts, water one thousand parts, may be injected several times daily. Mercury bichloride is also useful in this connection. The technique of such injections is as follows: At a distance of about ^ an inch from the margin of the indurated area the needle is inserted and the injection made; other GLANDERS. 12$ injections are given outside the periphery of the inflammation at such intervals that the tissue infikrated v^^ith the chosen solution shall act as a continuous barrier to the progress of the infection. The injection of the solution of iodine and potassium into the enlarged lymph glands is also advised. Internally we may give lo to 30 drops (0.66 to 2.0) of tincture of iodine daily or ^ an ounce (15.0) every two hours of the mixture of iodine and potas- sium iodide mentioned above. Stimulants such as alcohol and strychnine should be prescribed as indications arise and the dietary should be as plentiful, nutritious and as digestible as possible. Internal anthrax is likely to be little influenced by treatment. The bowels should be freely moved at the onset and kept open during the course of the disease in order that, if possible, the toxic matters may be removed; the treat- ment described above may be employed and the free exhibition of intestinal antiseptics is advocated. An antiserum for the treatment of anthrax has been elaborated and from the results claimed would seem to merit a trial. GLANDERS. Synonyms. Farcy; Malleus Humidus. Definition. An infectious disease particularly of the horse but com- municable to other animals such as the sheep, rabbit, cat, dog and mouse; cows enjoy immunity. The disease is manifested by nodular growths in the nostrils (glanders) and under the skin (farcy). .Etiology. The disease is rare in man but may be seen in stablemen and others who work about horses. Its specific cause is a micro-organism, the bacillus mallei. The infection is transferred to man by inoculation through an abrasion of the skin or through a mucous membrane, the conta- gium being given off in the discharges from the diseased animal. Pathology. The characteristic lesion of glanders is the appearance of granulomatous tumors of varying size, composed of epithelial and lymphoid cells and containing the bacillus mallei. These tumors occur beneath the skin and on the mucous membranes where they soon break down forming respectively abscesses and ulcerations. The nodules have also been observed in the viscera and in the nervous and osseous systems. Symptoms. Acute and chronic forms of both glanders and farcy occur in man. The incubation period of acute glanders is from three to five days. The onset is characterized by the usual symptoms of beginning febrile disease; at the site of the infection there are redness and swelling, the nasal mucous membrane in the vicinity becomes first dry and congested, the appearance of the nodular tumors rapidly follows, and these soon break down becoming 126 THE INFECTIOUS DISEASES. ulcers which discharge a muco-puriilent or bloody secretion. The infection may cause severe frontal headache due to accompanying involvement of the sinuses in this neighborhood. The submaxillary and cervical lymph glands become enlarged and may suppiu-ate and the inflammatory process spreads to the nasal septum, to the mouth, pharynx and even to the lower air passages, causing pain on swallowing, cough with foul expectoration, and even pneu- monia. A papular eruption which soon becomes pustulous and may be mistaken for smallpox may appear upon the face and upon the skin over the articulations. Chronic glanders is difficult of diagnosis. Its symptoms resemble those of a chronic rhinitis or laryngitis for either of which it is likely to be mistaken. There are ulcerations of the nasal mucous membrane. The diagnosis may be made by inoculating the peritonaeum of a guinea pig with the nasal secre- tion or with a culture grown from this substance. If glanders is present the testicles of the animal become swollen and inflamed within a few days and ultimately suppurate. The guinea pig dies within three or four weeks and nodules are found in the abdominal organs. Acute farcy is evidenced by the symptoms of an acute infection accom- panied by a subcutaneous nodule or an ulcer with a foul secretion. The neighboring parts become congested and oedematous and adjacent lymphat- ics are involved; "farcy buds," which are subcutaneous nodules along the course of the lymph vessels, develop and may suppurate. Intramuscular abscesses and articular swellings may appear and rarely a pustular rash occurs. The nose is not affected and the urine may contain the bacillus mallei. Chronic farcy is characterized by localized subcutaneous nodules, usually occurring upon the extremities; their development is sluggish and while they break down, forming abscesses or ulcers, there is no marked lymphatic involvement. The course is protracted and pyaemic symptoms or acute glanders may develop. The diagnosis in acute glanders is seldom difficult tut in the chronic form is less simple. Recently the agglutination test has been employed since it has been proven that while normal horse serum agglutinates glanders bacilli in a dilution of i to 200, that of a horse affected with glanders will agglutinate a I to 1000 dilution. MaUein, a product of the growth of the glanders baciUus analogous to the tuberculin of tuberculosis, may be employed in diagnosis. Inoculation with this substance causes a rise of temperature when glanders is present, a rise in horses of 3.5° F. (2° C.) being considered proof that the animal is diseased, while an elevation of 1.25° F. (0.75° C.) is considered sus- picious. Direct animal inoculation will quickly determine the presence or absence of the infection and implantation of cultures from the secretion upon cooked potatoes shows within three or four days an amber colored ACTINOMYCOSIS. 1 2 7 film, becoming by the end of a week red and encircled by a pale green area. The prognosis in the acute forms is almost invariably fatal. In the chronic types about half the cases recover. Treatment consists in the early excision and cauterization of the lesion; antiseptic dressings should then be applied. In the nasal form of the infec- tion antiseptic sprays and gargles of dilute phenol or hydrogen dioxide are to be employed. Farcy buds should be incised and dressed antiseptically. Mallein has been employed in animals and has been administered internally to human beings with no very positive results. The patient's nutrition should be kept up by a supporting diet, symptoms should be combated as they arise and stimulation prescribed when indicated. ACTINOMYCOSIS. Synonyms. Lumpy Jaw; Big Jaw; Bone Tumor; Swelled Head. Definition. A chronic infectious inflammatory disease of cattle and pigs, transmissible to man and caused by the strepfothrix aciinomyces or ray fungus. .Etiology. The disease is common in cattle, is more frequently seen in man in Germany than in England or America and affects males more fre- quently than females. The fungus probably reaches the human organism upon the ingested food. Direct infection with meat or milk has, however, never been proven. It has been shown that the disease may be conveyed to cattle upon oats and other grains and it is not improbable that man may contract the disease in the same manner. The infection takes place usually through the mouth, teeth or throat, rarely through the skin or respiratory passages. Pathology. The characteristic lesion is a miliary nodule, made up of a central mass of fungi radiating in all directions and surrounded by granula- tion tissue. The size of a single nodule is about that of a millet seed but numbers of these may be aggregated into tumors the size of a base-ball; about the larger tumors the connective tissue is greatly proliferated and finally suppuration with abscess formation takes place. Symptoms, a. The digestive tract. The infection usually takes place through the mouth or decayed teeth, the jaw becomes swollen and the face so enlarged that the condition may be mistaken for sarcoma; sinuses discharging pus are often present. Rarely the tongue, pharynx, intestines or liver may be involved primarily or secondarily as a result of metastasis. Actinomycotic appendicitis has been observed and the fungi have been demonstrated in the stools. h. Pulmonary actinomycosis. Infection of the lungs by the ray fungus is not infrequent and occurs in three types. First, a form with lesions resem- bling those of chronic bronchitis, the sputum containing the fungi. Second, a miliary form in which tubercles occur resembhng those due to thebaciUus 128 THE INFECTIOUS DISEASES. of Koch but in which the actinomyces are demonstrable. Third, a destructive form characterized by interstitial lesions and abscesses which may form cavities. The pulmonary type of the disease may occur synchronously with involvement of the jaw or other parts. The cough is accompanied by a foetid, sputum, in which the actinomyces may be demonstrated, and fever, which is usually septic in character if suppuration has taken place. The course of the infection is protracted, the average duration being about lo months; recovery is rare. c. Actinomycosis of the skin is a chronic condition characterized by the development of cutaneous swellings which break down and result in ulcers in the discharge of which the fungi have been found. d. Cerebral actinomycosis is a very rare type of the disease. It is charac- terized by the formation of abscesses in the brain, the pus of which may con- tain the myceliimi. The diagnosis can be assured only upon demonstrating the fungi in the pus or other discharges from the lesions; unless this can be done the condition is likely to be confounded with pyemia, which, in actuality, it is. Actinomycosis of the jaw may be differentiated from sarcoma by its more protracted course, greater tendency to suppuration and the presence of actin- omyces. Treatment in general consists in the administration of potassium iodide in doses of from 30 to 75 grains (2.0 to 5.0) daily, gradually increased to 90 to 120 grains (6.0 to 8.0) and the maintenance of the patient's strength by nourishing food, arsenic and other tonics. In pulmonary actinomycosis in addition to the internal administration of potassium iodide, antiseptic inhalations should be employed as in foetid bronchitis (see p. 623) and the vapor of iodine is particularly effectual. The internal measures applicable in the foetid form of bronchitis are also useful and especially the preparations of eucalyptus. Actinomycosis of the intestine necessitates attempts at achieving intestinal antisepsis. If the tumor is so situated as to allow of excision this should be performed and the dead bone and infected tissues removed, the wound and sinuses drained and irrigated with a solution of iodine and potassium iodide or of iodoform and glycerin. Cauterization of the infected tissues with zinc chloride is also recommended. Intestinal actinomycosis with localized pus foci neces- sitates laparotomy and in the cerebral type if the symptoms suggest a localized abscess surgical interference is also indicated. EPIDEMIC STOMATITIS. Synonyms. Foot and Mouth Disease; Aphthous Fever; Aphthae Epizo- oticae. Definition. An acute infectious disease of animals most frequently seen MILK SICKNESS. 1 29 in cattle, sheep, and pigs, occurring rarely in dogs, cats and fowls, and char- acterized by the presence of vesicles and ulcers upon the buccal mucous membrane, in the clefts about the feet and upon the udders. It may occur in epidemics, when it spreads with great rapidity and may entail consider- able loss to the grazing interests. The infection is transmissible to man. JEtiology. The disease occurs in human beings as a result of drinking the milk or more rarely of eating cheese or butter from infected cattle, and through contact with the contents of the vesicles in the mouths or upon the teats of the diseased animal. Meat from such animals does not appear to be infective. No micro-organism has yet been demonstrated to be responsible for this disease and while it may be of microbic origin the specific cause is probably too small to be visible through the microscope since the contents of the vesicles retains its infective properties after passage through a porcelain filter which is impermeable to the most minute bacteria. Animals may be rendered immune by a vaccine elaborated by Loffler. Infants may be infected by milk from diseased cows and a connection has been suggested between the aphthous stomatitis of children and foot and mouth disease. Symptoms. After an incubation period of from three to five days the onset is marked by a rise in temperature, malaise, anorexia and digestive distur- bance which may be preceded by a chill or chiUy sensations. Vesicles con- taining a yellow serum appear upon Hps, tongue and pharynx; the mouth is hot, its lining is red and swollen and there may be interference with speech and deglutition; the saliva is increased. An eruption of vesicles which may become pustules appears upon the skin particularly of the fingers and toes, about the nipples in women and at times over other parts of the body. This rash may be mistaken for that of smallpox or for vaccinia if it occurs after vaccination. The vesicles within the mouth may go on to ulceration. The prognosis is good except in young infants. Treatment. Prevention consists in boiling all suspected milk and insis- tence upon cleanUness in the care of animals. The diseased mucous membrane should be kept clean by means of simple antiseptic mouth washes of potassium chlorate, boric acid or liquor antisepticus. The ulcers should be powdered with biunt alum or if this is inefficient, touched with stick silver nitrate. The cutaneous eruption necessitates the employ- ment of mild lotions of i to 5 or 10,000 mercury bichloride solution and of dressings of sterile gauze. In other regards the treatment is wholly symp- tomatic. MILK SICKNESS. Synonyms. The Trembles; The Slows. Definition. An acute infectious disease of man and the lower animals 9 130 THE INFECTIOUS DISEASES. formerly common in the Western states but at present seldom seen except in certain parts of North Carolina. In animals it is termed the trembles. .Etiology. The disease is most frequently observed in newly settled lands and seems to disappear as the ground is cultivated and the forests are cleared Its specific cause is not known but the infection is probably trans- mitted to man through the milk, cheese and butter as well as by the means of the flesh of diseased animals. The contagium may have its origin in the soil and a spiriJl.um has been found in the blood of sufferers, but this as yet has not been proven to be a distinct aetiologic factor. Pathology. No characteristic morbid changes have been described, few autopsies upon human beings having been performed. Symptoms. After an indefinite incubation period and prodromal symp- toms lasting a few days and consisting of increasing malaise, headache and loss of appetite, the onset of the disease occurs This is sudden and marked by nausea and vomiting, gastric pain, obstinate constipation, pronounced thirst and moderate rise of temperatiu-e. The mouth is dry, the tongue tremulous and swollen and the breath is foul and of a characteristic odor. The pulse is at first full and rapid, later the typhoid state may supervene, when it becomes small and weak, and pronounced cerebral symptoms, such as restlessness and irritability which may be followed by a hebetude deep- ening into stupor or coma, appear. Convulsions may be noted. The severer and more acute cases may terminate fatally within a few days, in other instances the disease may be protracted for three or four weeks. The diagnosis is usually made by exclusion and upon the fact that "the trembles" is prevalent among the cattle of the neighborhood. The prognosis is usually favorable although convalescence may be pro- longed for several weeks. Treatment. Prevention consists in the avoidance of aU possibly infected milk, meat or other foodstuffs. The treatment is wholly symptomatic and eliminative, it being necessary to provide for the removal of the poisons of the disease from the blood by seciu-ing free action of the bowels, kidneys and skin, to prescribe stimulation in the form of alcohol, strychnine, ammonia, etc., and sedatives as indications arise. The dietary should be supportive and arranged in accordance with that of other acute infections. GONORRHCEAL INFECTIONS. The consideration of infection of the male urethra and of the vagina with the gonococcus is without the scope of this work but this fact does not render less the importance of the disease. Gonorrhoea is without doubt one of the greatest scourges with which the human race has to contend and its effects reach far beyond the seat of the primar}' inflammation. The extent of the GONORRHCEAL INFECTIONS. I3I ravages of the infection are prominently brought to notice by the recent statement of an eminent gynaecologist that probably not less than 80 percent, of the married women of New York City are suffering from pelvic disorders of various characters, the result of infection from their husbands whose youth- ful or later indiscretions become thus responsible for ills that render a woman's life miserable and end in sterility or even more serious conditions. The time is past when a specific urethritis is to be looked upon as little more grave than a cold in the head and considered a part of the education of every young man. It has been demonstrated that the gonococcus remains active in the urethral discharge long after this ceases to be purulent in character and even after years, when the host of this insidious organism believes himself wholly cured, is capable of as much mischief as when the infection was in its early stages. GONORRHCEAL SEPTICEMIA AND PYiEMIA. These conditions do not differ, so far as symptoms are concerned, from analogous states resulting from other microbic infections, except that they are associated with genito-urinary inflammations. The gonococcus may be dem- onstrable in the blood and the course of the affection varies in severity. The irregular temperature may continue for a number of weeks and, unless the endocardium becomes involved, recovery may take place; on the other hand rapidly fatal cases occm* usually associated with localized pus collections in different parts of the genito-urinary system. The most important and frequent local manifestations of general gonor- rhoeal infection are gonococcal endocarditis and arthritis. a. Gonorrhoeal endocarditis is a serious condition and for its more complete discussion the reader is referred to the section upon malignant endocarditis (p. 556). Gonococci may be demonstrated in the blood and in the ulcerations or verrucous growths upon the valves. Other cardiac lesions such as pericarditis and myocarditis may be associated with the endocardial inflammation. b. Gonorrhoeal arthritis is a septic inflammation of a joint due to the gonococcus. It is not an uncommon sequence of gonorrhoeal infection and is serious in its effects. It usually occurs during the attack of a gonorrhoeal infection of the urethra or vagina but has been observed to follow gonorrhoeal conjunctivitis in children. It seems to be more common in men than in women and may not appear until late in the attack or even during the chronic stage of the infection. One or more joints may be attacked and the inflam- mation at times involves articulations seldom affected by acute articular rheumatism such as the intervertebral, temporo-maxillary, sterno-clavicular, etc. Pathology. The morbid changes present are by no means uniform. 132 THE INFECTIOUS DISEASES. The inflammation may involve the tissues without the joint and spread along the tendon sheaths or it may be intra-articular. In each case the synovial membranes are affected and pus may or may not be present. From the ex- udate the gonococcus may be grown and this organism is at times associated with the common bacteria of suppuration. Symptoms. A number of different clinical varieties of gonorrhoeal arthritis have been described but it will suffice to mention two principal types, the acute and chronic. a. Acute gonorrhoeal arthritis differs in severity in different cases. It may be evidenced only by slight pain and stiffness or in the more acute instances one or more joints may become suddenly involved in severe inflam- mation with pronounced pain, tenderness, redness and swelling. Intra-articular fluid may be demonstrable upon palpation. If the exudate is purulent con- stitutional symptoms are usually present. In the extra-articular form the inflammation is prone to extend along the sheaths of the tendons. The symptoms are persistent and ankylosis, more or less marked, may follow. In general gonorrhoeal infection suppurative arthritis and endocarditis may co-exist. h. Chronic gonorrheal arthritis. In this condition there may be a serous joint effusion or a chronic inflammatory process may involve the intra- and extra-articular structures; in the former condition there may be little or no pain but in the latter pain is usually present and associated with swelling extending to some distance above and below the joint. Gonorrhoeal arthritis is especially prone to affect the knees, wrists and ankles and relapses are frequent. Its course is often protracted and obstinate. Complications are not rare and may be serious. Iritis, pericarditis, myo- carditis, endocarditis, pleurisy and septic pneumonia have been observed. The diagnosis when there is present a iu:ethral discharge is simple, but in other instances must be based upon the presence of gonococci in the blood or in the articular effusion. In the acute form the pain is more severe and the tendency to periarticular involvement greater than in acute articular rheu- matism; the latter is said to be more likely to affect several joints in succes- sion while an arthritis of a single joint is to be considered as more prob- ably of gonorrhoeal origin. Treatment consists firit in the employment of local measures with the intent of curing the local genital inflammation if this is present. In general constitutional infection iodine is the most reliable agent and good results may be obtained by the administration of the syrup of hydriodic acid in doses of ^ an ounce (15.0) half an hour before meals in two ounces (60.0) of water. The mode and time of administration are important since the drug is some- what irritant to the stomach. If not well borne 10 percent, of resublimed I GONORRHCEAL INFECTIONS. I33 iodine in oil of sesame may be employed in doses of 10 to 20 minims (0.66 to 1.33) every three hours. Iodine so given is taken into the blood stream as is proven by the fact that the saliva gives the starch-iodine reaction within 20 minutes after the administration of a dose per rectum. The above treatment is also to be prescribed in gonorrhoeal arthritis and endocarditis in connection with inunctions of colloidal silver ointment (unguentum Crede), | an ounce (15.0) into each affected joint three times a day. Within 6 to 10 days after the commencement of such treatment a noticeable improvement in the arthritic symptoms should be apparent. Syrup of iron iodide in doses of 10 minims (0.66) to one drachm (4.0) three times a day has also been recommended and the internal administration of the preparations of mercury has its advocates. The salicylates seem to be wholly useless. Favorable results have been reported from the treatment of gonorrhoeal arthritis by means of Bifr's method of passive congestion. The technique of the treatment consists in the application of an Esmarch bandage just long enough to encircle the limb two or three times at the desired tension and provided with strap and buckle at either end. The bandage is applied just above the affected joint and is secured when the desired degree of congestion has been obtained. The skin may be protected by a few turns of an ordinary bandage, and to avoid stasis in parts where it is not needed that part of the limb which lies peripherally to the infected area may be snugly bandaged. The congested limb should not be allowed to become cold to the touch and the patient should not be made uncomfortable. The congestion should be continued for from 10 to 12 hours at a time and, while the strap is off, the limb should be elevated to reduce the oedema which the constriction has produced. Upon the subsidence of acute symptoms massage and passive motion should be instituted. In general the duration of the stasis should depend upon the effect obtained. If the pain is relieved in an hour or two and motion becomes less difficult, this length of time is sufficient, but if the symptoms soon return a longer application of the bandage is necessary. In the chronic effusion following acute inflammation this form of treatment is useless. With regard to local treatment other than that by the silver inunctions, absolute rest of the affected joints is to be insisted upon and it may be advisable to apply a splint. This, however, should not be allowed to remain in place long enough to cause ankylosis. The continued application of a 10 percent, ichthyol ointment in the intervals of the silver inunctions may assist in the reHef of pain. The more chronic forms of joint involvement may be relieved by counter- irritation by blisters or the thermo cautery, baking in the hot air apparatus is to be recommended and the absorption of the effusion may be facilitated 134 THE INFECTIOUS DISEASES. by massage and passive movements. These last also are an excellent means combating the tendency to ankylosis. Constitutional treatment by means of iron, arsenic, quinine and strych- nine is important, especially in the chronic cases. Surgical treatment, consisting of opening the joint, evacuating the effusion and irrigating with mild antiseptics or sterile saline solution, has its advocates and in many instances has achieved excellent results. r SYPHILIS. Syyionynis. The Pox; Lues Venerea. Definition. A specific constitutional disease of slow course resulting from inoculation or from hereditary transmission. The disease when inocu- lated is known as acquired syphilis and when conferred by inheritance as hereditary s}'philis. In the acquired form there appears at the site of inocula- tion the so-called initial lesion or chancre which is usually an ulcer possessing special characteristics. This is followed within a month or two by consti- tutional manifestations and lesions of the skin and mucous membranes, the symptoms of the secondary stage, and after months or years by gummatous growths in the various tissues and organs, the tertiary lesions, and finally there may appear various morbid conditions in the nen'ous system such as locomotor ataxia and general paresis, which are known as quaternary lesions. .etiology. AATiile several micro-organisms have been described, which have been thought responsible for this disease, their connection with the infec- tion has not yet been definitely proven. Recently Schaudinn and Hoffmann have drawn attention to micro-organisms of the genus spirochaeta, which they have found in primary and secondary S}-philitic lesions, both at their surfaces and in their deeper parts and in the adjacent lymphatic glands. The former observer considers that the spirochsetae are related rather to the protozoa than to the bacteria and must, therefore, be clearly distinguished from the spirilla. He describes two varieties, one found only in S}^hilitic lesions, the other, saprophytic in nature and constantly met in stagnant secretions such as those occurring about the genitals. The former is termed the spirochcBta pallida, the other the spirochceta rejringens. The former is much the smaller and is seen only wnth the higher powers of the microscope and even then, with difficulty. Metchnikoff and Roux have found identical forms in experimental syphilitic lesions in monkeys and other observers have wholly confirmed the work of Schaudinn and Hoffmann. The spirochaeta pallida has been found in the blood and organs of infants suffering from congenital syphilis and in acquired syphilis in the blood procured by splenic puncture on the day before the roseolar rash appeared, proving that it reaches the skin through the blood- SYPHILIS. 135 vessels. Later it has been demonstrated in the circulating blood. In acquired syphilis it is found only during the primary and secondary stages, practically never during the tertiar}^ Most authorities agree that the spirochseta is never to be found in non-s\^hilitic lesions, one or two have, however, encountered it in other conditions. The balance of evidence seems to favor the aetiologic relation of the spirocheta pallida to syphihs and the most conservative admit that it probably plays some part in the causation of the disease. Syphilis is an extremely contagious disease but a solution of the continuity of skin or mucous membrane is necessary' to its inoculation. The secretions of the primary- and secondary lesions as well as the blood of the syphilitic patient are capable of transmitting the infection but the authorities differ as to whether the products of the tertiary manifestations, the gummata, are infectious. It is probable, however, that they are. Normal secretions, such as milk, tears, etc., unless contaminated by the secretions of specific lesions are not capable of conferring the disease. The spermatozoa or ova of syphihtic individuals are, however, infectious. In most instances the acquired form of the disease resuhs from sexual congress but the infection may be acquired innocently through the use of infected drinking cups or other utensils, by kissing, by the physician during operation or while handling infected patients, and in various other ways. The wet nurse may be infected by the s^-phihtic child, the initial lesion appear- ing upon or near the nipple and the disease has been transmitted by vaccina- tion with humanized virus. Hereditary specific disease is most commonly transmitted through the father in which case it is termed sperm infection. A syphilitic father may beget diseased oft'spring during the tertiary stage when all symptoms seem to have disappeared but he is most likely to beget a s}^hihtic child soon after the beginning of his infection; on the other hand the child of a syphilitic father may show no evidence of the disease when begotten diiring the tertiary stage or even when begotten while the disease is at its height. No certain assertion can be made that a father once infected with syphihs will not transmit the disease to his children but it may be stated that the greater the period since the occurrence of the initial lesion, the less likely are the children to be afiected. At least three years, during which the individual should undergo proper treatment, should elapse between the initial lesion and marriage. S>3)hilis transmitted through the mother is termed germ infection and is more likely to prove fatal than sperm infection. A child may also be infected during its passage through the parturient canal or, the mother acquiring the disease during pregnancy, the child may escape or may become infected through the placenta. It is a curious fact (Colles' law) that a s)Tphilitic infant bom of a non-syphihtic mother cannot transmit the disease to her, even though she nurse it while there exist syphilitic lesions upon its lips or withm 136 THE INFECTIOUS DISEASES. its mouth. This is probably due to an immunity possessed by the mother and which has been conferred without the manifestations of any symptoms whatever. Children born of parents who are both s}^hilitic are ver}^ unlikely to escape the disease. Pathology of acquired syphilis. The lesions of this form of the infection occur in stages the first being that of the primary lesion or chancre. This appears at the site of the inoculation and usually about three weeks after this occurrence. At first it consists of an abrasion upon which a papule or vesicle appears; later this disintegrates at its center and an ulcer results, the base and edge of which are firm and indurated. It varies in size and may be unnoticed if it occurs within the urethra and is especially likely to be over- looked in the female. In the male it is usually upon the penis and frequently upon the prepuce, while in females a frequent site is upon the labia or upon the cervix. Microscopically the indurated tissue is found o be the lesult of an infiltration of the connective tissue with small round cells, some of which may later become epithelioid or even giant cells. The intima of the vessels is thickened and the nerve fibres may be the seat of pathological change. The neighboring lymph ganglia are enlarged, hardened and may sup- purate. The lesions of the secondary stage consist of a cutaneous eruption or syphil- ide. This rash occurs in a variety of difi'erent forms, macular, papular, pustular, squamous and tubercular; the hue of these is characteristic and may be described as ham or copper color. The macular s^philide usually lasts one or two weeks and is especially apparent upon the chest, abdomen and flexor surfaces of the arms; the papular eruption occurs upon the face as well as upon the body and like the others tends toward a symmetrical distri- bution. The pustular rash is not unhke that of variola and the squamous syphilide possesses nothing t}^ical except its color; it is a rare form and its favorite situation is upon the extensor surfaces of the limbs. AU forms of the eruption are characterized by a tendency to symmetrical distribution and to leave behind a more or less permanent discoloration. With the cutaneous manifestations an involvement of the mucous membranes and of moist skin surfaces occurs; this is termed the mucous patch or broad condyloma [condyloma latum). These appear upon the buccal and pharjmgeal mucous membranes and at the muco-cutaneous junctions about the lips, anus, etc., and consist of a cellular infiltration of the epidermis and corium. The mucous patch is a flat or slightly convex pearl colored elevation, with a surface resembling mucous membrane, the secretion of which is highly contagious. The condylomata are exaggerated mucous patches and consist of rounded discs, reddish or grayish in color, granular of surface and slightly elevated. The secretion of these is also pronouncedly infectious. The SYPHILIS. 137 venereal wart* or condyloma acuminatum is also a manifestation of the second- ary stage. The lesions of the third stage may involve any of the deeper tissues or organs and consist of discrete tumors (gummata). These are usually firm in consistency and vary in size from that of a pin point to a diameter of from one to iv70 inches (3 to 5 cm.). On section they are seen to consist of a central area firm and caseous, surrounded by a layer of fibrous tissue outside which is an external layer of cellular granulation tissue. Such gummata are common in the skin, muscles, periosteum, bone — ^where they are termed nodes — and in the connective tissue of the brain and viscera. When situated in submucous tissues ulceration or suppuration may result with destruction of tissue such as is observed in syphilitic disease of the nasal or palatal bones. Arterial changes also occur as a result of tertiary syphilis. These will be considered in the section devoted to arterial disease (p. 593). Symptoms of acquired syphilis. These occur in stages and are intimately associated with the morbid changes above described. The incubation period of the disease is usually about three weeks, that is to say about this time intervenes between the inoculation and the appearance of the primary lesion or chancre. This and the associated glandular enlargements have been considered. The symptoms of the secondary stage usually appear in from 6 to 12 weeks. First there is a pharyng' al congestion with soreness of the throat. Sluggish ulcerations of a gray color are seen upon the mucous membranes of the throat and larynx, those in the latter situation being likely to cause deformity of the part upon healing. Mucous patches and condylomata may be present. There is usually a moderate febrile movement which seldom rises higher than 101° F. (38.3° C.) although temperatures of 104° to 105° F. (40° to 4o.5°C.) have been observed. The temperature is usually continuous or remittent; less frequently it is intermittent and may be mistaken for malaria. The pharyngeal inflammation may involve the middle ear by extension through the Eustachian tube. Cutaneous lesions now appear; the most frequent is the macular syphilide previously mentioned. The rash lasts for two or three weeks and may be followed by other forms of the syphilitic eruption. Recurrences of the rash may occur at intervals even as late as 11 years after the initial lesion. The hair often falls and there may be a syphilitic onychia. Iritis is common and may be serious. Choroiditis and retinitis are more rarely observed. Joint symptoms, at times so marked as to suggest acute articular rheuma- tism, and pains in the limbs are not unusual. Jaundice, nephritis, parotitis and epididymitis may occur. Anaemia is very common. The tertiary stage cannot be distinctly separated from the secondary. 138 THE INFECTIOUS DISEASES. During this stage the characteristic manifestations are various cutaneous eruptions, amyloid degenerations and involvement of the viscera by gummy tumors. The tertiary syphilides are usually deep seated, tend to ulcerate and may subsequently heal, leaving scars. They may be scattered over the body and are seldom symmetrical. Syphilitic rupia consists of pustules, ulcerated at the base and covered by a laminated crust. Hereditary sjrphilis may be evidenced by all the morbid changes and symptoms which are met in the acquired form of the disease except the pri- mary lesion. Still-births and abortions are very frequent consequences of foetal syphilis but the appearance of the newly-born syphilitic child is often that of health, the syphilitic manifestations appearing after a month or two; at other times the subject of syphilitic inheritance is poorly developed^ ill-nourished and shriveled in aspect; skin eruptions are frequent and the so-called pemphigus neonatorum, a bullous rash about the wrists and ankles,. hands and feet, is typical. The liver and spleen are enlarged, the lips are wrinkled, fissured and ulcerated and the child snuffles; the discharges are infective and may be sero-purulent or sero-sanguinolent; bone necrosis at the bridge of the nose may lead to the characteristic deformity. Middle-ear involvement may take place through the Eustachian tube. If the child is apparently healthy at birth the above described symptoms may appear up to the sixth month. The cartilages of the ribs and those of the epiphyses of the long bones are very commonly affected and even epiphyseal separation may take place. The child nurses poorly, is restless and a typical cry described as harsh and high-pitched has been observed. Haemorrhages into the skin, from the mucous membranes or from the umbilicus (syphilis hcsmorrhagica neonatorum) are a rather rare manifestation. If the child survives its growth is stunted and it is likely to present the appearance of premature age. Under proper treatment recovery may take place and while development may be delayed the disease may not give further symptoms. As a rule, however, further syphilitic manifestations appear at the time of second dentition or at puberty. The subject of hereditary syphilis who survives childhood is under-developed and looks younger than his age (infantilism), the frontal region is prominent, the frontal bosses protrude, the bridge of the nose is depressed (saddle-nose) and its tip turned up. Cran- ial asymmetry may be present and the teeth are notched (Hutchinson teeth). Those particularly affected are the upper central incisors which are peg- shaped and notched at the edges, the enamel often being wanting over the notches. Amongst other manifestations which are late in appearance are bone deformities, especially of the tibiae which are thickened and curved antero- SYPHILIS. 139 posteriorly, the convexity being forward; nodes may be present upon the bones; interstitial keratitis, iritis, syphilitic deafness and gummata of the nervous system or of the viscera may be observed. The diagnosis of syphilis is not difficult in the presence of a history of exposure or of heredity. There may be difficulty in deciding upon the char- acter of the initial sore, consequently it is well to wait until the appearance of secondary lesions before beginning treatment. The test of treatment by mercury and iodine will usually clear the diagnosis in doubtful cases. Justus' test consists in first estimating the haemoglobin content of the blood, then ordering a mercurial inunction or injection and subsequently making a second haemoglobin estimation. In cases of syphiHs there will be a reduction of from 10 to 20 percent. This test is based upon the fact that mercury causes a destruction of the haemoglobin which is rapidly replaced under normal conditions. In the syphilitic subject, however, this power of repro- duction is greatly diminished. The prognosis in acquired syphiUs under early and proper treatment is good but the length of time necessary to assure a cure is at least two years; consequently syphilitics should be strongly advised against marriage within two years after the appearance of the initial lesion; if active symptoms remain at the end of this period marriage should be forbidden as long as these per- sist. Even in individuals who have undergone thorough treatment it is not unusual to observe late compHcations referable to the nervous system. The prognosis of infantile syphilis is not so good as that of the infection in adults and hereditary infantile syphilis is much more grave than that acquired after birth. Even the subjects of hereditary syphihs who survive are ren- dered so weak of constitution by the disease that they fall an easy prey to even slight intercurrent affections. Treatment. The prophylaxis of syphilis acquired through illicit inter- course can only be instituted by insisting upon the absolute importance of sexual purity. The physician who advises the performance of the sexual act under illegitimate conditions cannot be too strongly condemned. The young man who finds his fleshly lusts too vigorous to be denied may do much to subjugate them by working hard physically and mentally. Practitioners associating with syphilitics in a professional capacity cannot be too guarded in their handling of specific lesions. Much may be done toward the prevention of hereditary syphilis by treating the mother during pregnancy if she has ever been affected with the disease or if the father is syphilitic. Syphilitic lesions of the genital tract should be cleansed and cauterized previous to labor. Should the child be born healthy it should never be nursed by a suspected mother or wet nurse, it should not be kissed by nor sleep with diseased parents and the greatest care should be exercised in rendering utensils and other objects with which the child comes I40 THE INFECTIOUS DISEASES. into contact above reproach. No syphilitic child shoiild be allowed to nurse from a healthy woman. The treatment of the primary lesion consists in the endeavor to heal it as soon as possible. This is to be accomplished by simple cleanliness. The sore sjioiild be washed with a i to 2 or 3000 mercury bichloride solution several times daily and kept dusted with equal parts of bismuth and calomel, iodoform — ^which should be used with care since an idiosyncrasy to this drug is not rare — or other bland antiseptic powder. A dressing of mercurial ointment may also hasten the healing process. Cauterization or excision of the lesion is useless. The secondary lesions should also be treated by the application of cleansing agents. The teeth should be frequently brushed and a mouth wash of ^ saturated solution of potassiufn chlorate, which not only has a beneficial effect upon the mucous patches but is prophylactic against mercurial stomatitis, should be frequently employed. The use of tobacco and alcohol shoiild be forbidden. Ulcers should be cleansed with the mercury bichloride solution, dressed with mercurial ointment or dusted with calomel and if necessary touched with silver nitrate stick or solution; the latter may also be employed upon the mucous patches in the mouth. Condylomata should be kept thor- oughly cleansed and either dusted with the powders mentioned above or dressed with mercurial ointment. Constitutional treatment should be instituted as soon as the diagnosis is assured and consists in the administration of merciury during the secondary stage and of iodine during the tertiary. The two may often, however, be given together with advantage during the second stage. Mercury may be administered in various ways; of these one of the best and one of the most commonly employed is by inunctions. Its disadvantages are that it takes considerable care and time and is not cleanly. The plan is as follows : The patient should take a warm bath daily to cleanse the skin and render it more capable of absorption. After the bath a drachm (4.0) of the ofiicial mercury ointment is thoroughly rubbed into the skin, the friction to be continued until the ointment has entirely disappeared. It is well to choose a different site for the inunction each day, first taking the inside of one thigh, next that of the other, the inner aspect of the arms, then the sides of the chest, etc. When these parts have been exhausted the list should be begun again. The rubbing should last at least ^ hour. Hairy parts should be avoided since the follicles offer favorable foci for the beginning of a mercurial eczema and the use of a potassium chlorate mouth wash is necessary to prevent, if possible, stomatitis. Should this occur, as evidenced by soreness of the gums and teeth, foul breath, etc., the inunctions should be stopped for a week or more until the buccal symptoms disappear. The frictions should be continued for about a month, when if the syphihtic symptoms have subsided they may be SYPHILIS. 141 omitted and internal treatment begun. Here mercury may be given in various forms, the preparations most usually employed being the yellow iodide (protiodide) gr. -| (0.016), the red iodide (biniodide) gr. J (0.004) or the bichloride gr. yV (0.005) three times a day. If the patient can be made to understand how essential continued treatment is the tertiary mani- festations may be prevented from making their appearance. To accomplish this desirable object, however, the treatment must be continued for an indefi- nite period. Various substitutes for the inunction method of treatment have been advo- cated and the one most in use at present is that by hypodermatic injection of various mercury salts. The injections are given by means of a long needle attached to the ordinary h3^odermic syringe, the solution is thrown into the deeper muscular structures and the procedure must be carried out under he most thorough aseptic and antiseptic precautions. The sites usually selected are the buttock, the sides of the thorax or the flanks. Such solutions as the following may be employed: Mercury bichloride 0.2 parts, sodium chloride 2 parts, distilled water to 20 parts. Of this a daily injection of 15 minims (i.o) may be given. Mercury benzoate 0.25 parts, sodium chloride and cocaine hydrochloride of each 0.06 parts, distilled water to 30 parts; peptone and ammonium chloride of each 0.3 parts, mercury bichloride 0.2 parts, glycerin 5 parts, distilled water 15 parts; neutral mercury lactate I part, distilled water 100 parts; mercury cyanide o.i part, distilled water 20 parts; mercury salicylate 4 parts, benzoinol 30 parts; of all the above the dosage is 15 minims (i.o) which may be injected daily. In very grave cases the dosage may be doubled or 15 minims (1.0) of a i percent, mercury cyanide solution may be introduced slowly, directly into a vein ; a mixture of calomel i| parts and sterile oil 15 parts may be given subcutaneously in doses of 15 minims (1.0) about once a week. The treatment by injections is especially indicated when it is necessary to mercurialize the patient without delay, in cases where the skin is badly affected by inunctions and the internal adminis- tration of mercury disturbs the digestion and in instances where the disease resists other methods. Mercurial fumigations have had a certain vogue. The patient, sitting on a chair, is surrounded to the neck by blankets arranged in the form of a tent. An alcohol lamp is placed under the chair and upon this is set a metal plate containing about ^ drachm (2.0) of powdered calomel. The seance should last about 20 minutes during which the calomel is volatilized by the heat of the lamp and it, with the steam from a vessel of water also placed over the lamp, is absorbed by the patient's skin. This treatment affects favorably both the constitutional symptoms and the cutaneous eruption. Calomel vapor when inhaled, the mouth being held about 20 inches from the containing vessel, often exerts a favorable influence upon the mucous patches. After 142 THE INFECTIOUS DISEASES. the inhalation the mouth should be thoroughly washed to prevent salivation. Hutchinson prefers to give mercury with chalk (hydrargyrum cum creta) in pill form, each pill containing i grain (0.065) ^^^h of this preparation and Dover's powder; one pill to be taken from 4 to 6 times a day. Most excellent results are said to be obtainable from this form of treatment. While undergoing mercurial treatment the patient should be forbidden to eat fruit and green vegetables. Instances are often met in which greater benefit is achieved by the alternate administration of mercury and iodine or by giving these drugs in combination, the so-called "mixed treatment." Those in which this form of treatment is particularly indicated are the cases with dry tubercular syphilides, cases with the syphilitic rupia, those with choroiditis, onychia, periostitis and cerebral syphilis. The following formula will be found useful: I^. Hydrar- gyri iodidi rubri, gr. iii (0.2); potassii iodidi, 5" ss (lo.o); syrupi simplicis, q. s. ad, 5iv (120.0). Misce et signa, one teaspoonful two or three times daily. The potassium iodide in this formula may be increased as indicated. Another useful prescription is composed of merciury bichloride two grains (0.13), potassium iodide three to five drachms (12.0 to 20.0) and distilled water and compound syrup of sarsaparilla equal parts up to four ounces (120.0). Here the combination of potassium iodide with mercm"y bichloride results in the production of a certain amount of red mercuric iodide which is dis- solved in the excess of potassium iodide. The mixed form of treatment has been considered especially effective in the intermediate period of the disease when the secondary stage is passing into the tertiary. It is also indicated in instances of sj^hilitic hepatitis and in the presence of the ascites of this con- dition the so-called Guy's diuretic pill which is composed of i grain (0.065) each of powdered digitalis, squill and calomel may be prescribed with benefit. In the third stage of syphilis iodine, administered in the form of the iodides and particularly potassium iodide, produces results which cannot be accom- plished by any other means, the rapid absorption of nodes, gummata and other deposits quite frequently being brought about. In order to seciu"e the best effect it is necessary to give very large doses in many instances, two to four drachms (8.0 to 16.0) being not an unusually large daily dosage. In syphilis of the nervous system especially large doses are called for and daily amounts of i ounce (30.0) are not infrequently required. The drug may be administered in saturated aqueous solution, in milk or in the compound S}Tup of sarsaparilla beginning with 10 drops (0.66) three times a day and increasing the doses i drop (0.065) daily until the disease Id con- trolled. Should the symptoms of iodism appear — nasal discharge, an erythem- atous eruption, increased secretion of saliva and swelling of the salivary glands causing a sense of tightness in the throat — the drug should be stopped or the dose diminished until these disappear. It has been advised to enlarge SYPHILIS. 143 the beginning dose to 30 to 40 minims (2.0 to 2.66), since when given in this way the drug has seemed less Hkely to cause toxic symptoms. Another most excellent method of giving iodine is in the form of the syrup of hydriodic acid. The dosage of this preparation is from i to 4 drachms (4.0 to 16.0) three times a day J hour before meals and diluted with a wine glass of water. Iodine itself may be administered in capsules each containing from 10 to 20 drops (0.66 to 1.33) of a 10 percent, solution of resuhlimed iodine in oil of sesamum. Strontium and sodium iodide have been suggested as substi- tutes for the potassium salt since they, especially the former, are pleasanter to take, are less likely to disturb the stomach and to cause toxic symptoms. It is said that the iodide should be suspended during menstruation if there is any tendency to menorrhagia. During a course of antisyphilitic treatment the patient should be advised to regulate his mode of life in accordance with strict hygienic principles; fresh air, moderate exercise and nutritious diet are essentials. The elimina- tory functions should be kept properly active and co-existent disease, especially tuberculosis or anaemia, should receive appropriate tonic treatment. The treatment of syphilis at mineral — especially sulphur — springs has no advantage over a thoroughly carried out home treatment. At such places it is perhaps easier for the patient to lead a regular and healthful life and the frequent employment of baths may render the skin more receptive to inunc- tions of mercury. The treatment of hereditary syphiHs should be instituted as soon as the symptoms of the disease appear or even sooner if the parents give distinct evidence of the disease. Mercury and potassium iodide are as potent here as in adults and may be administered in the same way. Usually the inunction method is preferable. The technique of the treatment has been already described and about 20 grains (1.33) of a mixture of equal parts of mercurial ointment and lanoline or vaseline are employed at each friction. For a child of two years 30 grains (2.0) may be used and at three years of age the dose may be increased to 40 grains (2.66). The inunctions should be continued for three weeks, suspended for a week or ten days and then repeated. The internal administration of mercury should then be begun. Either mercury with chalk i grain (0.065) or mercury bichloride -gV of a grain (0.00 1) four times a day may be given unless it is desirable to mercurialize the patient as quickly as possible when -yo oi o. grain (0.006) of calomel should be given three or four times daily. The mercurial treatment should be continued for a year with occasional intermissions of a week or two at the least, at the end of which period, mixed treatment may be prescribed. Here we may give a mixture consisting of -^V part of mercury biniodide, 5 parts of potassium iodide, simple syrup 250 parts; this maybe given in milk in the following doses. To a child of from i to 3 years, 15 to 30 minims (i.o to 2.0); 3 to 5 years, i 144 THE INFECTIOUS DISEASES. drachm (4.0); 6 to 10 years, 2 drachms (8.0). The treatment by hypo- dermatic injections may be employed in instances of digestive disturbance and where the mercurial frictions irritate the skin. In tertiary infantile syphilis with gummata, visceral, osseous and other lesions potassium iodide should be prescribed in sufficient dose to meet the indica- tion. ' In general it may be said that the daily dosage for a child of from i to 15 months is from f to 3 grains (0.048 to 0.2), from 15 months to 3 years 3 to 6 grains (0.2 to 0.4), from 3 to 5 years, 7^ to 15 grains (0.5 to i.o) and from 5 to 10 years, 15 to 45 grains (i.o to 3.0). The drug should be given well diluted with milk and if it is not well borne the substitutes suggested on p. 143 may be employed. Antisyphilitic treatment should be continued as long as luetic manifesta- tions are present. The local treatment of infantile syphilis is identical with that of the disease in adults and it is often of great advantage, particularly if the child's nutrition is poor and anaemia is present, to either intermit the specific treatment for a time or to diminish the dosage, in the meantime giving various tonics partic- ularly iron, codliver oil and the bitters. Attempts have been made to elaborate a serum for the treatment of syphilis but up to the present time little or no success has attended these efforts. TUBERCULOSIS. Definition. Tuberculosis is an infectious disease characterized by genera or local inflammatory processes resulting from the presence and growth within the organism of the tubercle bacillus. The typical lesions consist of nodules or diffuse tissue infiltrations which gradually become caseous, sclerosed, ulcerated or more rarely undergo calcification. .etiology. While tuberculosis was considered a disease of infectious character previous to Koch's demonstration of the bacillus tuberculosis in 1882, it remained for this observer to prove beyond question its specific origin. Koch's bacillus is a long, narrow, straight or shghtly curved bacillus, staining at times irregularly so as to present a beaded appearance. It is found in tuberculous lesions and discharges and in the dust of apartments occupied by affected patients as a result of the drying of unproperly cared for sputum. It is also found in the meat and milk of diseased animals, those most frequently harboring the infection being the bovines; it is rare in sheep and horses but pigs in certain districts are prone to suffer. Tuberculosis is very likely to attack apes in captivity but is unknown amongst them in the wild state. The bacillus effects entrance into the body in most instances upon the inspired air which may be contaminated by dried sputum or may contain the moist particles which are emitted by tuberculous individuals in coughing. TUBERCULOSIS. I45 sneezing and even during conversation. These fine bits of spray have been proven to contain the baciUi. These facts account for the frequency with which those closely associated with subjects of the disease, such as nurses, members of the family, etc., contract the disease, although there is no doubt that by careful attention to cleanliness and proper hygiene this danger can be almost wholly averted. The contagium may also be taken into the alimentary tract with the food, cases having been traced to the milk, meat and even the butter from infected animals. Food may become contaminated by proximity to tuberculous cooks, bakers, etc., and the milk from a diseased mother may infect her infant, accounting for the occurrence of tuberculosis of the digestive tract in children. Contact with the excreta of the tuberculous, with the meat of diseased animals, with the lesions of bodies dead from the infection, etc., may cause tuberculosis by inoculation. To the acquirement of the disease in this way the contact of the infective matter with an abrasion of the skin or mucous membrane is necessary. With regard to the hereditary transmission of tuberculosis it may be said that the disease has been noted in rare instances in the foetus and that infants have been born with tuberculous lesions; this circumstance also has been seldom observed. It is a fact that the children of tuberculous parents are more prone to the acquirement of the disease and possess poorer powers of resis- tance than do those of more healthy heredity. Other predisposing causes are: a. Race. The disease is met in all races, the negro and the American Indian living under civilized conditions being especially prone to the affection. Hebrews seem to a certain degree exempt, perhaps owing to the peculiar supervision exercised over the meat consumed by them. h. Age. Tuberculosis may occur at any time of life but certain types of the infection seem more common at certain ages than at others, thus pulmonary tuberculosis is most frequent between 20 and 35 while children are particularly prone to the glandular, meningeal and mesenteric forms. c. Sex. Females appear to be shghtly more susceptible than males, per- haps because their duties confine them to the house more than do those of the opposite sex. The progress of the disease becomes more rapid during pregnancy and lactation. d. Climate. Regions which are subject to dampness and sudden changes of temperature are most favorable to the development of tuberculosis, possibly because under such conditions catarrhal affections are common, these dimin- ishing the resisting power of the body and offering an acceptable nidus for lodgment of the contagium. The disease, however, does occur in all climates. e. Sanitation. Unhealthful surroundings, overcrowding, lack of fresh air, 146 THE INFECTIOUS DISEASES. and of proper food, and unhygienic occupations such as those which entail the respiration of dust-laden atmosphere are distinct predisposing factors. Further, any acute or chronic disease, particularly catarrhal affections of the respiratory tract, influences which bring about a diminished pulmonary blood supply, congenital or acquired narrowing of the pulmonary artery and other circiilatory diseases predispose to the occmrrence of tuberculous affections. Traumatisms of the thorax, although there may be no injury to the lung itself, also may be followed by pulmonary tuberculosis. Pathology. The characteristic morbid change is the occurrence in various tissues and organs of miliary tubercules. The most frequent sites for their development are the lungs, liver and spleen, they are also found in the meninges, the bone-marrow, the peritonaeum, the heart muscle and the choroid. The tubercles vary from microscopic size to that of a pea and histo- logically are made up of a number (from 10 to 50) of smaller tubercles. The fact that many of them resemble in size and form a millet seed has led to the term miliary. The tubercle is formed as follows: Bacilli having lodged in a certain tissue they act as an irritant, as a result of which there is an emigration of leucocytes from the neighboring blood-vessels; these, with the epithelioid and giant cells which are produced by proliferation from the cells of the adja- cent structures and with a supporting frame-work of connective tissue, which is most abundant near the periphery make up the miliary nodule. The bacilli occur within the substance of the epithelioid cells and the giant cells and the fact has been noted that where the latter are most plentiful the bacilli are fewest; accordingly in lupus, tuberculous joint lesions and adenitis the giant cells are many and the bacilli few, while in pulmonary lesions the opposite condition obtains. The tubercle also occurs in solitary form; here it is not composed of an aggregation of small miliary bodies but is a single cheesy mass of size varying from that of a pea to that of the fist. It consists principally of round cells in which the bacilli are found; these are supported by a fibrous reticulum and the latter may exist in such amount as to render the entire nodule fibrous in consistency. These single tubercles are found in different situations such as the spinal cord, the liver, the heart, the spleen and especially in the brain in children and are subject to caseous, suppurative and calcareous degen- eration. The Degenerations of Tubercle. Of these the most common is caseation. This begins at the center of the tubercle and is a process of coagulation necrosis of its cells; these gradually lose their outline, their nuclei become indistinct and are no longer demonstrable by staining and finally a structureless granu- lar mass results. The bacilli persist and the cheesy substance resulting may undergo softening, calcification or may become encapsulated by a fibrous wall. The first of these processes is the most frequent and the caseous mass TUBERCULOSIS. I47 degenerates into a piiriform substance which is not pus, strictly speaking, but which consists of fat droplets, granular matter, and disintegrated cells and contains tubercle bacilli in abundance. Calcification is less common; here a form of healing takes place by infil- tration of the tubercle with calcium salts. Tuberculous deposits in the lymph glands are particularly likely to undergo this change and exceptionally it may occur in the lungs. The sclerotic change in which the tubercle is converted into fibrous tissue consists of a metamorphosis, which, as the disintegration at the center of the nodule takes place, is characterized by hyaline degeneration and increase of fibroid tissue, a firm hard mass resulting; this is a healing process and depends upon the body's power of resistance to the growth and development of the bacilli. It is frequently observed in peritonaeal tuberculosis and at times in the lungs. Secondary inflammatory processes are changes, set up, not in the tubercle itself, but in adjacent tissues by the development of this structure; for instance an overgrowth of connective tissue may result causing a fibroid phthisis or a catarrhal pneumonia. Suppuration is a frequent associate of tuber- culous pulmonary inflammation but is the result of a mixed infection with pyogenic bacteria. Whether the tubercle bacillus is capable alone of produc- ing pus is a moot question. Certainly the fluid contents of a cold abscess is not true pus and does not contain the bacteria of suppmration. On the other hand in tuberculous inflammations of bones and joints pus is often observed; this, however, may be the result of mixed infection just as is the purulent sputum of pulmonary tuberculosis. Acute Miliary Tuberculosis. Synonym. Diffuse General Tuberculosis. Definition. An acute disease characterized by the presence of numbers of tubercle bacilli in the blood which find lodgment in various parts of the body and there cause the development of miliary tubercles. The disease is, as a rule, secondary to the softening of a tuberculous nodule, usually in the lungs or a lymph gland, and is the result of the dissemination of the bacilli by means of the blood or lymph circulation. The rupture of the nodule may be directly into a blood-vessel, an example of a veritable embolic process. This form of tuberculosis is most common in adolescents and young adults. Pathology. In considering acute miliary tuberculosis from its pathologic aspect it is not to be forgotten that it is the result of an old tuberculous lesion. The tubercles which are disseminated through the various tissues in this form of tuberculosis have already been described (p. 146). Acute tuberculosis occurs in three principal types: i. With symptoms 148 THE INFECTIOUS DISEASES. pointing to general infection, 2, General infection with pronounced pulmo- nary symptoms. 3. General infection with marked symptoms referable to the central nervous system. I. Acute General Miliary Tuberculosis. Symptoms. These are those of a severe general infection without marked local manifestations and there is great possibility of mistaking the disease for enteric fever. Prodromata, consisting of indefinite malaise, loss of ap- petite, etc., are common but an abrupt onset with fever may occur; afebrile instances of the disease have occasionally been observed. The pulse is rapid, the tongue dry and cerebral symptoms analogous to those of enteric fever are common. The temperature is usually lower in the morning (101° F. — 38.3° C.) and higher at night (103° to 105° F. — 39.4° to 40.5° C), although an occasional reversal of this type of temperature may occiu"; this is considered an important point in the differentiation of the disease as is also the fact that the temperature curve taken as a whole is more irregular than that of enteric fever and does not present the progressive rise of that affection. Bronchitis may be present but may not be more pronounced than that occurring in typhoid infection. Profuse sweating is common and herpes may be observed; splenic enlargement may be noted and spots resembling those of typhoid fever have been described. The latter, however, do not appear in successive crops. Early in the disease there are seldom physical signs referable to the lungs other than those of a slight bronchitis, later the respiration may be accelerated and sHght cyanosis may occur. As the disease progresses pulmonary and meningeal manifestations may appear. There may also be signs and symp- toms of pleuritic, pericardial or peritonaeal involvement. Tuberculosis of the choroid may also be noted. The diagnosis is often difl&cult, the disease being especially likely to be confounded with enteric fever from which it may be differentiated by its temperature ciirve, its duration, which is more protracted, the splenic enlarge- ment which appears later and is less pronounced and by the lack of rose- spots. Cyanosis and accelerated respiration are more frequent in tuber- culosis. In both diseases the leucocytes are not increased in number, but upon the incidence of mixed infection which sooner or later may manifest itself in tuberculous infection a leucocytosis appears. The examination of the sputum rarely reveals the presence of tubercle bacilli unless the pulmonary nodules disintegrate through the bronchial mucous membrane; they are however to be found in the blood, especially that withdrawn from the spleen. When not directly demonstrable, culture and inoculation experiments may reveai their presence. TUBERCULOSIS. I49 The absence of the Widal reaction is a valuable point in differentiation. The urine may contain albumin usually not as a result of tuberculous kidney involvement but of the febrile process. Unfortunately the Ehrlich diazo-reaction is often present in acute tuberculosis as well as in enteric fever. The cerebrospinal fluid, withdrawn by lumbar puncture may contain tubercle bacilli even though meningeal inflammation is not a feature of the case in hand. The prognosis of this as well as of other forms of acute tuberculosis is dis- tinctly unfavorable, a fatal outcome being almost inevitable. The course of the infection is usually froni four to eight weeks or more although more rapidly fatal cases have been observed. Treatment is wholly symptomatic and consists in the administration of proper noiurishing food in sufficient quantity, of stimulants as indicated, of antipyretics such as antipyrine or acetphenetidine — five grains (0.33) repeated as necessary — of sedatives such as the bromides to quiet the nervous symp- toms and of such drugs as heroine or codeine to allay the cough. The skin, kidneys and bowels should be kept properly active by means of the usual measures. 2. Acute General Tuberculosis of Pulmonary Form. Symptoms. This type of the disease occurs in adults who have been the subject of chronic bronchitis or of chronic tuberculosis and is often observed in children after measles or whooping cough. The symptoms are those of a marked acute bronchitis; with the cough there is muco-purulent expec- toration, rarely haemoptysis. Dyspnoea and cyanosis are pronounced; the pulse is rapid and feeble, the temperature irregular, rising at night to 102° to 103° F. (38.9° to 39.4° C.) or it may be elevated in the morning and low in the evening. The spleen is increased in size in cases of acute coiirse. The outcome is invariably fatal, death occinrring at times within two weeks. In other instances the disease may progress for several months. The Physical Signs are those of bronchitis (sibilant and sonorous rales), or there may be areas of diminished resonance with bronchial or broncho- vesicular breathing and fine crepitant rales due to scattered foci of broncho- pneumonia. Areas over which the note is hyperresonant as a result of localized emphysema may be evident. As the disease progresses the rales become louder and more moist. Tuberculous involvement of the pleura giyes rise to friction rales. The diagnosis is to be made upon the points already set down on p. 148. The presence of marked dyspnoea and cyanosis with the signs of bronchitis is always suspicious. The choroid should be inspected for the presence of tubercles and the sputum examined for the bacilli which are by no means 150 THE INFECTIOUS DISEASES. always present. The history of lymphoid enlargement or of measles or pertussis will often aid in the diagnosis. Treatment is likely to prove useless but the patient should be made as comfortable as possible and the symptoms should be relieved as they arise; otherwise the treatment is identical with that of chronic pulmonary tuber- culosis. 3. Acute General Tuberculosis of Meningeal Form. See Tuberculous Meningitis, p. 714. Pulmonary Tuberculosis. Acute Pneumonic Pulmonary Tuberculosis. Synonyms. Phthisis Florida; Galloping Consumption. This, type of pulmonary tuberculosis occurs in two forms, the pneumonic and the broncho-pneumonic. In the former one lobe or an entire lung may be affected and its condition resembles that found in acute lobar pneumonia. The pleiura is the seat of an exudative inflammation and is filled with cheesy matter composed of aggregations of tubercles, which if the disease lasts long enough soften, and cavity formation, especially at the apices, takes place. In the broncho-pneumonic type the consolidation takes place in scattered areas as a result of which there are disseminated foci of whitish cheesy matter which are separated from one another by congested pulmonary tissue. These foci tend to soften and become tiny abscesses. The bronchial lymph glands are usually the seat of tuberculous inflammation. Symptoms. The pneumonic type is more common in adults. Its onset is marked by a chill foUowed by rise in temperature, cough with mucoid, often blood stained sputum, pain in the side and dyspnoea. The affection is often mistaken for an acute lobar pneumonia which it resembles markedly in its early symptoms and physical signs, which are those of pulmonary con- solidation occurring in one or more lobes. Resolution, however, does not take place but as the consolidation softens the physical signs of a cavity become manifest and microscopic examination of the sputum reveals tubercle bacilli. The course of this type of the disease is usually from one to three months, when death may take place or the process may become a chronic pulmonary tuberculosis. A rapid course is rare. The broncho-pneumonic type is most often met in children in whom it is prone to follow measles or pertussis. The child is affected with a chronic bronchitis with a febrile movement, cough and dyspnoea; the signs are those of bronchitis, moist and subcrepitant rales being abundant and possibly small areas of consolidation evidenced by a high pitched percussion note, broncho- vesicular voice and breathing. Emaciation is rapid, the temperature becomes TUBERCULOSIS. I51 of hectic type and as the areas of consolidation soften tubercle bacilli appear in the sputum. The prognosis is bad, death usually ensuing within one to two months; more rare are the cases in which the disease is rapidly fatal and those which go on to chronic pulmonary tuberculosis. Treatment during the acute stage consists in maintaining the patient's nutrition and combating the symptoms as they arise. That of the chronic stage will be considered later under the treatment of chronic pulmonary tuberculosis. Chronic Pulmonary Tuberculosis. I. Chronic Ulcerative Phthisis. This is the most common form of pulmonary tuberculosis and begins with the formation of miliary tubercles in various parts of the lung, usually, however, in the apices. At its inception it is a purely tuberculous disease and so remains until the softening and breaking down of the tubercles, when the resulting ulcerating surfaces become infected with the bacteria of suppuration and a so-caUed "mixed infection" results. Pathology. The morbid changes present in the lung of chronic ulcerative phthisis are many and varied. The disease spreads from the initial point of infection which is usually a little below the apex of one or the other lung and often nearer the posterior than the anterior aspect. Consequently the situation at which physical signs are first perceptible is either on the anterior surface of the chest just below the middle of the clavicle or posteriorly in the supra-spinous fossa. From this spot the process spreads downward affecting the outer portion of the upper lobe rather than the inner. Later the apex of the other lung becomes involved but usually not before the disease has affected the upper part of the lower lobe of the lung first attacked. Primary involvement of the bases of the lungs is rare. The lesions found in the tuberculous lung are by no means constant nOr do aU the conditions to be described necessarily obtain in every case. The morbid changes which may occiu* are as follows: a. Miliary tubercles. These vary in situation depending upon whether the infection was the result of inhalation or of dissemination of the bacilli by the lymph circulation. In the former instance they are found in the walls of the smaller bronchi or air spaces, in the latter they occur about the pri- mary foci of the inflammation. They also may be seen in the walls of the small blood-vessels. b. Tuberculous broncho -pneumonia. Here we find areas of caseation due to the accumulation in and around the small bronchi of inflammatory prod- ucts. These foci tend to coalesce and, if rapid degeneration and softening takes place, break down and result in the formation of smaU cavities. If the process is more chronic fibrous tissue may develop about the cheesy mass 15? THE INFECTIOUS DISEASES. finally- e!ncapsulating it. The substance within this fibrous capsule may either remain soft and caseous with areas of calcareous degeneration or become entirely ' sclerotic . c. Tuberculous pneumonia. This is a condition characterized by an exudfltive inflammation involving the tissues surrounding the tubercles. The adjacent alveoli are filled with epitheUoid cells. Such areas of consol- idation on cut section resemble the red hepatization of lobar pneumonia or yellowish or whitish spots may be observed due to the presence of foci of fatty degeneration. d. Cavities, the result of the breaking down of the tuberctilous areas, are a characteristic anatomical feattue. The wall of the bronchus is vitiated by the tuberculous inflammation and ulceration, is strained by the effort of coughing, yields, and finally gives way forming a cavity at first small but later of larger size, since adjacent cavities tend to unite until an entire lobe may be involved in the process. Fresh cavities possess caseous and necrotic walls, while those of long standing are lined with smooth walls of granulation tissue which produce pus. Into such cavities blood-vessels of considerable size may protrude which may either be the seat of an obliterating endarteritis or of aneurysmal dilatations. Such vessels, if not entirely occluded by the arteritis, when eroded by the inflammatory process cause haemorrhage. The cavity contains the pus produced by its lining, tubercle bacilli and other micro-organisms. The lung about the cavity may be consolidated. Small cavities often have ragged and necrotic walls which continually are breaking down. Cavities may also result from the softening at the center of a caseous mass or be bronchiectatic in character. Rupture of a cavity into the pleura with consequent pneumo- or pyo-pneumo-thorax, may take place. e. Pleurisy accompanies chronic phthisis in the great majority of instances; it may be either simple or tuberculous in which case miliary tubercles or cheesy deposits are present. There may be thickening of the pleura with adhesions, serous hsemorrhagic or purulent exudations or a condition of pyo-pneumo- thorax. /. The bronchial lymph nodes usually participate in the infection. In the cases of rapid onset and coiurse they are enlarged and softened and con- tain cheesy areas and miliary tubercles; in instances of more protracted evolution caseous foci, calcareous degeneration or suppuration may be ob- served. g. Lesions of other organs. The larynx is frequently involved even to the extent of destruction of the epiglottis and vocal cords. The cervical and retro-peritoneeal glands may be seat of tuberculous inflammation and mili- ary tubercles may be found in the intestine, the spleen, the kidneys, the brain, the liver and the pericardium. Tuberculous endocarditis may be observed. Especially in the protracted cases we frequently find amyloid and fatty degen- TUBERCULOSIS. 1 53 erations of the viscera. The former occurs in the liver, kidneys, spleen and intestinal lining while the latter is most prone to affect the liver and kidneys. Symptoms. The invasion of this disease is most insidious and conse- quently frequently overlooked. The various modes of onset may be classified as follows: a. With successive attacks of bronchitis, each more obstinate than its predecessor. The patient takes cold easily and finally i^ attacked by a bron- chitis that refuses to respond to treatment. The cough becomes frequent and distressing and examination reveals the presence of physical signs. b. With symptoms referable to the stomach. This is by no means a rare mode of invasion but is often overlooked and the patient is sent to the gas- trologist who exerts himself in the direction of his specialty while the patient loses much valuable time. Such patients complain of no symptoms pointing toward the lung but suffer from gastric irritability, eructations, vomiting and perhaps hyperacidity. An accompanying anaemia with palpitation, loss of strength, evening rise of temperature and irregular menstruation is very frequent in young women. Too much stress cannot be laid upon the great importance of a thorough physical examination of the lungs in patients present- ing such symptoms. c. The onset may take place without exciting the suspicion of the patient to the fact that he is ill or the pulmonary symptoms may be masked by mani- festations due to affections of other tissues such as the peritonaeum, intestinal tract or the bones. The lungs of such patients, very much to their surprise may be found to be the seat of advanced tuberculous disease. d. An onset with regularly recurring chills, fever and sweating may occur in which the manifestations strongly suggest malarial infection. e. Pleurisy either fibrinous or with the exudation of serum may mark the invasion of -the tuberculous process, signs of the latter appearing after the former conditions have been present for longer or shorter intervals. Certain German observers have considered all instances of serous pleurisy to be of tuberculous origin but this is quite too sweeping an hypothesis. Those from which blood-tinged fluid is drawn are frequently the result of infection with the bacillus of Koch. Bowditch has reported 90 cases of serous pleurisy which eventuated in pulmonary phthisis. /. Haemorrhage from the lungs appears as an initial symptom in a certain number of cases but in these careful questioning may elicit a history of chronic cough or hereditary tuberculous predisposition showing that pulmonary involvement has pre-existed. g. Laryngeal symptoms, especially hoarseness, as initial manifestations would seem to argue tuberculous infection of the larynx as a primary lesion to which those of the lungs are secondary. h. Pulmonary tuberculosis^may be preceded by enlargement of the glands 154 THE INFECTIOUS DISEASES. of the neck or axilla and examination often will reveal involvement of the lung of the same side. Of the symptoms of chronic phthisis cough is one of the most generally present. At first it is slight, and while it may remain so, as the disease pro- gresses^ it usually increases in severity. It is the result of the irritation caused by the bronchitic or pneumonic process or is due to the accumula- tion of matter in the tuberculous cavities. These when filled are often cleared by successful fits of coughing. Under such conditions paroxysms of coughing occur at intervals. The expectoration varies with the ex- tent of the pulmonary involvement. At first it is scanty and mucoid, and does not contain the bacilli; this is during the so-called pre-bacillary stage, the latter being a misnomer since the bacilli are present within the pulmonary tissues although they do not occur in the bronchial exu- date. After ulceration or the rupture of the tuberculous nodules bacilli are present and, as mixed infection usually takes place at this time the sputum also contains pus. Blood also may now be present owing to the involvement of blood-vessels by the process of ulceration or the breaking down of the tubercles. In quantity the sputum varies from J an ounce (15.0) to eight ounces (250.0) during 24 hours. It is seldom foetid, usually possessing a faint sweetish odor. The expectorations often take a circular form which is termed nummular from supposed resemblance to a coin. Haemoptysis occurs in from 60 to 80 percent, of cases and is a result of the rupture of vessels whose walls have become weakened by the tuberculous infiltration or of the erosion of vessel walls by the inflammatory process. Early in the disease the quantity of blood is small but in the later stages it may be so large as to result in death. Another danger of haemoptysis is that bits of clot may be drawn deeper into the lungs by respiration, and acting as irritants cause inhalation pneumonia. Small hasmoptyses early in the disease may occur as a result of the inflammation of the bronchial mucous membrane. Microscopically the sputum of phthisis may contain mucous, epithelial cells from the respiratory tract or mouth, bits of food, Charcot-Leyden crystals, red blood-cells and, after the lung tissue has begun to break down and mixed infection has taken place, pus cells, tubercle bacilli and elastic tissue. For the technique of the chemical and microscopical examination of sputum the reader is referred to any reliable work upon clinical diagnosis. The cough, especially late in the disease, often incites emesis, probably due to the irritation of the pharynx caused in the act of coughing. Pain is not a typical symptom of the disease but may be caused by excessive coughing, in which case it is usually in the lower part of the chest, or by the pleurisy ; here it is sharp and stabbing in character and located at the site of the pleural inflammation, although at times it may be referred to the other side of the thorax. TUBERCULOSIS. 1 55 Fever is a very constant symptom. Early in the infection it is the result of the tuberculous process within the lungs and is usually slight and of continued type with, perhaps, slight evening exacerbations. With the breaking down of the tuberculous tissue in the lungs and the incidence of mixed infection, to which latter it is due, the so-called hectic temperature occiirs. This is septic both in origin and character, usually reaching its highest point during the afternoon or evening and its minimum during early morning hours. Certain cases may exhibit no distinct febrile movement during their entire coiurse, although these probably have had fever at the onset of the infection. When a continuously high temperature, lasting from a day to a week is ob- served, it is usually due to the establishment of a fresh focus of broncho- pneumonia. With the hectic temperature there are usually sweats. These are the result of septic infection and as a rule occur at night — ^hence the term " night sweats " — although they may appear at any time. The pulse is accelerated even early in the disease and this increase in its rate is often an important point in the diagnosis of incipient tuberculosis. The respirations are not markedly increased in number even with con- siderable pulmonary involvement. Dyspnoea may occiu- when there is pneu- monic involvement, when there is serous pleurisy or pneumo-thorax and in old cases with emphysema or with pleural thickening and retraction of the thorax. Emaciation is progressive and is a pronounced and constant symptom. It is a dependable index of the evolution of the disease. Late in the disease manifestations due to involvement of other organs often occur. Tuberculosis of the intestine is evidenced by obstinate diarrhoea. Meningeal infection causes headache and other cerebral symptoms (see p. 715). Amyloid and fatty degeneration of the viscera result in enlarge- ment of the organs affected and, in the case of the kidneys, albuminuria. Tuberculosis of the genito-urinary tract with pus and tubercle bacilli in the urine may occur. Physical Signs. These vary with the stage of the disease. Careful physical examination of the chest is very important in all suspected cases and the early physical signs, i.e., those present in the incipient or pre-bacillary stage while typical and easily detected by the acute ear, may be overlooked. These are: a. Myoidema of the chest muscles. This phenomenon, while not characteristic of pulmonary tuberculosis, is significant of a hypersesthetic condition of the reflexes and is likely to occur as a result of any disease inter- fering with nutrition, b. Upon auscultation of the heart the pulmonary second sound is found to be accentuated owing to the obstruction to the pulmonary circulation caused by the inflammatory process in the lung. c. The cardiac sounds are heard at the apex of the lung as a result of trans- 156 THE INFECTIOUS DISEASES. mission through the infiltrated pulmonary tissue, d. The whispering voice at the apex or just below the clavicle is bronchial in character, e. A blowing murmur in the subclavian or the pulmonary artery may be present. Upon these signs the diagnosis can be made even before distinct dulness upon percussion or the presence of rales can be detected. In the more advanced first stage of the disease the signs are: a. Inspection. The shape of the chest, while not characteristic, is often long and narrow with wide intercostal spaces and ribs tending toward the vertical in direction. The scapulag are of the "winged" type. The thorax in other instances may be flattened antero-posteriorly and the costal cartilages are prominent. Depression above the clavicle and retraction below are impor- tant signs, the clavicle being more prominent than normal. The body may be more or less wasted, the respiration may be slightly accelerated and the pulse rate increased. A cardiac apex pulsating over an increased area is suggestive of involvement at the left apex. On deep inspiration one side of the thorax wiU often expand less than the other; especially is this diminution of expansion noticeable above and just below the clavicle. h. Mensuration often reveals not only a diminished expansion of the affected side but the fact that this half of the chest is of less circumference than the other while at rest. c. Palpation may detect the presence of increased resonance over the affected apex, but the normal predominance in the resonance of the right over the left apex should not be forgotten. d. Percussion. At this stage the note above or just below the clavicle is usually duller than normal. e. Auscultation reveals an increase in the length of the expiratory murmur and a diminution in the intensity of the inspiratory sound or the latter has become harsh or broncho-vesicular. The vocal resonance is increased, the whispered bronchophony referred to above is present and the physical signs of a more or less generahzed bronchitis are usually obtainable. Crepi- tant and subcrepitant rales at the apices are a frequent and characteristic sign. They are due to pleuritic adhesion in which case they are close under the ear, occur with both inspiration and expiration and are increased upon pressure by the stethoscope, or to bronchitis; here they are more distinct, are heard at the end of inspiration and are not increased on pressure. Cough- ing may render them audible when they cannot be detected upon respiration. In the second stage inspection reveals an increase of the changes already described, the emaciation is more pronounced, the hectic flush may be present and the surface temperature may be heightened. The exaggerated vocal fremitus may be easily detected unless a thickened pleiira prevents its recog- nition. The percussion note is now distinctly dull. Auscultation reveals an increased and perhaps a broncho-vesicular quality TUBERCULOSIS. 1 57 of the spoken voice, the breathing has become more bronchial in character and the expiration is further prolonged and is blowing in quality. Ultimately the breathing and voice, as the consolidation becomes more pronounced and of greater extent, become bronchial. Rales due to pleuritic and bronchial inflammation are also present. The signs revealed during the third stage by inspection are those of the second in a more advanced condition; the wasting is still more apparent, the retraction of the chest is more marked, the respiratory movement more re- stricted. The surface temperature is perceptibly increased, the skin may be moist if sweating is present and the vocal fremitus is further exaggerated. The dulness on persussion is often increased to flatness and upon the occur- rence of cavity formation becomes tympanitic, amphoric or "cracked pot" in character if the lesion is near the surface. The note may be unchanged if the cavity is small and deeply-seated. Wintrich's sign is pathognomonic; given a cavity communicating with the bronchus the note elicited by per- cussion is Ipwer in pitch with the mouth shut than with open mouth. Auscultation reveals the presence of moist rales resulting from the softening and breaking down of the tuberculous deposits. Over cavities the breathing is cavernous or amphoric and the voice possesses similar quantities; pector- iloquy upon whispering or speaking aloud may be present. The amphoric quality is given to the breathing if the cavity walls are firm and smooth, while with softer waUs a cavernous quahty is transmitted to the voice. Gurgling rales may be caused by the air passing through the fluid contents of a cavity. The diagnosis of chronic phthisis presents difficulties during the early stages only; unfortunately the presence of the bacillus in the sputum is not likely to occur until there is ulceration or disintegration of the tuberculous nodules. It is most important that the diagnosis should be made as early in the disease as possible for at this time treatment, properly applied, is able, in most instances to effect a cure. The early physical signs upon which stress should be laid are the presence of slight dulness and diminished breathing and prolonged expiration at the apices, together with whispering bronchophony, a trans- mission of the heart sounds toward the apices and an accentuation of the pulmonary second sound. These last three signs are obtainable two to three months before the X-ray will give a shadow. An increased rapidity of the pulse, slight evening rises of temperature coupled with a flushed cheek, a dilated pupil and perhaps loss of flesh are always suspicious. Streaks of blood in the expectoration, though these may come from the naso-pharynx, should always lead the physician to make a most careful physical examination. It may be stated that the patient in whom a pulmonary haemorrhage is an early symptom is fortunate since it induces him to consult the medical man and to watch his condition most carefully. The tuberculin test may be employed in dubious instances; it is without 158 THE INFECTIOUS DISEASES. danger and is usually reliable. Its technique is as follows: A hypodermatic injection of 5V of ^ grain (o.ooi) of piu-e tuberculin is given. Should no febrile reaction ensue within 10 or 12 hoiurs the dose is doubled 2 or 3 days later and is progressively increased until yV of a grain (0.005) ^^ given. If no rise of temperature is evident after this dosage tuberculosis is probably absent. The agglutination and serum tests advocated by Arloing and Courmont may prove to be very useful. Early in the disease the Rontgen ray has only a limited use in the diagnosis since the only noticeable abnormality is a diminished excursion of the diaphragm upon the affected side. Areas of consolidation are indicated by distinct shadows and special infiltrations may be evidenced by a blurred appearance upon the plate. Fibroid Phthisis. In this disease, associated with the tuberculous process, is a productive inflammation of the lung resulting in an increased growth of fibroid tissue. Its onset is gradual and it may occur following chronic ulcerative phthisis or it may be engrafted upon a tuberculous broncho-pneumonia or pleurisy. The lung is firm, tough and grayish on section as a result of the over-growth of fibrous tissue; the bronchi may be dilated and bronchiectatie cavities are often present; tuberculous cavities are observed at the apex; cheesy foci surrounded by fibrous tissue may be present; in the two last lesions tubercle bacilli are to be found. While one lung is in the condition described the other may be emphysematous or contain miliary tubercles. The right heart, and sometimes the left as well, is hypertrophied and there may be amyloid degeneration of the viscera. Sjanptoms. Cough is present and is frequently paroxysmal, but this, with the other symptoms, emaciation, fever, etc., is less pronounced than in ulcer- ative phthisis. The sputum is often profuse, owing to the presence of bron- chiectatie and other cavities, and may be foetid. Bacilli are less easily found than in ordinary chronic phthisis. Pulmonary haemorrhage may occur and oedema of the feet may result from failure of the heart's action. The coiurse of the disease is usually protracted. Physical Signs. The chest wall over the diseased lung is sunken and the heart may be displaced owing to retraction of the lung. The intercostal spaces are narrow and the area of the cardiac apex beat may be much enlarged. The characteristic percussion note is dull and high-pitched; vocal fremitus is diminished. Auscultation may reveal the presence of cavities especi- ally at the apices, elsewhere there areas of bronchial breathing and increased vocal resonance unless the pleura is thickened. Bronchiectatie cavities may be present in the middle or lower lobes. The signs of emphysema may be noted in the other lung and cardiac murmurs are not infrequent. TUBERCULOSIS. 1 59 The Prognosis of Chronic Pulmonary Tuberculosis. In the ulcerative as well as in the fibroid form of the disease, although the duration of the latter type is longer, the prognosis is serious, but it is certain that many subjects of pulmonary infection with tuberculosis do spontaneously recover. This is proven by the numberless autopsies, in deaths from other causes, in which healed tuberculous lesions are found. In these the tuber- cles have undergone fibroid or calcareous degeneration. In the encapsulated caseous masses while the process may be considered inactive it cannot be said to have wholly ceased to exist. Even patients in whose sputum bacilli and elastic tissue have been demonstrated, have recovered; consequently in the light of the above stated facts we may safely say that pulmonary tuber- culosis is a curable disease. The cases in which the prognosis is most favorable are those with good heredity, previous robust health and good digestion, slow invasion, only slight febrile movement and sHght pulmonary involvement. When the initial inflam- mation is pleuritic, recovery may be considered probable, while the oppo- site is true of cases with frequent pulmonary haemorrhages. The average duration of the disease differs, being, according to the statis- tics of different observers, from two and a half to seven years. Proper treatment will, in the great majority of instances, render the patient more comfortable and materially prolong his life. Prophylaxis. This consideration is quite as important as treatment, for in the light of our present knowledge the disease is distinctly preventable in most cases. The public should be educated by such means as those employed by the Department of Health of New York City, and pulmonary tuberculosis should be considered a reportable disease on account of its infectious character. The following is a copy of a circular issued and circulated by the New York Health Department indicating the attempt that is being made to awaken the masses to the importance of the crusade against tuberculosis. " Consumption is a disease of the lungs, which is taken from others, and is not simply caused by colds, although a cold may make it easier to take the disease. It is caused by very minute germs, which usually enter the body with the air breathed. The matter which consumptives cough or spit up contains these germs in great numbers — frequently millions are discharged in a single day. This matter, spit upon the floor, wall or elsewhere, dries and is apt to become powdered and float in the air as dust. The dust contains the germs, and thus they enter the body with the air breathed. This dust is especially likely to be dangerous within doors. The breath of a consump- tive does not contain the germs and will not produce the disease. A well l6o THE INFECTIOUS DISEASES. person catches the disease from a consumptive only by in some way taking in the matter coughed up by the consumptive. " Consumption can often be cured if its natiire be recognized early and if proper means be taken for its treatment. In a majority of cases it is not a fatal disease. "It is not dangerous to live with a consumptive, if the matter coughed up by him be promptly destroyed. This matter should not be spit upon the floor, carpet, stove, wall or sidewalk, but always, if possible, in a cup kept for that purpose. The cup should contain water so that the matter will not dry, or better, carbolic acid in a five percent, watery solution (six teaspoonfuls in a pint of water). This solution kiUs the germs. The cup should be emptied into the water closet at least twice a day, and carefully washed with boiling water. " Great care should be taken by consumptives to prevent their hands, faces and clothing from becoming soiled with the matter coughed up. If they do become thus soiled, they should be at once washed with soap and hot water. Men with consumption should wear no beards at all, or only closely cut mus- taches. When consumptives are away from home, the matter coughed up should be received in a pocket flask made for this purpose. If cloths must be used, they should be immediately burned on returning home. If hand- kerchiefs be used (worthless cloths, which can be at once burned, are far better), they should be boiled at least haK an hour in water by themselves before being washed. When coughing or sneezing, small particles of spittle con- taining germs are expelled, so that consumptives should always hold a hand- kerchief or -cloth before the mouth during these acts; otherwise, the use of cloths and handkerchiefs to receive the matter coughed up should be avoided as much as possible, because it readily dries on these, and becomes separated and scattered into the air. Hence, when possible, the matter should he received into cups or flasks. Paper cups are better than ordinary cups, as the former with their contents may be burned after being used. A pocket flask of glass, metal, or pasteboard is also a most convenient receptacle to spit in when away from home. Cheap and convenient forms of flasks and cups may be purchased at many drug stores. Patients too weak to use a cup should use moist rags, which should at once be burned. If cloths are used they should not be carried loose in the pocket, but in a waterproof receptacle (tobacco pouch), which should be frequently boiled. A consumptive should never swallow his expec- toration. " A consumptive should have his own bed, and, if possible, his own room. The room should always have an abundance of fresh air — the window should be open day and night. The patient's soiled wash-clothes and bed linen should be handled as little as possible when dry, but should be placed in water until ready for washing. TUBERCULOSIS. l6l " If the matter coughed up be rendered harmless, a consumptive may frequently not only do his usual work without giving the disease to others, but may also thus improve his own condition and increase his chances of getting well. "Whenever a person is thought to be suffering from consumption, the Department of Health should be notified and a medical inspector will call and examine the person to see if he has consumption, providing he has no physician, and then, if necessary,^ will give proper directions as to treatment. " Rooms which have been occupied by consumptives should be thoroughly cleaned, scrubbed, whitewashed, painted or papered before they are again occupied. Carpets, rugs, bedding, etc., from rooms which have been occupied by consumptives, should be disinfected. Such articles, if the Department of Health be notified, will be sent for, disinfected and returned to the owner free of charge, or, if he so desire, they will be destroyed. "When consumptives move they should notify the Department of Health. " Consumptives are warned against the ?nany widely advertised cures, specific and special methods of treatment of consumption. No cure can he expected from any kind of medicine or method, except the regularly accepted treatment, which depends upon pure air, an out-of-door life and nourishing food.'' Legislation with reference to the sanitary condition of tenement houses, to the inspection of the sources of our meat and milk supply and against promiscuous expectoration is a necessary step in prevention, as well as thorough disinfection of rooms and their contents after occupation by tuberculous individuals and the estabhshment of municipal, state or even federal sana- toriums and tuberculosis dispensaries. At least one of the hospitals of New York City has a corps of visiting nurses who go to the houses of patients who are under treatment at the institution's out-patient department and instruct the family in the necessity of cleanliness, in the care of sputum, etc. The sputum being the chief means by which the disease is disseminated should be thoroughly and at once destroyed. It should be received into earthen or enamel-ware cups in which a i to looo solution of mercury bichloride or a 4 percent, solution of carbolic acid is constantly kept; where it is impossible to procure these germicides water should be substituted since the bacilli unless dried are not carried by the air, or the patient may expectorate into bits of old muslin or even a Japanese napkin which is to be immediately burned. The burnable pasteboard sputum cup is a useful and safe appli- ance. All permanent receptacles for sputum should be scalded out with boiling water at least once a day. The proper care of delicate children whether born of tuberculous parents or not is most important. The tuberculous mother should not nurse her child and the general surroundings of the predisposed infant should be of the most healthful character. Catarrhal diseases are much to be feared, consequently the child should not be allowed out of doors upon cloudy, damp l62 THE INFECTIOUS DISEASES. days during the cold months and the condition of the upper air passages should be kept as healthful as possible. The importance of the removal of adenoids and h}^ertrophied tonsils cannot be over-estimated. Proper clothing — woolen next the skin — should be vt^om. After the child's bath, sponging with cold water — 60° to 70° F. (15.5° to 21° C.) — is an excellent method of hardening. The diet should be plentiful, plain and nourishing and a Hking for milk, if not already present should be cultivated. All ill- nesses, no matter how insignificant should be carefully treated and the admin- istration of such tonics as iron, especially syrupus ferri iodidi, arsenic and codliver oil may be attended with benefit. As the child grows older he should be encouraged to lead an out-door life, exposirre to cold and wet, however, being avoided, and in the pursuance of gymnastic and respiratory exercises. When it becomes necessary to choose his life-occupation one which will tend to keep the subject in the open air as much as possible is to be preferred. Protection by Immunization. Von Behring claims to have discovered a method of immunization of man which is sure, rapid and without danger. He believes that the immunizing substance is contained in the bodies of the tubercle bacilli and acts by combining with certain living cellular elements. His theories have been proven . by animal experimentation and he believes that it is possible by the same methods to protect the human subject against tuberculous infection. The discovery is not to be given to the world until further experimentation and clinical study have been carried out. A state- ment like the above coming from Professor von Behring carries much weight. Treatment. Pulmonary Phthisis is an infection and should be treated as such. The patient's life should be regulated and his condition watched as carefully as in enteric fever or diphtheria. Each patient is a law unto himself consequently no one method is applicable in all cases and seldom does any single method succeed in a given case, the best results being obtained by a combination of appropriate modes of treatment. Climatic treatment, dietetic treatment, drug treatment, each has a distinct place but we should not be satisfied to employ them singly; we should use all means at our dis- posal, keep up the patient's nutrition, constantly watch him in every phase of his disease and work continuously to benefit him. The special consider- ations are to improve the nutrition by proper hygienic mode of life and feed- ing; to arrest the tuberculous process; and to relieve the unpleasant symp- toms as they arise. a. Climatic Treatment. When it is possible to remove the patient, a suitable climate should be sought as soon as the diagnosis is suspected. The ideal climate is dry, of equable temperature and one which affords the largest number of sunny days; such a one is, however, impossible to find since no dry climate possesses an equable temperature, consequently we should select a region the meteorological characteristics of which approach as nearly as TUBERCULOSIS. I63 possible to this ideal. In many instances it will be impossible to choose a climate for a given case and the only possible method of selection is to experi- ment until one is found in which the patient does well. In general it may be stated that an altitude of from 2000 to 2500 feet is more favorable than a low lying region. Another important consideration is that the patient must not be sent to a place where good accommodations and food cannot be obtained. Evans gives the following useful classification of climates. 1. Cool moderately moist climate, general elevation 2000 feet — the western slope of the Appalachian range, the Adirondacks, Catskills, Alleghanies, and Cumberland mountains. 2. Moderately warm and moist climate, elevation 2250 feet — Asheville, N. C; Aiken, S. C; Marietta and Thomasville, Ga. 3. Warm and moist climate— the coast regions of Florida and Southern California. 4. Warm and moderately dry climate, elevation about 2000 feet — South- western Texas and Southern California inland. 5. Cool and moderately dry cUmate, elevation about 1000 feet — Min- nesota, Nebraska and Dakota. 6. Cool and dry climate, elevation 4000 to 7000 feet — Montana, Wyoming, Colorado, Northern New Mexico and Western Kansas; Davos and St. Moritz, Europe. 7. Warm and dry climate, elevation 3000 to 5000 feet— Southern New Mexico and Southern Arizona. The Adirondacks are a very favorite resort for the tuberculous of the vicinity of New York City and even though the elevation is considerable the per- manence of an estabhshed cure is not jeopardized by a return to sea-level. The patients who do best at an altitude are those in whom the disease has not gone on to cavity formation and whose nutrition is good; the opposite is true of advanced cases especially if emphysema or cardiac weakness is present. Such conditions usually contraindicate removal to a high altitude and the patient is more likely to be benefited by a moist and warm climate than by one which is cold and dry. In conclusion it may be stated that Hfe in the open air is essential in whatever climate the patient may be. Hygienic treatment consists in first securing ventilation and simlight. The dwelling should be situated upon high rather than low ground and should be as accessible to the sun as possible. The importance of the latter consid- eration is shown by the fact that case after case of tuberculosis continued to occur in certain houses in Massachusetts until the removal of the numerous trees which shaded them. After this was done the disease disappeared as if by magic. Proper drainage is important and the patient's apartment should be one to which the sunlight has access for as much of the day as possible. 164 THE INFECTIOUS DISEASES. Ventilation by a fire place is to be advised and the patient should sleep with the windows open even in the coldest weather, but protection from draughts must be secured. The air within the sleeping-room should be identical with that out of doors. During the day the patient should spend as much of the time in the open air as possible and should take such exercise in moderation as the condition of his circulatory apparatus will allow. Sitting in the sunlight should be encouraged but it is better to keep in motion if the physical condition permits. The employment of hydrotherapeutic treatment as a cturative measure may be neglected; it is however important in prophylaxis. Daily baths, however, should be taken in order to keep the skin and circulation active. Cool water may be used but not unless the rub dov^n after the bath is suc- ceeded by a good reaction. The risk of chiUing the body should not be taken. Breathing exercises are important and by their means the lung capaciy and chest expansion are capable of a considerable increase. They consist in taking several successive deep breaths, the patient standing upright in the open air meanwhile. Each breath is held for a few seconds and then slowly exhaled. In proper cases, the condition of the heart permitting, calisthenics in moderation are excellent. The exercises which make up the " setting up drill" of the United States Army may be employed. The patient's clothing is an important consideration, wool of weight varied according to the temperature should be worn next the skin at aU seasons of the year, both day and night. As a sleeping dress nothing is better than pajamas of flannel or a night-gown reaching to the feet. The open-air treatment has been of late much exploited and is undoubtedly a method of great value. It may be employed at home in the city or country, or in institutions. It may be difficult to carry out in the city but if the phy- sician insists upon its importance it will be possible to overcome many obsta- cles. The roof or back yard may be used upon pleasant days, and an ordinary steamer chair provided with cushions and blankets makes an excellent couch if it is necessary that the patient recHne. Days upon which it is not advisable to send the patient actually out of doors he should recline, warmly WTapped, if necessary, before the open window of his apartment which should be the most sunny and airy room in the house. At night the windows should be open so that unless the weather absolutely forbids the patient spends practi- cally all his time in the open air. Such symptoms as fever, sweats and haemop- tysis should not be allowed to interfere with the treatment. The sanatorium treatment has recently been developed to a considerable degree. The great advantage of institutional treatment is that the patient's mode of life is in every way regulated upon the Unes most beneficial to him. Exercise, sleep, diet, amusement, etc., are arranged in accordance with the most hygienic methods. Emphasis must be laid upon the importance of TUBERCULOSIS. 165 the establishment of pubhc sanatoriums near large cities so as to be avail- able for early cases and those of moderate means. Tent life for the tuberculous. This mode of treatment is only another phase of the out-of-door fresh air method. Tents or tent cottages may be con- structed according to any desirable plan and life in these is practically an existence in the open air. Dietetic treatment is perhaps the most important consideration in the management of pulmonary tuberculosis but presents certain difficulties. The importance of proper feeding cannot be too strongly emphasized; the well-nourished organism is able to throw off tuberculous infection and it is certainly probable that the poorly nourished organism which is the subject of a tuberculous infection can better combat this prejudicial condition if its nutrition is improved in every possible way. Many patients will state that they cannot eat, yet if they are encouraged to tr}', they will, before the meal is finished, give evidence of a very respectable appetite. Any system of feeding which departs markedly from the proper propor- tion of proteids, fats and carbohydrates is not a wise one, as is shown by the failure of the raw-beef and hot-water treatment which fails in a large pro- portion of cases because the amount of albuminous material is so great that it over-taxes elimination. The Debove method of treatment by over-feeding (see p. 616) mav be followed by considerable gains of flesh but unfortunately while the increase in weight is going on the tuberculous process remains stationary, and the method has the additional disadvantage that very careful watching of the patient is required to prevent the disagreeable consequences of over-feeding. This mode of feeding is best reserved for patients with tuberculous laryngitis where it has one distinct advantage that is of great value in certain cases. It is a curious fact that these patients, who are often prone to vomit, a very distressing symptom in tuberculosis of the larynx, seldom do so when food is introduced by the stomach tube. The proper diet for patients suffering from pulmonary tuberculosis should consist of meats, starches and fats, with an excess of the last, and a certain amount of phosphates. Light and nutritious food should be given, it should be easily digestible and the meals should be frequent. They should be sepa- rated into those containing the bulk of the starchy food and those consisting chiefly of proteids. Three to three and a half hours should be allowed for the digestion of the hea\aer meals so that the stomach shaU be fairly emptied before it receives the next consignment of food. The first meal should be at about 7 A. M. when the patient takes a glass of warm (not hot) milk containing a tablespoonful of strong coffee made according to the French method, or, if the previous night has been an exhaust- ing one, a dessertspoonful of rum or other spirit which has previously been mixed with enough water to reduce its alcohol content to not more than 5 1 66 THE INFECTIOUS DISEASES. percent., otherwise the spirit will coagulate the albumin of the milk and render it less digestible. Breakfast is taken at g A. M. The patient is allowed eggs cooked in any way except by frying, although if fr^nng is an essential it may be done in the ItaUan method, i.e., in olive oU. Prepared thus they are much less indigestible than when fried in lard. Bread is also permitted and mar- malade if the patient likes. Finnan haddie pleases certain patients, when it is cured by smoking and without salt and it seems to agree with them although it is a theoretically incorrect article of diet. Toasted bread or good rolls (not hot) are allowable and bread and butter, milk and coffee may be used for variety. About eleven o'clock the patient has the second breakfast, which usually consists of a little cocoa from which the fat has been taken out. Cocoa butter is about the most indigestible fat there is, therefore it should be removed, or else predigested. The patient may also have coffee, a little bread, a little soup or a little beef extract. An eggnog is permissible, and kumyss or mat- zoon is often acceptable. The dinner should be served about one o'clock in the afternoon, and should be the meal of the day. The patients may have any kind of meat they relish, except salted meat, but it must not be fried. Potatoes, fresh vegetables, fruits, and puddings may also be allowed. Coffee, tea, or possibly a bottle of Hght beer can be added. About four o'clock in the afternoon they should have a little meat extract with toasted bread, and about five o'clock, a httle more should be given. About seven o'clock in the evening comes supper, consisting chiefly of farina- ceous food. Many of these patients like what is known as hasty-pudding which is made by putting corn meal into a kettle with water, and stirring it while it is boiling, seasoning to taste. Various jellies, beef extracts, and gruels are useful at this time. If the patient is awake at eleven a cup of milk or hot soup may act as a hypnotic. Patients who exhibit a hectic temperature are better without alcohol after the I P. M. dinner because the alcohol seems to increase the fever. In general alcohol should be taken only in moderate amount and well diluted. After noon only beer is to be permitted, with perhaps, stout upon retiring. The starchy foods, since upon these we must depend to improve nutrition, should be given with as Httle liquid as possible and their digestibility should be increased by the addition of a malt extract, which in itself is nutritious and contains diastase. All liquid malt extracts are utterly useless for the transformation of starch into dextrin and maltose, because they contain alcohol which inhibits the effect on the starch, and because they contain acids, gener-^ ated in the process of fermentation, which also inhibit the action of the diastase. The semi-solid extracts of malt convert starch into sugar. This conversion commences to take place in the mouth. For the first thirt}' or forty minutes TUBERCULOSIS. 167 after food has been taken into the stomach, this process goes on. It later stops, but recommences in the duodenum and continues until all the starches are converted into dextrin, and finally into maltose. That this conversion continues in the stomach has been proven conclusively by Kellogg. The great disadvantage of most of the active preparations of malt is their viscosity, which renders them, after a httle time, objects of disgust. It is now possible to obtain a preparation of malt, which contains from four to five percent, diastasic converting power. With such a preparation as maltzyme we can be assured that the starches will be digested. The starches are for nourish- ment, for the generation of heat, and for the formation of fat. This is just what one wants for a tuberculous patient. Further than this recent investi- gations tend to show that the sugars are important in the generation of force. That is to say: Under a constant diet more than a proportionately larger amount of energy is developed if sugar be added to the dietary. Life in the open air is a great stimulant to the appetite and an occasional gastric lavage may remove the mucus from a sluggish stomach and increase a desire for food and a dose of one of the vegetable bitters taken before meals now and then is an excellent measure. Of these perhaps the best is condiir- ango, dose of the fluidextract 20 to 30 drops (1.33 to 2.0). Nux vomica and gentian are also to be recommended. Medicinal Treatment. Creosote has been employed in pulmonary tuber- culosis since 1842 and is perhaps the only remedy which has never been aban- doned. Its chief disadvantage is that it is often irritant to the stomach and the kidneys but this can be avoided in great measure by the use of creosote carbonate or of pure beechwood creosote. The former is preferable since it may be, on account of its less irritant qualities, administered in much larger dosage. It contains 92 percent, of creosote and may be given in dose of from 15 to 60 minims (i.o to 4.0) in a wine glass of sherry after meals or in milk or bouiUon. It may also be given in codliver oil, i part to 10. Creosote carbonate is slowly absorbed and is probably eliminated chiefly by the bron- chial mucous membrane. It is the drug upon which we place oiir chief reli- ance in treating pulmonary tuberculosis. Creosote itself may be used in various ways but it is very important that it should be pure; it is frequently contaminated with phenol the presence of which may be proven by moistening a match with the suspected fluid; if impure the wood is stained bluish. Creosote may be administered in the form of an emulsion with codliver oil and acacia, with codliver oil and the h}'po- phosphites, with syrup of wild cherry and acacia, 2 minims (0.3) of creosote to I drachm (4.0) of the emulsion in each case — or in a mixture of glycerin and whiskey. The dose of creosote should be ^ to 2 minims (0.03 to 0.13) given thrice daily and gradually increased to 20 to 25 minims (1.33 to 1.66) in the 24 hours. Administered in pills coated with keratin, which wifl dissolve 1 68 THE INFECTIOUS DISEASES. only in the intestine, a daily dosage of from 45 to 50 minims (3.0 to 3.3) can be reached without inconvenience. The follo'wing prescriptions may be found useful: I^ creosote 5i (4-0)5 tincturae nucis vomicae §ss (15.0), tincturae gentianae compositfe q. s. ad giv (120.0). Misce et Signa, one teaspoonful 3 timqs a day after meals; I^ creosoti 5i (4-o), balsami tolutani gr. cv (7.0), terpini hydratis gr. 15 (i.o), acidi benzoic!, q. s. Misce et divide in pilulas numero bcxx. Signa. Take 10 pills per day. Hypodermatic administra- tion of creosote in sterile oil requires a special apparatus and is very tedious and painful. Creosote by inhalation is especially indicated vi^hen the sputum is foetid. The sponge of a perforated zinc inhaler is wet with a mixture of equal parts of beechwood creosote, spirit of chloroform and alcohol and the apparatus is used for 15 minutes in ever}^ hour. If the dosage of creosote, when given by mouth, is increased too rapidly, nausea, epigastric distress and even vomiting may result and the urine may become darkened and contain blood and granular casts, but if the increase of dose is slow the patient may acquire a tolerance for the drug; 50 minims (3.33) should be considered a maximum daily dosage. When it is impossible to give creosote by mouth it may be given in enema as follows. This method is preferable to its hA-podermatic administration and is specially indicated in tuberculous diarrhoea or enteritis. The enema is made up of J to i drachm (2.0 to 4.0) of creosote dissolved in 6 drachms (25.0) of oil of sweet almonds. This is emulsified by the addition of the yolk of an egg and the whole is mixed with 6 ounces (200.0) of water. A more easily made enema consists of from 15 to 45 minims (i.o to 3.0) of creosote mixed with 4 to 8 ounces (125.0 to 250.0) of water. This mixture should be thoroughly agitated before ad- ministration and may be given 2 or 3 times daily. An excellent substitute for creosote is gomenol, an oily liquid analogous to oil of cajuput and distilled from the leaves of Melaleuca viridiflora; its dosage is from 30 to 60 minims (2.0 to 4.0) in capsules daily. Another sub- stitute is guaiacol — 8 minims (0.5) — 3 times a day or better, guaiacol carbo- nate, the dose of which is twice as large. Codliver oil is a valuable aid in the treatment of tuberculosis. Pure oil is unpleasant to the taste but fortunately children frequently take it with avidity. The objections of older persons may be avoided by giving it in soft capsules or in the official emulsion. Some patients are able to take the oil by pre\'iously rinsing the mouth with whiskey or brandy or by putting a little salt in the mouth after swallowing the dose. To render the oil less unpalatable 10 minims (0.66) of pure aether or a drop or two of peppermint or clove oil may be added to each dose. One part of essential oil of eucal- yptus is said to entirely do away with odor and taste and a nutritious com- bination may be made by rubbing together equal parts of codliver oil and malt extract. Another method of disguise is to add to 400 parts of the oil TUBERCULOSIS. 169 10 parts of animal charcoal and 20 of ground roasted coffee; the mixture is digested in a water bath at 122° to 140° F. (50° to 60° C.) and after standing for three days is filtered and stored in well-stoppered bottles. Iron may be combined with the oil as follows: I^ olei morrhuae 5iv (i5-o), ferri et ammonii citratis gr. v (0.33), potassii carbonatis gr. iii (0.20), saccharini gr. ^ (0.015), olei cari n^ J (0.015), aquae destillatas q.s.ad §i (30.0). Codliver oil is considered as contraindicated in diarrhoea, hsemoptysis, dyspepsia, vomiting and fever. The hj'pophosphites are useful especially in the primary stages when our prime object is to improve the patient's nutrition. It is important that they should be chemically pvu-e and neutral in reaction, for the presence of free alkali or alkaline carbonates quickly causes an atonic dyspepsia. The offi- cial syrups of mixed h}^ophosphites are faulty in that each salt has a pecu- liar property; the final effect of h\^ophosphite medication is due to the beneficial effect upon nutrition of the particular salt prescribed. In the early stages of phthisis (infiltration) the sodium salt only should be administered; where cavities are present the calcium salt only is indicated, provided that it does not too suddenly check expectoration, when the sodium salt should be resumed. The potassium salt is a valuable expectorant in chronic bronchitis but its usefulness in phthisis is limited. The hypophos- phites, intelligently administered, wiU improve nutrition and relieve certain of the symptoms of pulmonary tuberculosis, but when given in too large doses, or simultaneously with iron, arsenic, strychnine or other stimulants or cod- liver oil, they are likely not only to fail but to cause digestive disturbances. Quinine hj^ophosphite is useful in the last stages of the disease only, and then probably merely as a placebo. The tonics, especially iron and arsenic, are often useful to combat the secondary anaemia of chronic phthisis. The latter should not be given to alcoholics or to patients who suffer from gastro-intestinal disturbances or haemoptyses. It is often wise to give the arsenic for 3 days in the week or 15 or 20 days in the month. The drug may be given in the form of sodium arsenate gr. iV to J (0.005 to 0.016), or as Fowler's solution, 2 to 8 minims (0.13 to 0.5) 3 times a day. The latter may, if necessary, be administered per rectum mixed with water in dosage twice the size of that given by mouth. Sodium cacodylate which contains 50 percent, of arsenic may be given in pill form — each piU to contain | of a grain (o.oii) — from 3 to 6 pills a day and in the anaemia of those predisposed to tuberculosis a combination of this drug with iron and ammonium citrate is to be recommended. The Treatment of Special Symptoms. Fever necessitates rest, which of course may be taken in the open air. Quinine and the salicylates are of little use, the former, if given in dose large enough to control the temperature is very prone to disturb the digestion. Small doses of salipyrine, acetpheneti- 170 THE INrECTIOUS DISEASES. dine or antipyrine are often effectual.. Temperatures above 103° F. (39.5° C.) may be relieved by sponging with cool water. The cough if sUght may be relieved by simple mixtures containing dilute hydrocyanic acid 2 to 3 minims (0.12 to 0.18) to the dose; as vehicles the syrups of tolu or wild cherry may be employed. Syrups, however, when continued, are very apt to disturb the gastric functions. More distressing cough necessitates the administration of heroine -2^ to tV of a grain (0.0025 to 0.005) o^ codeine ^ to J a grain (0.0165 to 0.0033) every 4 hours. In the advanced stages frequently only morphine will relieve this symptom. Suffi- cient quantity may be given to control the cough during sleep but not so much as to inhibit the expectoration of the accumulations of the night when the patient awakes. This may be faciUtated by administering a glass of hot milk or a milk punch. If the bronchial secretions are tough and not easily raised they may be softened and their expectoration made less difficidt by the admin- istration of soluble capsules containing terpene hydrate gr. v (0.33) and heroine gr. 2-7 (0.0033). Terebene is also useful in this connection although it may disturb the stomach. It may be given in doses of 5 to 10 minims (0.33 to 0.66) 3 times a day well diluted. If the cough, after examination, appears to be due to involvement of the larynx the measures described on p. 615 are applicable. Haemoptysis is an important symptom. The patient should be kept abso- lutely at rest, in the recumbent position, but with the shoulders slightly raised. Cold applications should be made to the chest in the form of the ice coil, the ice bag or cold compresses wrung out in ice water, and the patient may be given bits of ice to suck. The early administration of a hypodermatic injection of morphine sulphate | to |- of a grain (0.016 to 0.022) is usually advisable. All measures which increase the blood pressiure should be avoided and if the arterial tension is high aconite may be given in doses of 3 to 5 min- ims (0.2 to 0.33) of the tincture every hour until the desired effect is produced. A very important measure is the administration of one of the salts of calcium in order to increase the coagulability of the blood. The most effectual of these is the lactate, next in order is the chloride, the former being from 2 to 3 times as potent as the latter. The initial dose of either is 40 grains (1.66) and they afterward may be given in 20 grain (1.33) doses three times a day. The exhibition of the preparations of ergot, gaUic and tannic acid and of the lead salts is probably useless. Supra-renal extract in doses of 5 grains (0.33) every 2 or 3 hours and the hypodermatic administration of 3J ounces (100. o) of a 10 percent, gelatin solution at 110° F. (43° C.) are recommended; the lat- ter, it is said, possesses haemostatic properties and may be given also by mouth. The ordinary preparation, which may be found in every kitchen, may be taken dissolved in water in doses of 2 ounces (60.0) every 2 or 3 hours. Fortu- nately pulmonary haemorrhage in itself is seldom fatal and tends sponta- TUBERCULOSIS. 171 neously to become checked. In cases where the quantity of blood lost jeopar- dizes the Hfe of the patient the limbs should be bandaged from the fingers and toes toward the body; enteroclyses and hypodermatoclyses of hot normal saline solution should be given to supply the loss. The treatment of haem- optysis by means of inhalation of amyl nitrite has recently been much extolled and is apparently based upon reasonable principles. Sweating is often a distressing symptom and numerous drugs have been employed in its control. An excellent method of reheving the night sweats which usually make their appearance during the early morning is to wake the patient about 4 A. M. and give him a tumbler of warm milk containing a little whiskey; this procedure has the additional advantage of supplying extra food. Aromatic Sulphuric acid — 15 minims (i.o) three times a day — camphoric acid — 15 to 30 grains (i.o to 2.0) — given in powder or in spirits 2 or 3 hours before the sweat is expected may be prescribed for this symptom and in excessive instances a h}^odermatic injection of J (0.016) grain of morphine with y^o of a grain (0.0006) of atropine is often effectual. Mus- carine, 5 minims (0.33) of a one percent, solution, picrotoxin eV of a grain (o.ooi), agaricin, | to J of a grain (0.008 to 0.016) and agaric acid in similar dose have all been recommended. The diarrhoea of phthisis before there is tuberculous inflammation of the intestine may be controlled by bismuth subsalicylate or subnitrate gr. xx (1.33) 3 times a day. Later in the disease larger doses may become necessary. If the diarrhoea is persistent a little opium may be given and better results may follow the use of bismuth tetraiodophenolphthaleinate — gr. V to viii (0.33 to 0.5) — than that of the commoner bismuth salts. If the diarrhoea is the result of tuberculous involvement of the bowel it is likely to be persistent and in addition to the above means, irrigations and larger doses of opium given with the salts of lead, silver or zinc, may be prescribed. Tuberculin has been persistently employed as a therapeutic agent by a certain number of observers but has never been in general use. It is prob- ably harmless and the earlier it is employed and the less general the infection the more likely will it be to achieve benefit. It is said to be contraindicated if either fever or haemoptysis is present. The preparation employed should be the tuberculin residuatum or tuberculin R. which is potent to produce immunization and if administered carefully will cause no reaction. The initial dosage is 15 minims (1.0) of a solution of 15 grains (1.0) of tuberculin R. in i pint (500.0) of normal sahne. This solution should be freshly prepared — within 24 hours of the time of administration. A dose should be injected into the muscular tissues of the back every other day. If there results a rise of temperature the succeeding dose should be postponed until this has disappeared. The patient after repeated injections 172 THE INFECTIOUS DISEASES. usually is able to take much increased doses without reaction and with, perhaps, improvement in his condition. In the Hght of our most recent knowledge it has become necessary to take into consideration the opsonic power of the blood when administering tuber- culiniand other such substances as a therapeutic measure. The opsonins are certain bodies which are contained in the serum of normal blood and in whose presence the phagocytic power of the leucocytes over pathogenic micro-organisms in the blood stream is much more potent than when these bodies are absent. The term opsonic index has been employed to designate the relative amount of opsonins in the circulation, consequently a patient whose blood contains them in considerable quantity is said to possess a high opsonic index and vice versa. Tests have shown that in the tuberculous the tuberculo-opsonic index is below normal. By comparing the resistance of the opsonic power of a patient's serum with that of the serum of normal individuals it has been demonstrated that in all infectious processes times occiu* when the patient's resistance is on the increase and other times when it wanes. In the latter condition the introduction of bacterial vaccines corresponding to the infective micro-organism present still further lowers the opsonic index and the patient's power of resistance is correspondingly lessened. In view of this fact the im- munizing substance should be given during the periods of high opsonic index, thus endeavoring to maintain the antibacterial power of the blood at as high a level as possible by observing the condition of the opsonic index and regu- lating the time and amount of dosage in accordance with its variations. Exper- imentation has shown that much smaller doses of "new tuberculin" than are usually given produce the maximum immunizing response without causing constitutional disturbance and in consequence a dosage equivalent to ■g-oiTS'ir to T6i"o¥ of a grain (ttoo" to is\-^ of a milligram) of tubercle powder are recommended; such doses, when given corresponding to the rises and falls of the opsonic index and in connection with means calculated to increase the flow of blood and lymph through the diseased area, which latter aid in increasing the action of the antibodies upon the bacteria present, promise well and seem to imply that this method of treatment will prove a distinct advance in the combat against tuberculous infection, particularly those forms which affect the bones, joints and lymphatic system. It is also quite clear that the treatment is worthy of a careful trial in the pulmonary forms of the disease. Serum treatment, however, has not as yet given any results which justify its employment to the exclusion of other methods. Favorable reports have been published upon the use of the serums of Marmorek and Maragliano. In October, 1905, at the International Tuberculosis Congress, von Behring stated that he had found a method by the use of which he was able to per- TUBERCULOSIS. ' 1 73 manently immunize calves and that he had succeeded in rendering the proc- ess appHcable to human beings. The substance employed is an attenuated culture of tubercle bacilli from which certain injurious elements are removed, transforming it into an amorphous state, in which condition it is directly absorbable into the lymphatics of the organism. This method of treatment is at present sub judice. Apropos of the International Congress, Cheinisse has recently been quoted as saying that : " Serum therapy was the subject of a great number of com- munications, but the many disappointments which everyone has in mind make us skeptical, and the very multiplicity of 'serums' and 'new tuberculins' recommended in the treatment of tuberculosis is the best possible proof of the inefficacy of every one of these pretendedly specific remedies." Tuberculosis of the Lymphatic Glands. Synonyms. Scrofula; Tuberculous Adenitis; King's Evil. .Etiology. Tuberculous inflammation of the lymph glands may occur at any age but is most frequently met in children. All catarrhal affections of the mucous membranes are predisposing causes, the tubercle bacilli which find lodgment upon the diseased surfaces being taken up by the lymph circulation and deposited in the adjacent lymph ganglia which explains the occurrence of involvement of the submaxillary and cervical glands in instances of naso-pharyngeal or tonsillar inflammations, of the bronchial and mediastinal glands after measles or whooping cough and of the mesenteric glands as a result of catarrh of the intestines. The specific cause of tuberculous adenitis is the bacillus tuberculosis. Symptoms. The glandular involvement may be either general or localized. The former is rare but has been observed, and particularly in the colored race. The appearance resembles that of Hodgkin's disease, there being enlargement of the cervical, submaxillary, axillary and inguinal glands with pain and tenderness, and post mortem examination revealls an analogous state of the bronchial, mesenteric and other internal lymph nodes. There is a febrile movement and death may take place from the pressiure of the enlarged ganglia upon the bronchi or trachea or from associated disease. Enlargement of the bronchial glands is frequent in pulmonary tuberculosis; the condition may be so pronounced as to be recognized intra vitam or in less marked instances is not disclosed until after death. Local tuberculous inflammation of the lymph glands is most frequent in those of the cervical region. It is common in children, especially those of delicate constitution and whose surroundings are unsanitary. It may follow the glandular enlargements which occur as a result of tonsillar enlargement, inflammations of the ear and pediculosis or eczema of the scalp. The glands 174 THE INTECTIOUS DISEASES. are at first firm in consistency and discrete, later they become matted together into a diffuse mass and finally they may soften and suppurate, and becoming adherent to the overlying skin, ruptvire externally and discharge their contents. There is an irregular febrile movement, and the patient is poorly nourished. In ce^-tain instances the glandular involvement extends to the lymph nodes beneath the clavicle, those of the axiUa and even to the bronchial ganglia; these last tend to undergo caseous degeneration rather than to suppurate. A unilateral inflammation of the axillary glands may be the precursor of a tuberculous involvement of the pleura or lung. Involvement of the mesenteric or retroperitonaeal glands {tabes mesenterica) occurs as a result of tuberculous enteritis or primarily in simple catarrhal inflammations of the intestine. The latter form is especially common in children. The patient is emaciated and anaemic, the abdomen is prominent and tympanitic and diarrhoea with foul-smelling movements is present. The febrile movement is moderate. Palpation reveals the presence of the enlarged glands, more rarely of tuberculous deposits in the peritonaeum itself. Death takes place from intercurrent disease or from exhaustion. In adults tabes mesenterica is less frequent but may occur primarily or secondary to pulmonary tuberculosis. The tuberculous glands of the mesentery and those of the retroperitonaeal region tend rather to undergo cheesy and calcareous degeneration than to suppurate. The diagnosis of tuberculous adenitis from Hodgkin's disease (pseudo- leucaemia) is usually not difficult. In the former the glandtilar involvement is less likely to be general, the glands tend more to become massed together, to become tender and to suppurate, while in the latter they are more movable and less adherent to the surrounding tissues. The examination of the blood will differentiate tuberculous glandular enlargement from that of lymphatic leucaemia and the glands of simple lym- phoma are harder, more discrete, less tender and less likely to become in- flamed; likewise constitutional symptoms are absent. Malignant disease is more rapid in its progress and attended by cachexia and metastases if sarco- matous, while in carcinoma we have the primary growth to which the glandular enlargement is secondary. The prognosis of cervical adenitis is usually good, but that of tabes mesen- terica is distinctly bad. Many cases of acute tuberculosis are said to result from the glandular form of the disease. Treatment consists in the employment of the general measures, hygiene, fresh air, feeding, tonics, etc., mentioned under the treatment of chronic pul- monary tuberculosis and especially the administration of iron iodide — 15 minims (i.o); iodine locally in the form of the tincture painted on, the compound iodine ointment or as iodine-vasogen seems to have a certain in- TUBERCULOSIS. 175 fluence in lessening the glandular enlargement. The internal administration of codliver oil is also to be recommended. Rather encouraging results have been reported from the X-ray treatment of tuberculous glands of the neck and in the opinion of certain observers the prospect of success is sufficient to warrant the employment of this means. Suppurating glands should, however, be incised and evacuated; the sluggish sinuses which so often persist may be benefited by the application of the X-ray which seems to stimulate the healing process. The early surgical treatment of tuberculous glands consists in their removal by dissection, often a difficult and prolonged operation. Tuberculosis of the Pleura. Tuberculous involvement of the pleura occurs primarily in two chief forms: a, with a sero-fibrinous exudate which is likely to be blood tinged; b, with a piirulent exudate. Either of these may be acute in onset or slow of evolution. They are usually associated with tuberculous infection of the lung but in certain instances may precede the incidence of the latter. Secondary tuberculous pleurisy occurs in an acute and a chronic form. The former is the result of the extension of the inflammation involving the adjacent pulmonary tissue and may be characterized by the exudation of fibrin, serum or pus. The latter is characterized by the exudation of fibrinous exudate which becomes organized and with the accompanying cell proliferation, results in marked pleural thickening and adhesions. This newly formed tissue is subject to tuberculous infiltration. Symptoms. These are identical with those of the various forms of non- specific pleurisy (see p. 643), with the addition of the manifestations due to the accompanying tuberculous involvement of the lung. The physical signs also differ in no way from those of simple pleurisy. Treatment consists in the employment of the methods applicable to pul- monary tuberculosis in general and in the evacuation of the accumulated fluid by aspiration, if serous, or if purulent by incision and the excision of a rib if necessary. Tuberculosis of the Peritonaeum. The peritonseal membrane may be the seat of tuberculous disease which manifests itself in the following forms: a. A non-inflammatory form in which the miliary tubercles are scattered through the visceral and parietal layers of the peritonaeum. b. An inflammatory type in which the tubercles are associated with pro- liferation and adhesions of the two layers of the membrane which may pro- 176 THE INFECTIOUS DISEASES. ceed to obliteration of its cavity, or there is pronounced thickening with less tendency to adhesions. The mesentery is infiltrated and the omentum is greatly thickened and contains deposits of tuberculous tissue and similar areas may occur in the peritonaeal coat of the intestine and that portion of the memlprane which envelops the spleen and liver; the disease may occur with hepatic cirrhosis. Serous, bloody or purulent fluid may be present in the general peritonaeal cavity or collections may be walled off by adhesions. The disease may occur at any age and is especially frequent in the colored race. Children, subject to catarrhal affections of the bowel, and young adults are often affected. Symptoms. Tuberculous peritonitis may exist without being evidenced by any symptoms whatever. In other instances these may appear with such suddenness as to suggest an internal hernia which has become strangulated; in still others the disease may resemble a simple acute peritonitis or enteric fever. The temperature in the more acute cases is elevated but in others the febrile movement may be almost wholly absent. The patient's nutrition may be but slightly impaired. Abdominal tenderness may or may not be present. Physical examination reveals a great variety of conditions, tym- panites and ascites are frequent and a stiff, rigid abdominal wall is considered characteristic of the disease. Sacculated collections of fluid walled by adhe- sions may be detected and nodular firm masses may be made out. The diagnosis offers many difficulties unless examination of the other organs and tissues reveals associated tuberculous involvement. The tuber- culin test may be employed to clear up doubtful cases. Treatment consists in the employment of the measures aheady suggested to increase the patient's nutrition and power of resistance. The febrile movement may be controlled as suggested upon p. 169. Diarrhoea should be controlled by intestinal antiseptics, and laxatives may be prescribed when indicated. The abdominal pain may be relieved by the local use of the tincture of iodine or the actual cautery. Inunctions of ichthyol 4 parts, belladonna extract 2 parts, mercurial ointment, vaseline and lanolin each ID parts or applications of guaiacol i to 2 parts, tincture of iodine 15 parts, glycerin 20 parts may be employed. lodine-vasogen may also be employed a§ an inunction. The use of the ice bag may assist in relieving the pain as may also rubbing with a mixture of chloroform 10 parts, hyoscyamus extract 10 parts, camphorated oil and lanolin of each 25 parts. Marked ascites should be relieved by aspiration and in certain instances considerable benefit has followed laparotomy. Tuberculosis of the Pericardium. Tuberculosis of this structure occurs less frequently than similar affections of the pleura and peritonaeum. It may be either primary or secondary. The TUBERCULOSIS. 1 77 condition may be unrecognized during life and cause no characteristic symp- toms or it may manifest the symptoms of acute pericarditis with the effusion of serous, sero-sanguinolent or purulent fluid. In other instances the inflam- mation is characterized by adhesions of the pericardium with accompanying symptoms of cardiac dilatation and hypertrophy and various cardiac mur- murs. Acute tuberculosis may result from a primary tuberculous involve- ment of the pericardium. Tuberculosis of the Kidney. Pathology. Tuberculosis of the kidney occurs, either associated with general tuberculous infection, in which there are miliary tubercles scattered through the organ, or as an affection characterized by areas of tuberculous degeneration which are prone to coalesce, become cheesy and softened, spread- ing so that the entire kidney is converted into a caseous or purulent mass. Such a condition may be secondary to tuberculous prostatitis, cystitis, ureteritis, or pyelitis and may spread also to the epididymis or testicle, ovary or tubes. One or both organs may be involved. Symptoms. Miliary tubercles may be present in the kidney without caus- ing any especial symptoms. In the second type of the disease the symptoms consist of the passage of purulent urine which may contain blood from time to time. Micturition is usually frequent and there may be dull lumbar pain. The patient usually loses flesh and strength and suffers from chilly feelings and irregular rises of temperature. Tuberculosis of the lungs or of other organs is very frequently present. Palpation of the region of the kidney causes pain and the kidney itself may be felt. A large tumor is seldom made out but if the pelvis of the organ is distended with pus this may be detected as a fluctuating mass. The urine contains pus, epithelial cells, cheesy masses, at times red blood cells. Casts are seldom seen but albumin is present due to the pus cells. The reaction is more usually acid than in cystitis and upon sedimentation by means of the centrifuge and staining by the ordinary methods tubercle' bacilli may be found, assuring the diagnosis. If there is doubt as to which kidney is involved the catheterization of the ureters is a simple matter to the skilled hand. Treatment aside from the employment of the usual means to improve the patient's general condition is entirely surgical. If only one kidney is affected it may be removed in toto or if but a few tuberculous nodules are found these may be excised and the kidney restored to place. Tuberculosis of the Pelvis of the Kidney, Ureter and Bladder. The symptoms of these conditions are in no way to be distinguished, except by the detection of the tubercle bacillus in the urine, from simple inflam- lyS THE INFECTIOUS DISEASES. mations of these structures. Frequency of urination, pyuria and occasional haematuria are the principal manifestations. Finding the tubercle baciUus in the urinar}' sediment does no more than to prove that there is tuberculous infection of the genito-urinary tract, it does not distinctly locate its position. Cystoscopy is of some aid and by means of this and the searcher we should be able to eliminate calculus. Ureteral catheterization which draws a non- purulent urine should prove the freedom of the ureters from disease, but it is doubtful if it is advisable to risk infecting these structures by catheterlzing them through a diseased bladder. Still this is a matter for the specialist to decide and the procedure may be without danger if the bladder is previously washed and then filled with an antiseptic solution. A persistent cystitis of iodiopathic origin is always suspicious, particularly if there is tuberculous involvement elsewhere in the body. Treatment consists in attending to the patient's general condition and the employment of the usual means, irrigations, etc., applicable in cystitis. Unfor- tunately hexamethylene seems less capable of destroying the tubercle bacil- lus than other pathogenic organisms in the urine. Tuberculosis of the Testicles, Prostate Gland and Seminal Vesicles. Tuberculosis of the testes and prostate gland occurs as a caseous degen- eration seldom proceeding to liquefaction. Testicular tuberculosis is not rare and may be either primary or secondary to tuberculous disease of other parts. It is seen in children and in adults and has been observed in the foetus. The epididymis is usually first invaded whence the affection spreads to the testicle itself; the organ is enlarged, later becomes softened, ulcerated and fistulae, the walls of which are infiltrated with tuberculous tissue, are formed. The condition may be mistaken for syphilis; both are painless but the latter affects primarily the body of the testis in which are situated irregu- lar nodules of a stony hardness. In prostatic tuberculosis the gland is nodular, the nodules being palpable upon rectal examination, there is vesical irritability and catheterization is painful and difficult. Treatment aside from the employment of general measures is surgical. Tuberculosis of the Ovaries, Uterus, and Fallopian Tubes. Tuberculosis of the tubes is the most frequent of these affections and may occiir primarily. The diseased tube is enlarged, infiltrated and hard and contains mucus, pus and caseous matter. Abscesses followed by peritonitis may occur. Both tubes are usually involved. Ovarian tuberculosis is usually secondary to tubal disease; the organ may be infiltrated with tubercles or caseous areas, which may form abscesses, may be present. ACUTE INFECTIOUS PNEUMONIA. 1 79 Uterine tuberculous disease is rare and may be primary; usually, however, it is secondary to disease of the tubes or vagina. The waU of the organ is infiltrated with tubercles and its mucous lining is thickened. The tubercles may undergo degeneration and result in ulceration and metritis, the symp- toms of which differ in no way from uterine inflammation due to other causes. Tuberculosis of the Mammary Gland. This affection may occmr in either sex but is by far more common in women; it is most frequent between the ages of 40 and 60. Tubercles are deposited in the glands; these degenerate and soften, breaking through the skin and forming suppurating fistulse, in the walls and discharge of which baciUi may be found. The axillary glands may be enlarged. Cold abscesses of the breast may occur. The course of the disease is usually protracted, but recov- ery is possible under proper constitutional and svirgical treatment. Tuberculosis of the Heart and Blood-vessels. Tuberculous disease of the myocardium with tubercles in the substance of the muscle may occur as part of acute general tuberculosis; caseous degen- eration is very infrequent. Secondary tuberculous endocarditis due to a mixed infection may be observed in pulmonary tuberculosis and a verrucous endocarditis with tubercles in the valvular vegetations has been observed. Primary tuberculous disease has been found in the waU of the aorta in rare instances and the disease may involve, by extension, the vessels of diseased tissues; such inflammation weakens the vessel wall and perforation with haemorrhage may result. ACUTE INFECTIOUS PNEUMONIA. Synonyms. Croupous Pneumonia; Pneumonitis; Lung Fever; Lobar Pneumonia; Fibrinous Pneumonia. Definition. An acute, infectious inflammation of the lungs, rendering the involved portion of the organ impervious to air, and characterized by a chill, fever, dyspnoea, rusty sputum, and prostration. Etiology. Acute infectious pneumonia is common in all countries. It occurs chiefly in adults and is most frequently seen during the cold and damp seasons of the year. Males are more prone to the disease than females, prob- ably because of the greater liability to exposure of the former. Alcoholism, debilitated conditions and exposure to cold and wet are predisposing factors. One attack is likely to predispose to another. At times the disease seems to occur epidemically. The specific cause of the disease is probably infection by either the micro- l8o THE INFECTIOUS DISEASES. COCCUS lanceolatus or diplococcus of Frankel, or the bacillus pneumonic^ of Fried- lander or both these together. Streptococci, staphylococci and various other micro-organisms may be found in pneumonic sputa as the result of a mixed infection. It seems to be the accepted idea at present that a number of differeht bacteria are capable of producing the disease. Pathology. In lobar pneumonia the pathological anatomy may be di- vided into three stages. a. Congestion or hyperaemia. h. Red hepatization or exudation. c. Gray hepatization or resolution. The lower lobes are most frequently affected, but involvement of the upper lobes is not rare, and even the whole of one lung may become the seat of the morbid process. When the upper lobes are involved the disease is usually of severe type. During the stage of congestion the lung is oedematous but not consolidated and in the air spaces are Ifeucocytes, red blood cells, fibrin and epithehum. The vessels in the walls of the alveoli are distended. The small bronchi undergo a like change, but the larger bronchi may or not be involved. The pleura as a rule remains normal. The first stage usually lasts only a few hours but may continue throughout several days. When the first stage has reached its height the air spaces and bronchi which are the seat of the inflammation are filled with its products and the lung becomes solid, the stage of red hepatization. The air vesicles, spaces and bronchi are plugged with the red blood cells, leucocytes and fibrin, but the vessels of their walls are not rendered impervious. The pleura over the affected lobe is the seat of a fibrinous pleurisy. The solidified lobe is enlarged so that it may interfere with the action of the other lobes; about 25 percent, of the fatal cases die in this stage from one to ten days after the onset of the disease. After the air spaces have become filled and the lobe is solidified the third stage ensues. The inflammatory material becomes gray in color and soft- ened. The lung remains solid. If the patient recovers the exudate continues to soften and disintegrate, the stage of final resolution begins and the lymph circulation carries off the inflammatory products. Resolution should begin when the temperature falls to normal and should be complete in a few days. The stage of transition between red and gray hepatization takes place between the second and eighteenth days of the disease. About 50 percent, of the fatal cases die in this stage. If perfect recovery takes place the lung is restored to its original condition. Symptoms. In a certain number of cases there are prodromata such as chilliness, slight fever, general malaise and a sense of oppression, due probably to a lengthened first stage or period of congestion, but in a great proportion ACUTE INFECTIOUS PNEUMONIA. i8i of cases the disease is ushered in by one or more distinct chills. The tem- perature immediately rises and continues elevated, with morning remissions until defervescence. Sudden rises in temperature during the course of the disease usually mean an extension of the inflammation or the onset of a com- plication. When the inflammation affects the upper lobes the temperature is likely to be especially high. Certain patients, especially old persons, show very little rise of temperatiure, but this does not indicate a mild attack. DRV OF DISEASE 1 ^ 3 4 5 6 7 8 T "^ u 12 13 14 15 16 17 18 ^ ^ ^ -42° HOUR M V, 5!v MIM «Im wiw MM mIm m'm £lS K'% m'm s's aIp 5m aIp JLm aIp P p u ^= ± Et eIe dz q= -^ z^ bz ^ i E E E 107 VWj = ^ zlr zr E^ cr — 3Z — = E - \ — pJ - — -- — -^ — -Y- —^ —r- — — — - — •5 105 4= EE I E E e EE - F E E - z d z E E z E ^ E E z -41° ^ d z = EE i^ E - E E E E z i ^ ^- z I E I F : B 9 w^ S P p - * ^ Zl I r t ; = - ±i Zl zh - I r -40 ^ ±. z z q z t: ;i I a ~ H = ~ = 3 =5 — - zi - = s 3"^ z c I - h E ;e z E E E E - E z = z E EE z z z 1 c 'f r - ^ I - c : : :=] 4 t z = z : = z z = = - z! = z39 B 3 g 101 - - ^ - — - - - - — J - — - - w ^ o 100 - - H -^ - — - — - ^ - -^ - — — - — - -) - - - -^ — — - - — - — - - - -^ - — - - — - -38 3 99° - - - - d - - - - z :r - z z z - : z z z q z d z tz z z = o ^ --^ I _ _ - _ _ _ _ _ _ _ _ , _ _ _ J _ — — — —^ - — 1 — — ■ — - — -^ — ' — ' ' — — — — — — — — — — — -37° _ _ -■ _ & _ _ _ ^ cf _ __ ^ _ — 1 — 1 _ jr z — — z — — z — S, * a: z z b: z ~ z ~ z; ~ z z 3 97° — ' — 1 —• — — — — -^ — — — — ' — — — — — — '— — : - - -> — -- - — - — — — — - — - — — — L- — - -^ - L — L -J — - — -- -^ — ^ — — - — - — — -J - — 1-^ — -36° 96 — —' -^ — — — — - — — — — ' — — — — — — ; — 15Q 140 180 ^ 1 120 f r ' v a 110 / ^ / V, 'J 100 ^ s: 90 80 70 60 -- - r 50 40 - RESP. S i % 5 % g S ^ ^ ? sj; S t CI ^ s -„ ss _ u _ _L Fig. 7. — Clinical chart of acute infectious pneumonia. Defervescence usually takes place by crisis on the seventh day, but may occur earlier or later, crisis on the fifth, ninth, or eleventh days being not rare. In other cases the defervescence takes place by lysis — this being particularly likely to occur in the pneumonia complicating epidemic influenza — the fall to normal extending over a number of days. The pulse is at first fuU and rapid, later becoming weaker as the heart is embarrassed by the obstruction to the passage of the blood through the lungs and the lack of oxygen due to the diminished respiratory smrface. l82 THE INFECTIOUS DISEASES. The respiration is rapid and shallow and as the disease progresses varies with the amount of lung involved; the inspiration is short and may be accom- panied by a grunting sound. The normal pulse-respiration ratio (4 to i) is disturbed, a ratio of two pulse beats to one respiration being not infrequent. Very labored breathing indicates large involvement of pulmonary tissue, marked congestion, severe bronchitis, tendency to heart failure or inflam- mation of the pleura or pericardium. With the onset there is usually sharp stabbing pain in the chest, increased on coughing or inspiration and due to pleuritic inflammation. Cough may be an early symptom or appear later in the disease. In the aged, especially, it may be absent. The sputum is a blood stained muco-pus, (the so-called "rusty sputum") and very viscid, so much so that it adheres tenaciously to the sides of the containing vessel. In severe cases the sputum may be thin and dark colored — "prune juice" — and large in quantity. As resolution takes place the sputum becomes lumpy and yellowish or greenish. In certain cases and not infrequently in old persons there may be no expec- toration. From the onset the prostration is marked, the face assumes a characteristic expression of anxiety and there is usually a deep flush over the malar bones. Herpes labialis is not rare, and cyanosis of the lips and extremities may occur when there is marked obstruction to respiration. At the invasion there are often nausea and vomiting ; the tongue is moist and coated. In severe cases it becomes dry, brown and cracked. Headache and general pain are common early symptoms. In severe types of the disease delirium and stupor are often seen. In alcoholic patients the infection is especiaUy virulent and is usually accompanied by marked delirium, often by delirium tremens. The urine is scanty, hyperacid and diminished in quantity. It may con- tain albumin and casts and its chlorides are diminished. A distinct leucocytosis is a feature of this disease. Physical signs. Inspection, first stage: Respiratory movement is likely to be diminished on account of pain. Second stage: The normal side of the chest moves as in health, movement in the affected side is diminished. If both lower lobes are involved the movement of the diaphragm is interfered with and the respiratory movement is most apparent in the upper part of the chest. Palpation. First stage: The vocal fremitus is slightly increased. Second stage: The vocal fremitus is distinctly increased as a rule, rarely diminished or absent, probably due to occlusion of the bronchi by inflammatory products. Percussion. First stage: UsuaUy the note is unchanged, but it may be higher in pitch, shorter in duration and less distinctly pulmonary in quality. Second stage: The note is now more or less dull, though it may be flat, ACUTE INFECTIOUS PNEUMONIA. 1 83 tympanitic or even cracked-pot. If the pleural cavity contains fluid, over this the note will be flat. Auscultation. First stage: The respiratory murmur may be harsh or diminished. There may be subcrepitant rales due to the exudation into the small bronchi and coarse rales with sibilant and sonorous breathing due to inflammation of the larger tubes. Second stage: In most cases both voice and breathing over the consolidated lobe are bronchial but there may be bronchial voice without bronchial breathing or both voice and breathing may be absent. Third stage: As resolution progresses the breathing becomes broncho-vesicular, subcrepitant and coarse rales in the bronchi are heard, due to the presence of the softened products of the inflammation. As resolu- tion continues normal vesicular breathing becomes more apparent and the percussion note approaches nearer to pulmonary resonance. The dulness is the last of the physical signs to disappear, it often remaining to a slight extent long after the patient has recovered. Complications. Of these pleurisy is the most common, indeed it occurs whenever the pneumonic process reaches the siirface of the lung and accord- ingly is so frequent as hardly to deserve the dignity of being numbered with the complications. To it is due the severe pain of the early stages and it is evidenced by the typical friction sounds, which, however, may be obscured by the other physical signs present. Effusion of serum into the pleura is not rare and may go on to empyaema, in the pus of which pneumococci are usually found; in infrequent instances streptococci may be present. Purulent fluid is accompanied by a septic temperatiire with rigors and sweats and an increased leucocytosis. The physical signs are those of fluid in the pleural cavity. If there is doubt the use of the aspirating needle is justifiable. Pericarditis is occasionally observed and is easily overlooked; the fluid is usuafly of small quantity, serous in most instances; rarely it may be pioru- lent. Endocarditis is not very rare and is of the malignant type. It is especially likely to occur if there has been previous disease of the heart. The physical signs may be absent but if the temperature persists and becomes of septic character, signs of embolism appear, or if a cardiac murmur develops, involve- ment of the heart should always be suspected. Meningitis is a serious but not very common complication. The most usual time for its appearance is while the fever is at its highest and it may not be recognized, being masked by the cerebral symptoms of the disease. Endocarditis may be co-existent and as a result of this latter there may be cerebral embolism with its accompanying symptoms. CompHcations which are infrequently met are neuritis, jaundice, parotitis, thrombosis of the peripheral veins, usually those of the leg, and peritonitis. In considering the complications of pneumonia that form of the onset of 184 THE INFECTIOUS DISEASES. the disease which is marked by abdominal pain may be mentioned. In some instances the symptoms referable to the lung, if present at all, are wholly subordinate to severe pain in some part of the abdomen. If this occurs in the appendiceal region inflammation of the underlying structure may be suspected. The pain may also be localized near the navel or deep in the epigastrium and suggest haemorrhage into the pancreas. The diagnosis is easy when the physical signs are typical, pleurisy with effusion being more usually mistaken for lobar pneumonia than any other disease. In the latter condition, however, vocal fremitus is increased, while in the former it is absent and the constitutional symptoms are much less severe. The aspirating needle may be used if necessary. In pneumonia there is an increased leucoc}1;osis, while in pleurisy, unless the fluid is purulent, this is not the case. Pneumonic sputum usuaUy contains the specific micro- organism of the disease which will aid in the differentiation from tubercu- lous conditions. The prognosis shoiild be guarded, the outcome of the disease depending in great measure upon the age of the patient, his previous condition, and upon the extent of lung affected. Involvement of the upper lobes is considered more serious than that of the lower. Death usuaUy takes place as a result of cardiac failure or of one of the complications, meningitis and endocarditis being particularly likely to cause a fatal termination. Under the treatment to be described the mortality should be much lowered. Prophylaxis. Pneumonia has recently become classified as one of the infectious diseases, consequently all discharges, especially the sputum, which may contain the contagium should be treated as usual in infectious conditions, and as an additional precaution rooms which have been occupied by pneu- monia patients should receive proper fumigation before being again occupied. Cleanliness on the part of the nurse and physician should also be maintained as strictly as in the handling of the more \irulently contagious diseases. Treatment. From the onset of the disease the patient should be confined strictly to bed and not allowed to rise for any consideration, sudden attacks of heart-failure having been known to occur as a result of so slight an exertion as merely sitting up in bed. The patient should wear a flannel night gown or shirt which should open behind to facihtate examination of the chest. The room should be large, light, weU ventilated and kept at a temperature of from 65° to 70° F. (18.3° to 21.1° C). At the onset of the disease calomel should be administered, followed by a saline, and throughout the infection the bowels should be kept freely open. Medicinal treatment should be directed i, toward limiting the infection; 2, toward overcoming the mechanical disadvantages; 3, toward the elimi- nation of the products of the bacterial cause of the disease. In the exhibition of creosote carbonate we have a means of limiting the ACUTE INFECTIOUS PNEUMONIA. 185 infection as proven by the statistics of various authorities. This drug cuts short or aborts a large percentage of cases, mitigates almost all the rest, and in a small proportion of patients no result is obtained. Certainly if the early appearance of the crisis is any indication of the value of the treatment this remedy is deserving of a trial. Unlike creosote itself the carbonate is not disturbing to the kidneys or stomach even when administered for considerable periods of time. The usual dose is from two to four drachms (8.0 to 16.0) daily, the dose interval being sLx hours, but to a vigorous man as much as one-half a drachm (2.0) every two hours may be given. It may be given in milk, sherry, or pure. The medication should be continued until the tem- perature has remained normal for four or five days, but when the febrile stage is passed the dosage may be reduced one-half. The mechanical obstruction to the circulation is best combated by the use of nitrites (glyceryl nitrate or sodium nitrite). These relieve the high tension in the pulmonary circulation to a slight extent and that of the systemic circulation markedly. Of late erythrol tetranitrate in doses of one-half grain (0.032) every four to six hours has given more even and controllable effects than the evanescent glyceryl nitrate or the uncertain sodium nitrate. Hypodermatic stimulation by strychnine nitrate or sulphate in doses of from one-fiftieth (0.0012) even to one-tenth of a grain (0.006) every four to six hours may be employed as indicated, and continued until the desired result is obtained. The heart should be carefully watched for signs of dilatation and when these — weak- ness of the pulse and of the pulmonary second sound — appear the stimu- lation is necessary. Care should be taken not to mistake the appearance of defervescence for threatened cardiac weakness, for at the crisis the pulmonary second sound loses its booming character on account of the lessening of the tension in the pulmonary circulation consequent upon beginning resolution. Alcohol as a stimulant shoiild usually be confined to patients accustomed while in health to it. The amount given should be gauged by the patient's condition and may even reach a quart (litre) per day. Ammonium carbonate in 10 grain (0.66) doses, in 2 ounces (60.0) of milk every 2 hours, replaces the strychnine in the aged. Excellent results are. claimed for and obtained by veratrum viride in the very early stages of the disease occurring in young or even middle-aged individuals, but unfortunate results are quite as fre- quent as successes with this drug and it is to be employed exceptionally only. To bleeding the same remarks, though perhaps, more stringently will apply. It is also well known that venesection does not give as good results in pneumonia as in cyanosis with dilated right heart due to other causes. This observation leads us to question as to how much the pressure in the pulmonary artery is raised by extensive pulmonary consolidation. Toward elimination of the products of the bacteria causing the disease we 1 86 THE INFECTIOUS DISEASES. can do much by means of high rectal irrigations of normal (0.9 percent.) saline solution, one gallon at 112° F. (44.4° C.) given twice daily. It is particularly potent in patients with complicating renal disease. It is a most valuable method of provoking diuresis, stimulating the heart, cleaning the large intes- tine and to a less extent producing diaphoresis. One-sixth of a grain (o.oii) of calomel every hour for six doses, with saline laxatives sufficient to empty the bowels completely and keep them open afterward, with from three to six grains (0.2 to 0.4) of zinc phenolsulphonate every two to four hours, may be administered with benefit. When the odor has disappeared from the stools the zinc should be given in doses just sufficient to prevent foetor and if constipation occurs a second course of calomel followed by a saline may be prescribed until the stools are odorless. It is true, however, that under the creosote treatment tympanites is rare and the necessity for intestinal disinfec- tion is much lessened. Oxygen is of value if the respiratory surface is much decreased and its inhalation is advocated by many as a valuable curative measure. It gives ease to the patient, relieves the cyanosis, the failing heart and the laboring respiration and may induce sleep. The best method of administering it is to arrange a funnel attached to the container in front of the patient's nose and mouth. It must be given for considerable periods at a time and in some cases incessantly. Certain observers advocate its intermittent use from the beginning of the disease on the ground that it is likely to ward off respiratory failure. Expectorants when necessary may be prescribed, the preference to be given to apomorphine hydrochloride -^ of a grain (0.002) every 4 hoiu:s. Acute infectious pneumonia in the aged is a very serious disease on account of the tendency of old persons to heart weakness and pulmonary hypostasis. Free stimulation is likely to be necessary and the patient should be rolled from one side to the other several times a day. It is the author's custom, when the stomach will bear the drug, to administer 10 grains (0.66) of ammo- nium carbonate in 2 ounces (60.0) of milk 3 times a day in these cases. Local applications which interfere with the patient's comfort are to be avoided. A pneumonia jacket of cotton batting overlaid by oiled-silk is pleasing to many and if pleuritic pain be present a layer of cataplasma kaolini spread on the chest and covered with layers froril a roller bandage often affords relief. A liniment of equal parts of menthol, chloral and camphor well rubbed in at the seat of the pain is also useful. In very marked pleuritic pain hypo- dermatic injections of morphine may become necessary. The headache and deUrium may be mitigated by the use of the ice helmet. Treatment by means of an antitoxin has been extensively attempted but the results, as a whole, fail to carry conviction. An efficient serum, or one which will shorten the disease, has not yet been elaborated but in the opinions BRONCHO-PNEUMONIA. 1 87 of certain observers the serums at present available have a limited use. The results so far attained by the use of treatment by antitoxin have modified the mortality to scarcely sufficient degree to warrant its universal employ- ment. The serimis thus far elaborated possess no antitoxic qualities and that they possess anti-infectious properties has yet to be proved. Notwith- standing the discouraging results attained up to this time in the attempt to discover a potent treatment for pneumonia along this line, further research is to be encouraged. Diet. Milk, preferably peptonized or diluted with Vichy or lime water, or the fermented milks, kumyss or matzoon, should be our chief reliance. The preparations of the meats in the form of extracts may be allowed. Taking all into consideration the treatment of pneumonia is especially satisfactory. In fine we should rely upon: i. The continuous, persistent and generous administration of creosote carbonate. 2. Careful adjustment of mechanical conditions. 3. Thorough evacuation of toxins by all possible means. 4. Temporary supplemental oxygen by inhalation. 5. Liquid diet until all physical signs disappear. BRONCHO-PNEUMONIA. Synonyms. Catarrhal Pneumonia; Capillary Bronchitis; Lobular Pneu- monia. Definition. A disease of the lungs caused by microbic infection and char- acterized by areas of consolidation of varying size scattered through the lung, each surrounding a bronchus. .etiology. It is this form of pneumonia which occurs most frequently in children; it is also prone to attack the aged. The disease may occur primarily as a result of exposure; especially is it predisposed to by catarrhal affections of the air passages and particularly by the presence of adenoids and enlarged tonsils. Secondarily broncho-pneumonia occtu-s as a complication of the acute infec- tious diseases particularly those to which children are prone, measles, scarlet fever, diphtheria and whooping cough, which accounts for the numerous in- stances of the disease during the early years of life. It may occur secondary to bronchitis in adults as well as in infants and in the former, especially in old age, it may complicate the infectious diseases and various chronic affections such as nephritis and endocarditis. The so-called foreign-body or inhalation pneumonia is a variety of broncho- pneumonia; this type of the disease is caused as follows: In comatose states or when for any other reason the sensibihty of the glottis is impaired, particles of food or drink may pass into the trachea and thence into the smaller bronchi where they cause irritation, subsequent inflammation and even sup- l88 THE INFECTIOUS DISEASES. puration and gangrene. Inhalation pneumonia may follow operations upon the pharynx or larynx, and the inhalation of particles of blood clot raised during haemoptyses; it may occur in individuals whose occupations necessi- tate the respiration of air impregnated with dust, such as coal miners, stone- cutters, etc. Poor hygienic surroundings and poor sanitary conditions predispose to the incidence of broncho-pneumonia. The mirco-organisms most often associated with broncho-pneumonia are the streptococcus pyogenes, staphylococcus albus and aureus, the pneumobac- illus and the micrococcus lanceolatus. The diphtheria bacillus also may be found if the affection is secondary to diphtheria. Mixed infections are the rule. Pathology. The surface of the lung, if the areas of consolidation reach the surface of the organ, shows prominences, over which the pleura may be the seat of a fibrinous exudation, and depressions of darker color; the latter representing collapsed lung which may, however, be reinflated. Other parts of the lung may be the seat of a compensatory emphysema. The pro- jecting areas represent consolidation. These are firm and may be small, consisting of a zone of inflamed tissue surrounding a single bronchus, or large as a result of the coalescence of several such areas. Cross section of the consolidated zones reveals a central spot of lighter color from which pus may be expressed; this is the bronchus the lining which is the seat of an exudative inflammation. MicroscopicaUy the exudate in the consohdated portions of lung is seen to be composed of fibrin, pus and red blood cells and epithe- lium. The bronchial mucous membrane is swoUen and infiltrated with leucocytes; its lumen is blocked by an exudate of mucus, pus and exfoliated epithelial cells. The air cells adjacent to the areas of consolidation are dilated and emphysematous. In adults a later stage of the consolidation may resem- ble in appearance the gray hepatization of lobar pneumonia and it may finafly undergo permanent sclerosis. In inhalation pneumonia the inflam- matory process is more pronounced and may be followed by abscess formation or gangrene. The pneumonic process may terminate in resolution, chronic interstitial broncho-pneumonia (cirrhosis of the lung), suppuration or gangrene, or a secondary infection with the tubercle bacillus may take place, leading to acute or chronic pulmonary tuberculosis. Symptoms. In the primary form of the disease the onset may be sudden, with a chill, which may be unnoticed, or a convulsion, but more commonly the invasion is gradual with cough, increasing dyspnoea and a rise of tem- perature. In the secondary type we usually have the symptoms of the primary affection and a cough to which a febrile movement is added — ioi° to 104° F. (38.5° to 40° C). The cough becomes more marked, the pulse rapid and the BRONCHO-PNEUMONIA. 189 respiration increased — 46 to 60 or even higher — there is dyspnoea and often cyanosis of face and extremities. As the disease progresses the cough becomes less frequent but the pulse and respiration remain accelerated, the former growing gradually weaker, until death occurs from failure of the right heart. In more favorable cases after a few days the symptoms abate and recovery takes place. Convulsions may occur as a late symptom. In adults the onset varies but is usually gradual, with cough, rapid pulse, dyspnoea and fever. The diagnosis is usually impossible without physical examination. In inhalation pneumonia the invasion is prolonged and the development of the symptoms slow. Physical Signs. In certain instances the areas of consoUdation may be too small to give distinctive physical signs. Here at first we may have the coarse rales of a general bronchitis, and over a certain part of the lungs, usually in one of the lower lobes posteriorly, coarse sonorous and finer sibilant rales are heard which are soon replaced by fine moist subcrepitant rales with an enfeebled and high pitched respiratory miurmur. Larger areas of consol- idation give the moist subcrepitant rales which, directly over the solidified portion of the lung, are louder and seem closer to the ear. Here the respira- tion is higher pitched and broncho-vesicular. The voice is also of increased resonance. The percussion note and vocal fremitus are often unchanged but if the consoHdated zones are of considerable size slight dulness may be apparent and perhaps slight increase in fremitus. At the center of the solid area the voice and breathing are bronchial, becoming less typically so as the margin of the consolidation is approached. The rales are often absent over the point of maximum consolidation but become more frequent at a distance from this situation. When resolution begins the bronchial voice and breath- ing are the first to disappear; rales may persist for several weeks. It must be remembered that frequently ordinary respiration wiU not suffice to render the physical signs perceptible; the child must be made to take deep respira- tions or to cry. In old persons the signs are analogous to those in children. When the consolidation involves but a small portion of the pulmonary tissue there may be no sign but fine moist rales. In larger areas of solidification the signs are more marked. The diagnosis in children may be easily made, especially in the secondary instances of the disease, for a cough, fever, rapid pulse and respiration, with the occurrence of fine moist rales over a portion of the lungs signify bron- cho-pneumonia and nothing else, but if the consolidated area is large and the physical signs bear a close resemblance to those of acute infectious pneu- monia the differentiation from the latter affection may be difficult. In lobar pneumonia the temperature is likely to be persistently high while in bron- cho-pneumonia it is frequently remittent. 190 THE INFECTIOUS DISEASES. The prognosis is always serious in children, but depends to a great extent upon the previous condition and upon the primary disease if the pneumonia is secondary. In private the patient's chances are far better than in hospital practice. Young infants are more likely to perish than those over i year of age. Patients who take nourishment and assimilate well are likely to recover, but those who suffer from digestive disturbances less commonly do weU. Convulsions in the latter part of the disease are a serious symptom. Even in children the disease may go on to piilmonary tuberculosis. In setere infections death may take place within 24 hours; in favorable cases the disease lasts a week or 10 days and is followed by a convalescent period of similar duration. Treatment. Prophylaxis consists in careful treatment and care for all instances of catarrhal affections of the upper or lower air passages, the removal of adenoids and enlarged tonsils, careful nursing during and avoidance of exposure after all acute infectious diseases and the isolation of broncho- pneumonia patients, when the disease breaks out in hospitals. The patient should be kept in bed, unless he is small enough to be held in the nurse's arms for some time each day, in a thoroughly ventilated apartment — one with an open fire-place is best — and it is wise to remove him to another room at least twice during the 24 hours, while the sick-room is aired. The food should be of liquids entirely and chiefly of milk. If the child is receiving a modified milk mixture it is well to dilute this with equal parts of water during the acuity of the illness. At the onset the bowels should be opened by calomel — tV to J of a grain (0.006 to 0.016) of calomel at J hour intervals until 6 doses have been taken. Poultices or blisters should not be applied, the application, however, of a mild mustard paste of a strength of i part mustard to 6 of flour mixed with lukewarm water and put on while warm is advised. This should be large enough to cover the whole chest, should be applied every 2 to 4 hours and allowed to remain in place until the skin is well reddened, not blistered. If fever is absent the pneumonia jacket of cotton batting laid between muslin and oil-silk, the former being placed next the skin may be worn, but if the temperature is elevated this is best omitted. The cough may be relieved and the bronchial secretion rendered less ten- acious by steam inhalations which are given by means of a croup kettle, the spout of which is passed into a tent made of blankets and arranged over the crib. Either water alone or Hme water may be employed in the early stages; later creosote, eucalyptol or compound tincture of benzoin may be added. Each inhalation should last about a quarter of an hour and these may be given as many as 10 times daily, depending upon the patient's condition. It is very important that the digestion remain undisturbed, consequently BRONCHO-PNEUMONIA. 191 the less medication given by mouth the better; however, we may in many instances prescribe creosote carbonate with benefit. A child of 2 years may take from 2 to 3 minims in a spoonful of milk every 3 or 4 hours. If expec- torants are deemed necessary, and this is seldom the case, to older children in the first stage we may give antimony and ipecac in minute doses and later one of the stimulating expectorants. The following prescriptions may be useful: I^, vini ipecacuanhae 5ij (8.0), vini antimonii 5j (4.0), vini xerici 5iij (12.0). Misce et Signa, 10 drops every 2 hours for a child 2 years old. I^, am- monii chloridi gr. x (0.66), spiritus camphoras 5j (4.0), spiritus setheris nitrosi 5ij (8.0), s)Tupi tolutani 5iij (12.0), aquse gaultherige, aquae destillatae, aa q. s. ad §iij (90.0). Misce et Signa, one teaspoonful every hour for a child 2 years old. Too much stress cannot be laid upon the danger of the indiscriminate admin- istration of expectorants and emetics to children with bronchitis or broncho- pneumonia. Emetics are allowable only when the secretion is profuse and the cough insufiBcient to reheve the bronchial tubes; here we may employ the SATup of ipecac in dose of i drachm (4.0) for a child of 2 years. Emetics are strictly contraindicated in severe infections with depressed circulation. If the cough is distressing smaU doses of pulvis ipecacuanhae et opii with the addition of acetphenetidine (phenacetine) if there is high temperature and restlessness — | a grain (0.03) of the former and i grain (0.065) of the latter — may be given to a child of 2 years. To younger children these drugs should be administered vidth great care on account of their depressing influence upon the heart and respiration and the constipating effect of the opium. Heroine is useful in older children to reheve the cough, the dose for a child of 5 years being from yio" to eV of a grain (0.0006 to o.ooi). Tincture of aconite in doses of 2 minims (0.13) may be given in the early stages of the disease every two hours, when the pulse is full and bounding, until its effect is noted. Stimulation is necessary as soon as there is any evidence of circulatory weakness and here our chief dependence must be placed upon alcohol, in the form of brandy or whiskey, and strychnine; 20 drops (1.33) of either of the two former may be given to a patient of from i to 2 years old every 2 hours. It should be well diluted with water and the dosage may be increased if necessary. The dose of strychnine for a child of 2 years is 2^(7 of a grain (0.0003) every 2 or 3 hours. Attacks of respiratory failure should be combated by full doses of strych- nine and atropine and the administration of oxygen inhalations. The child may be made to cry, which will cause fuUer inspirations of air and freer oxygen- ation of the blood, by continued spanking or the employment of alternate hot and cold applications of water to the chest; a hot mustard bath is useful in collapse. The repetition of these procedures is often necessary. Nervous symptoms, restlessness, sleeplessness, etc., may be relieved by small 192 THE INFECTIOUS DISEASES. doses of acetphenetidine and if the fever reaches 105° F. (40.5° C.) or over, cold sponging is useful. During convalescence tonics, especially codliver oil and the syrup of iron iodide should be prescribed and in cases of persistent cough small doses of creosote carbonate are very useful. It may be necessary to complete recovery to prescribe a change of climate. The treatment of the broncho-pneumonia of adults is essentially the same as that of acute infectious pneumonia see (p. 184.) Inhalation pneumonia is usually secondary to other serious disease and while the general treatment is that of broncho-pneumonia, the results are not all that might be desired. CHRONIC INTERSTITIAL PNEUMONIA. Synonyms. Cirrhosis of the Lung; Sclerosis of the Lung. Definition. A chronic inflammatory affection of the lung characterized by an over-growth of fibrous tissue which replaces the normal pulmonary parenchyma. This interstitial change may be either local or diffuse, accord- ing as to whether it involves small or large areas of the lung tissue. .Etiology. This disease is chiefly a secondary affection and occurs with nearly all chronic pulmonary inflammations. In tuberculosis the fibroid phthisis (q.v.) which at times results is a form of interstitial pneumonia. It also frequently follows a broncho-pneumonia even in children, very rarely it succeeds acute infectious pneumonia. It occurs as a result of the inhala- tion of dust by those whose occupations necessitate working in a dust-laden atmosphere. It may be caused by any of the tumors and cysts which may involve the lung and may be induced by pulmonary abscess. Chronic fibrin- ous pleurisy or pleurisy with effusion may so compress the lung as to lead to fibroid change and the same degeneration follows compression by aneurysmal tumors and the irritation caused by the presence of a foreign body. Microbic infection in addition to mechanical influences bears a distinct relation to the production of interstitial pneumonia. Pathology. The affected lung is shrunken and much retracted within the thoracic cavity and displacement of the heart is usually observed if the affection involves the left lung; pleuritic adhesions are common. On section the lung is dense and firm and of grayish color due to the presence of the fibrous tissue and through this the bronchi and blood-vessels make their course; the former may be the seat of bronchiectatic dilatations, the latter of a sclerotic inflammation. The pulmonary alveoli are to a greater or less extent encroached upon by the over-growth of interstitial tissue. In the tuberculous type of the disease there may be miliary tubercles or cav- ity formation. There is compensatory emphysema of the uninvolved lung and the right ventricle of the heart is hypertrophied and per- CHRONIC INTERSTITIAL PNEUMONIA. I93 haps dilated. Microscopically the fibrous infiltration begins in the wall of the bronchi and spreads thence to the alveolar walls, the entire lobule ultimately becoming fibrous and firm. If the interstitial pneumonia fol- lows an acute infectious pneumonia the exudate in the air vesicles becomes organized into fibrous tissue and a connective tissue change takes place in the alveolar walls as well. Symptoms. Of these the most constant is cough which is much more distressing at some times than at others; it may be paroxysmal. With the cough there is muco-purulent expectoration; when bronchiectatic cavities are present considerable quantities of sputum may be raised from time to time, this manifestation occurring when the cavity is emptied; this sputum may be fcetid. Haemoptysis may take place. Dyspnoea is a frequent symp- tom; it is seldom of very distressing character. The course of the disease is chronic and may be protracted for years, but the patient is seldom prevented from doing light work. Physical Signs. Inspection reveals a retraction of the thorax upon the affected side and a restriction in its respiratory movement; the unaffected side is more prominent and of greater circumference than normal as a result of compensatory emphysema. The apical impulse of the heart may be displaced. Vocal fremitus is diminished if the pleura is thickened. Upon percussion there is dulness or a tympanitic note; over a bronchiectatic cavity the note is amphoric. The note over the unaffected side is hyper-resonant. Auscultation over lung that is solidified by fibrous change reveals a dimin- ished respiratory murmur, broncho-vesicular or even bronchial breathing, or if a cavity is present amphoric breathing. The voice corresponds to the respiratory sounds. The hypertrophy of the right ventricle of the heart results in an accentuated pulmonic second sound; failure of this ventricle is evidenced by the appearance of cardiac murmiurs. The diagnosis is usually easy; fibroid phthisis may however be mistaken for interstitial pneumonia. Differentiation may be made upon the more frequent fever, signs of tuberculosis in the other lung and upon the presence of tubercle bacilli in the sputum in the former condition. The prognosis is unfavorable as to recovery. The course of the disease is prolonged — ten years or even more. Death usually takes place from gradual failiure of the right side of the heart, more rarely from hyaline degener- ation of the viscera, or haemoptysis. Treatment consists in the employment of tonics, nourishing food and all measures calculated to improve the patient's general condition. Life in a warm dry climate may do much to increase the sufferer's comfort and to pro- long his life. Respiratory exercises may be advised but should be carried on under the physician's supervision. The cough may be controlled by the means suggested in the section on the treatment of chronic bronchitis and 13 194 THE INFECTIOUS DISEASES. should the sputum become foul the treatmejit applicable to foetid bronchitis is indicated. Hyoscyamus or belladonna may lessen the tendency to spas- modic cough. EMBOLIC PNEUMONIA. Haemorrhagic Infarct of the Lung. -Etiology. This condition is caused by the lodgment in one of the branches of the pulmonary artery of an embolus which has had its origin in or has reached the right heart from the systemic circulation. Large emboli may cause sudden death, smaller ones cause infarcts of varying size unless the site of lodgment is not in a terminal artery. In this case collateral circulation may be established. Pathology. Pulmonary infarcts are conical in shape and correspond to that portion of the pulmonary area which is deprived of its blood supply by the plugging of its artery by the embolus. The base of the cone is toward the periphery of the lung and the infarct varies in size from that of a pea to that of an egg; when fresh it is red-brown in color and its plemral surface projects beyond the surrounding tissue. The pleura covering it becomes the seat of a deposit of fibrin. In consistency it is more or less solid owing to the transu- dation of blood which later undergoes an inflammatory change. This con- sists first of an emigration of leucocytes from the neighboring vessels, then disintegration and absorption of the red blood cells takes place causing the dark red or brownish color of the infarct to diminish. Finally the infarct becomes pale and the tissues which have been the seat of the transudation contract until little but a fibrous scar remains. The ultimate result is a grayish contracted spot in the lung. If there is a deposit of haematoidin crystals the resulting color is dark red. Larger infarcts may soften in part and disintegrate, the degenerated portion being absorbed or expectorated. In certain instances the scar in the lung may undergo cheesy degeneration and calcification. Symptoms. Large emboli, as has been stated, may cause sudden death without symptoms. Smaller emboli are evidenced by increasing pain in the side and if a portion of lung of considerable size is obstructed there is dyspnoea. Cough with bloody expectoration may be present. The physical signs depend upon the size of the infarct. In those of small area only the signs of a localized pleurisy are obtainable. If the consolidation is of large extent there are dulness, exaggerated vocal fremitus, crepitant and sub- crepitant rales, bronchial voice and breathing. The diagnosis. The symptoms in slight instances where the infarct is of small size may be very slight. In more marked cases the sudden onset with pain in the lung, cough and dyspnoea, without rise of temperature, BERI-BERI. 195 especially if the patient is the subject of arterial disease, renders the condition one not easily to be mistaken. The prognosis is good except when the embolus is very large, when death may take place without warning, considerable portion of the lung being left without blood supply. Treatment. The patient should be kept absolutely quiet in bed. The pain may be relieved by counter-irritation in the form of dry cups or a mild mustard paste; if this symptom is very severe morphine may be necessary. Otherwise the treatment is wholly symptomatic. Septic Embolic Pneumonia. Synonym. Metastatic Abscess of the Lung. .Etiology. This condition is the result of the lodgment in one of the vessels of the lung of a septic embolus. Such infective emboli may become detached from a thrombus in a vessel at a localized infective process such as a septic phlebitis, operation wound, compound fracture, septic puerperal uterus, etc. The embolus passes through the circulation into the right heart, thence it reaches the lung, through the vessels of which it is transmitted until it reaches one of insufficiently large calibre to permit its passage; here it lodges and being loaded with infectious matter terminates in the formation of an abscess. Pathology. The early stage is evidenced by the appearances found in simple pulmonary infarct; the extra vasated blood is, however, more plentiful. Marked inflammation soon arises, the tissues are infiltrated with leucocytes which soon degenerate into pus and the whole area of the infarct softens and becomes an abscess cavity, which if near the pleura may rupture into the cavity of this membrane resulting in pyopneumo-thorax, or, the inflamma- tion spreading by extension, simply a pyothorax. Symptoms. The patient usually is suffering from pyaemia (q.v.) before the lodgment of the embolus which adds to the symptoms of the primary condition a sudden pulmonary pain and a chill followed by rise of tempera- ture and diaphoresis. Treatment. If possible the abscess should be opened surgically and drained; otherwise the treatment consists in the administration of stimulants and the employment of other means applicable in pyaemic conditions (see P- 113)- BERI-BERI. Synonym. Kakkd. Definition. A multiple neuritis of specific origin occurring epidemically and endemically in tropical and subtropical countries and characterized by motor and sensory paralyses and a tendency to oedema. 196 THE INFECTIOUS DISEASES. etiology. This disease is most commonly observed in Malayan countries where it attacks chiefly the natives; Europeans are affected with comparative infrequency. It prevails extensively in China, Japan and the Philippines and from time to time appears in epidemics which may be attended by great mortality. In our own country cases are not infrequently observed in the various seaports and the disease has been met in insane asylums in Alabama and Arkansas, in Louisiana and among Chinese fishermen in Alaska. The chief predisposing cause seems to be the aggregation of a number of individuals in crowded quarters, barracks, jails, ships, etc., under unsanitary surround- ings, in connection with an improper or insufl&cient diet. The disease is seldom seen at high altitudes and warmth and dampness are the most favorable meteorological conditions for its development. Males are more frequently affected because they are more frequently exposed and the majority of instan- ces occur in adolescents and young adults. The theories that the disease is caused by a diet of fish, of diseased rice, and by intestinal parasites are untenable but it is a fact that there has been a great diminution in beri-beri in the Japanese navy since a more general dietary has been allowed, which fact leads Takaki to believe that a regimen containing too much carbohydrate and too little proteid is a considerable factor in the production of the disease. The germ theory of the affection has various arguments in its favor which are summed up by Hamilton Wright in the statement that beri-beri is due to a specific micro-organism entering by the mouth and developing and evolving a toxin chiefly at the pyloric end of the stomach and in the duodenum, which is absorbed and acts upon the peripheral endings of the afferent and efferent neurons. He believes that the specific cause of the disease is given off in the faeces and is capable of producing the affection whenever conditions of weather, climate and mode of life are favorable. At such times the specific germ enter- ing the body upon food or drink gives origin to the disease. Pathology. The most constant and characteristic morbid changes are a degeneration of the terminal branches of the peripheral nerves, atrophy of the nerve cells of the heart and of the terminations of the pneumogastric nerve; later the trunk of this nerve as well as those of the phrenic and splanch- nics are involved. There is degeneration of the heart muscle and of the voluntary muscles. Wright has found in acute cases congestion and pete- chial haemorrhages of the pyloric end of the stomach and of the duodenum. He believes these to be the specific pathologic changes of beri-beri and that they are constant in cases terminating fatally within 3 weeks of the onset. Symptoms. The incubation period is indefinite but is probably a number of months. Premonitory symptoms such as anorexia, epigastric pain, respi- ratory oppression and slight fever are common; chills and cerebral symptoms are more unusual. BERI-BERI. 197 Four clinical forms of the disease may be described. a. The mild or incomplete form of which the chief manifestations are pain, weakness and numbness in the legs. There may be small and distinctly marked areas of anaesthesia; oedema of the legs may be present; palpitation and cardiac irritability are common. Muscular weakness and abdominal dis- tress may occur. Such instances of the disease usually last only a short time but may recur during the next warm season or develop a sudden acute attack of cardiac weakness. b. The dropsical or wet form resembles in its onset the preceding type, but oedema, beginning in the feet and legs and soon involving the whole body including the serous cavities, soon appears; the nerve symptoms are not partic- ularly marked but cardiac disturbance, with dyspnoea and cyanosis is fre- quent and distressing. c. The atrophic form is characterized by an increasing disability to walk, there are pains and contractions in the muscles of the legs; the paralysis extends to the body and sometimes to the arms; there are areas of hyperaes- thesia and anaesthesia and there may be extensive atrophy of the muscles with wrist and foot drop; there is ultimate loss of both galvanic and faradic irri- tability. Cardiac symptoms are slight and may be absent. d. The acute pernicious form. Here the symptoms of onset may be those of the mild type of the disease with suddenly developing manifestations of cardiac failure or the attack may be of the cardiac type from its inception. There is severe precordial pain with marked palpitation and dyspnoea; the patient gasps for breath, the face is anxious, the Hps are flecked with blood- stained froth and death may take place within 24 hours, but in most instances life is prolonged for several weeks. Nausea and vomiting and diminished or suppressed urine are often seen when the disease is near its termination. Fever is not usually noted after the onset of beri-beri unless caused by a complication or a recrudescence. Various cutaneous manifestations such as mottling of the limbs, petechial and herpetic eruptions of the lips are not infrequent. The urinary solids are usually diminished as is the total quantity of this excretion. Albuminuria is not present. The diagnosis in the tropics is easy and cases of neuritis, especially if associated with oedema, seen upon vessels coming from tropical ports should be viewed with suspicion. In doubtful cases irritability of the heart, if pres- ent, is strongly in favor of beri-beri. The prognosis in the pernicious cases is most unfavorable; in other types the mortality varies in different epidemics from 2 or 3 to 40 percent. It must be remembered that patients apparently doing well may suddenly mani- fest most distressing heart symptoms. The sensory, motor and trophic dis- turbances are not permanent. Treatment. Much may be done in the way of prevention. The diet IQb THE INFECTIOUS DISEASES. should be rich in fatty and nitrogenous food and if rice enters into the regimen it is preferably eaten unhusked. All over -crowding should be avoided. The diet of a sufferer from the disease should be generous and regulated in accordance with the suggestions given above. If possible he should move to another climate, faihng this he should be allowed to be up and in the open air as much as possible and his apartment should be one which may be thor- oughly ventilated and to which the sun has free access. Massage and frictions should be prescribed and in the dropsical type of the disease this symptom may be relieved in the usual manner by means of diuretics and diaphoretics; the bowels should be opened by laxatives when necessary. Accumulations of fluid in the serous sacs may be drawn off by aspiration if indication exists. In the atrophic type faradism, galvanism, massage, hot and cold douches and frictions are useful. The cardiac attacks necessitate the administration of stimulants and here our chief dependence should be placed upon inhala- tions of amyl nitrite in emergencies and if necessary upon the continued use of er}1:hrol tetranitrate. The action of this drug is quicker than that of glyceryl nitrate (nitroglycerine), to which it is analogous, and tolerance is not easily established; it is best given in pills of ^ a grain (0.032), made up with kaolin, every 4 to 6 hours. Nitroglycerine is also useful as is digitahs in full doses. Venesection and the withdrawal of 12 to 14 ounces (350.0 to 420.0) of blood will often tide the patient through a cardiac paroxysm. The precordial pain and sense of oppression may be relieved by the hypodermatic use of morphine. Tonics have a place in combating the tendency to wasting and ansemia, and arsenic, potassium iodide, iron, the glycerophosphates and strychnine are all useful. The hypodermatic injection of the following prescription has been suggested. Sodium cacodylate i^ parts, iron and ammonium citrate 3 parts, strychnine sulphate yfo" part and water 25 parts. The dose is 7^ minims (0.5) at first, to be gradually increased to double this amount. The treatment of the paralyses and of the muscular atrophy is identical with that of similar conditions occurring in an ordinary multiple neuritis. (See p. 770.) MYCETOMA. Synonyms. Madura Foot; Fungus Foot. Definition. A disease of one or both feet due to mycotic infection and characterized by the appearance of black granules (the melanoid type) or yellow or white granules (the ochroid type). j3Etiology. The disease is caused by one of two varieties of streptothrix, the melanoid form by strepothrix madurce, the ochroid form by streptothrix FEBRICULA. 1 99 mycetomcB. The organisms are nearly akin to the ray fungus. Madura foot is most common in India but is observed in other Asiatic countries, Europe and South America. Symptoms. The nodules appear upon the sole and are at first hard and dense, later they break down and persistent sinuses result which discharge a foul pus which contains the black or yellow granules. The foot increases in size and ultimately all its tissues become involved, a soft oily mass resulting. The appearance of the affected extremity is typical, its surface being the seat of the discharging sinuses, its sole thickened and the toes extended. The ray fungus may cause a similar condition which may be differentiated from true madura foot by microscopic examination of the organisms contained in the discharge. In certain instances there may be metastases in other parts, the disease being transmitted by the lymphatics. Treatment is wholly siirgical. Excision of the diseased tissues may be effectual if done early enough; when the entire extremity is involved amputa- tion becomes necessary. FEBRICULA. Synonyms. Ephemeral Fever; Irritative Fever. Definition. A transient febrile disease due to any one of a number of irritant causes. The term ephemeral fever is applied to instances in which the rise of temperature lasts not over 24 hours. If the febrile movement persists for several days the condition may be denominated febricula. .Etiology. The usual cause of these disturbances is a disorder of the digestive function, caused either by temporary derangement or by some irri- tant or toxic quality of the ingested food, by the changes in which ptomaines or toxalbumins are produced — intestinal autointoxication. The existence in the body of the specific ffitiologic factor of one of the infectious diseases in insufl&cient amount to cause the typical manifestation of the affection may result in an abortiye form of the infection which may disappear within a few days without having been evidenced by any characteristic symptom. Such conditions may be met in epidemics of scarlatina, enteric fever, etc., and other cases of idiopathic fever may be attributed to abortive types of pneumonia, rheumatism, tonsillitis, etc. The inhalation of sewer gas and of other foul odors has been held responsible for the occurrence of transitory fevers but it is possible that the condition has been mistakenly attributed to these causes. Symptoms. These are usually sudden in onset but may be preceded by indefinite malaise. Rarely is there an initial chill. The rise in temperature is seldom over 103° F. (39.5° C), the pulse is rapid, there are headache, bodily weakness, a coated tongue, loss of appetite, nausea and vomiting. There 200 THE INFECTIOUS DISEASES. may be either constipation or diarrhoea; the urine is dark, scanty, and often loaded with urates. Nervous symptoms, even delirium, are often observed in children. The temperatiue usually falls by crisis within a few days or a week. The diagnosis must be made by exclusion. The absence of cutaneous manifestations or of local symptoms and the disappearance of the febrile movement within a few days are the most important points. Treatment consists in clearing the alimentary tract by the administration of repeated small doses of calomel — J of a grain (0.016) every J hour to 6 doses — followecl by a sahne purge, the restriction of the diet to fluids, the induction of free action of the skin and kidneys by giving the sweet spirit of nitre and one of diuretic potassium salts. The patient should remain in bed during the febrile movement and aconite tincture, 2 to 3 minims (0.13 to 0.2) given every 2 or 3 hours will tend to control this symptom and lessen the cardiac rapidity. Should there be marked evidence of intestinal putrefaction this may be combated by means of one of the bismuth salts, preferably the tetra- iodophenolphthaleinate. PROTRACTED IDIOPATHIC CONTINUED FEVER. From time to time fevers are observed which last from a few weeks to several months and present no symptoms which aid in ascertaining their specific cause. These may be atypical forms of the various infectious diseases, enteric fever, malta fever, etc., they may be due to pyogenic, or rarely to pneumococcic infection. Their chief symptoms are a moderate febrile movement lower in the morning, higher in the evening, prostration, impair- ment of digestive function, prostration and, it may be, symptoms referable to the nervous system. The spleen may be enlarged. These fevers are to be distinguished from enteric fever by the absence of the Widal reaction, from malaria by their resistance to quinine and the absence of the Plasmo- dium, from tubercidosis by the absence of tubercle bacilli in the excretions and failure to respond to the tuberculin test. In the instances due to pyo- genic infection the presence of an increased leucocytosis should aid in ascer- taining the cause. These patients usually recover; fatal instances developing in most cases manifestations from which an absolute diagnosis of some infection can be made. Treatment is eliminative and symptomatic; the bowels, skin and kidneys should be kept active, the diet should be of nourishing and easily digestible fluids and the various symptoms should be relieved as they appear. The patient's strength should be further maintained by the administration of tonics, particularly iron, quinine and strychnine in small doses. Weil's disease. 201 WEIL'S DISEASE. Synonyms. Acute Febrile Jaundice; Infectious Jaundice; Epidemic Catar- rhal Jaundice. Definition. An acute disease, probably due to a specific infection and characterized by a remittent febrile movement, jaundice and pains in the muscles. .Etiology. This affection usually attacks individuals in young or middle life and males rather than females. It is more common in the summer months and epidemics have been described as occurring in various parts of the world as India, Egypt and South Africa. It is rare in Europe and America although it has appeared in Greece and in North Carolina. Butchers seem particularly prone to the infection and it is also frequent in brewers and laboring men. The specific cause is not known but while the bacillus froteus fluorescens has been held responsible by certain observers, it is probable that the condi- tion may be caused by a number of infectious agents. Pathology. Post mortem examination reveals nothing characteristic. The intestinal mucosa may be congested and the liver and spleen hyperaemic, there may be acute degeneration (cloudy swelling) of the kidneys. Symptoms. The onset of the disease is usually sudden, with a chill, fol- lowed by fever, headache, nausea and perhaps vomiting and general pains; the temperature is remittent and seldom rises higher than 104° F. (40° C). Jaundice is an early symptom and subject to great variations in intensity; the stools may be clay colored. The liver and spleen may be increased in size and the former is often tender. The urine is dark, heavy, containing albumin and casts, bile pigments and perhaps blood. In the severer cases nervous symptoms and even delirium may be present. The fever lasts from 8 days to 2 weeks and falls by lysis as a rule. Secondary fever may occur. The diagnosis from bilious malarial fever may be made by the failure to find Plasmodia in the blood; from acute catarrhal jaundice by the presence of fever and pains; from acute yellow atrophy of the liver and phosphorus poisoning by the favorable course and outcome. The prognosis as to recovery is good as a rule but certain epidemics have been characterized by a considerable mortality. Treatment is eliminative, supportive and symptomatic. For the first con- sideration small doses of calomel to free purgation followed by sodium phos- phate once daily until convalescence is established, should be prescribed. GLANDULAR FEVER. Definition. An acute infectious disease of mild type, occurring chiefly in children and characterized by moderate pharyngeal congestion, fever 202 THE INFECTIOUS DISEASES. and enlargement of the cervical lymphatic glands, and at times those of the axillse and inguinal region as well. .etiology. This affection is seldom seen after the age of i6 years and most cases are observed diiring the colder months. While probably due to a micro-organism which effects entry through the tonsils or pharynx, no specific cause for the disease has been isolated. Epidemics of glandular fever occur from time to time and the condition seems to be contagious since it often affects several children of the same family. Path&logy. The lymph glands are enlarged but if they suppurate this is probably the result of some secondary infection; there is said to be enlarge- ment of the liver and spleen. Certain observers state that there is accom- panying enlargement of the lymph nodes of the bronchi and mesentery but others refute this assertion. Symptoms. After an incubation of from 5 to 8 days the disease is suddenly ushered in with stiffness in the neck, pain upon moving the head, loss of appetite, nausea and sometimes vomiting. There are pains in the head, abdomen and limbs. The temperatiire rises to 102° to 104° F. (38° to 40° C), the tongue is coated and the cheeks are flushed. After 24 to 48 hours, palpa- tion in the cervical region reveals an enlargement and tenderness of the lymph glands. The throat and tonsils may be congested. The axillary and inguinal glands may be swollen. The evening temperature persists for from 2 days to a week when it falls to normal either gradually or by crisis; the symptoms soon ameHorate, but while the tenderness of the lymph glands disappears their enlargement may persist for several weeks. Recovery takes place almost without exception. The diagnosis is simple, the various types of angina which are accompanied by glandular involvement being excluded by examination of the pharynx. Treatment. At the onset the bowels should be freely moved preferably by divided small doses of calomel. The fever and restlessness may be controlled by sponging with cool water or by small doses of acetphenetidine (pbenacetine) or antipyrine. Rest in bed and a fluid diet should be enjoined during the febrile period. Cold or warm compresses may be applied to the tender glands,, a compress wet in cold mercury bichloride solution has been recommended. The after treatment consists in the administration of tonics, especially the S)7rup of iron iodide and codliver oil. MILIARY FEVER. Synonym. Sweating Sickness. Definition. An infectious disease characterized by fever, profuse sweating and an eruption of miliary vesicles. .Etiology. Very little is known of the causation of this affection; it occurs in epidemics which are distinctly localized; often the inhabitants of a certain JAPANESE RIVER FEVER. 203 town or district only are afflicted. It occurs most often in the spring and summer months and seems to attack women more frequently than men. It is a disease of adults. Unhealthy surroundings and lack of sanitation do not seem to be predisposing causes. At present the disease is seldom seen outside of France and Italy. Pathology. No characteristic morbid changes have been described. The spleen may be enlarged; the blood is thin and dark. Symptoms. Mild prodromata such as malaise, headache and anorexia may precede the invasion of the disease or the onset may take place abruptly, the patient, after retiring in apparently good health, waking in the night bathed in profuse perspiration. The sweating persists and the patient suffers from a sense of precordial oppression or pain, epigastric discomfort, head- ache, muscular cramps, prostration and the other usual symptoms of febrile disease. The temperature is elevated, the pulse accelerated, the respiration rapid. On the 3d or 4th day there is a tingling of the skin which is followed by an eruption of tiny miliary vesicles containing a clear fluid which later may become tiirbid. The vesicles rapidly increase in size and appear first upon the neck and chest, spreading thence to the back and Hmbs. They break after 2 to 4 days and crusts form which later fall. With the incidence of the eruption the other symptoms abate. Rapid emaciation is characteristic. The disease usually lasts about a week but is sometimes more protracted, the rash, at times, being delayed even for 2 weeks. Severe instances with haemorrhages or pronounced cerebral symptoms have been observed. Relapses are not infrequent. The diagnosis during an epidemic is easy. The profuse diaphoresis and the miliary eruption are characteristic. The prognosis varies, the mortality in certain epidemics being high; the mean death-rate is stated to be from 8 to 9 percent. Treatment. The channels of elimination should be kept freely open by means of laxatives and diuretic drinks. Quinine is said to be efficient in controlling the fever. The excessive sweating may be reheved, if necessary, by means of repeated hypodermatic injections of tw of a grain (0.0006) of atropine sulphate and the patient's comfort may be greatly augmented by frequent sponging with tepid water. The sense of cardiac and respiratory oppression, if distressing, may necessitate the employment of hypodermatic injections of morphine. The patient should be kept in bed during the acuity of the attack and the diet should consist of nourishing and easily-digestible liquids. JAPANESE RIVER FEVER. Definition. Japanese river, or flood fever, is an acute infectious febrile disease which is observed in the workers who tiU the submerged banks of 204 THE INFECTIOUS DISEASES. certain Japanese rivers. Its causation is not definitely known but it seems to be borne by corn or hemp and at the point of its entrance into the body an ulcer is developed. The natives believe the disease to be the result of the bite of an insect. Autopsy reveals no characteristic morbid changes; bronchial congestion, considerable enlargement of the spleen and of the mesenteric lymph nodes may be found. Sjrmptoms. The invasion of the disease is marked by the appearance of a round ulcer in the inguinal region, neck or axilla. This may be preceded by a prodromal period of several days during which the patient complains of weakness and chills. Following the initial lesion there are lymphangitis of the vessels draining the region of the eschar, conjunctivitis, bronchitis and a moderately high temperattire. At the end of 6 days or a week a rash, con- sisting of red papules breaks out upon the face, limbs and body; this persists for from a day or two to a week. The elevation of temperature continues for about 7 days more when the initial ulcer begins to heal, the symptoms abate and rapid defervescence takes place. The prognosis varies; in certain epidemics the disease is very fatal. Treatment consists in rendering the primary sore surgically clean and maintaining it in this condition, the appHcation of cold to the lymphangitis and the employment of approved methods to relieve the other symptoms as they arise. The cautious use of quinine and sodium salicylate has been advised. TICK FEVER. Definition. This is a disease prevalent in certain parts of Africa, partic- ularly in the Congo, in western Uganda and in the western portions of Ger- man East Africa. The affection is due to the introduction into the body, by means of the bite of a certain variety of tick, the ornithodorus mouhata, of a spirillum. Observations upon this disease seem to show that the period intervening between the bite and the declaration of the disease is about one week. The invasion is abrupt but not marked by a distinct chill. There is prostration and the patient complains of headache and pain in the back and limbs. Food is distasteful and vomiting at the invasion of the attack is usual; moderate diarrhoea is common. The temperature is highest in the evening, an elevation of 104.5° F- (40-3° C.) not being uncommon. There are usually 3 to 4 attacks of fever which often terminate in sweating. Each attack lasts 3 or 4 days and the intervals from 5 to 19 days. Splenic enlargement may be observed and herpes, hiccough and epistaxis may occiu*. The principal characteristic of the affection seems to the prostration of the patient during the febrile attack and the quick return to comparative health with the subsidence of the tern- TRYPANOSOMIASIS. 205 perature. Under proper care the disease is very seldom fatal and it would seem that one attack of the disease confers immunity. The ticks which inoculate this disease into the human being infest the rest houses along the traveled roads and seem to be nocturnal in their habits. The natives when bitten, burn the ticks which they are able to capture and rub the ashes into the scarified skin at the site of the bite as a preventive of the fever. TRYPANOSOMIASIS. Definition. This term is appHed to the two conditions which may result from the occurrence within the human body of the trypanosoma ganibiense. This trypanosome is an elongated flagellated body in length 2 to 4 times the diameter of a red blood cell; its body is fusiform, more or less curved and spirally twisted, and is elongated into a single flagellum at one end; an xmdu- latory membrane extends throughout its length, at the base of which at the non-flagellate end is a small refractive body which is regarded as a centrosome. Near the middle of the body is an oval nucleus. It is analogous to several other tr}^anosomes, notably, t. Brucei and t. Evansi which are respectively parasites of horses and cattle and rats, and is transmitted to man by the bite of the human tsetse fly {glossina papalis), and perhaps by other means. The conditions which result from inoculation with the trypanosoma gam- biense are the so-called trypanosoma fever and sleeping-sickness or African lethargy. Both these affections occur at present only in the tropical regions although cases have been imported into other countries in the past. The blacks are chiefly affected, tr}^anosomiasis being extremely rare in the white colonists and missionaries; one or two cases of sleeping-sickness in Caucasians, have, however, been reported. It is a recognized fact that the tr}^anosomes may be present in the blood without causing significant symptoms but under certain conditions defijiite manifestations occur. Tr}^anosoma fever is characterized by a temperature of irregular type which may reach 104° F. (40° C.) and may be continuous or remittent. At intervals of from a few days to 2 or 3 weeks, periods, diiring which the tem- perature faUs to normal, occur. Erythematous patches and scattered areas of oedema, the latter being particularly likely to involve the lower eyelids, may appear. The pulse-rate is rapid, the tongue is red, and there are pro- gressive wasting and weakness. The superficial lymph glands are enlarged and examination of their fluid contents frequently reveals the presence of the trypanosome. Blood examination shows a moderate anaemia and an in- crease in the number of large mononuclear leucoc}'tes as weU as the pres- ence of the trypanosome; the last may be absent at times for considerable periods. 206 THE INFECTIOUS DISEASES. Treatment. The patient should be kept in bed and so protected that he cannot be bitten by the flies which transmit the disease in order that he may not prove a sovirce of further infection. The diet should be nutritious and easily digestible. Arsenic seems to have some effect upon the parasites in the blood and may be administered hypodermaticaUy. The best results are said to be obtained by iron arsenate and sodium cacodylate. Ehrlich and Shiga consider that a new aniline dye, trypan-red, is useful in this affection. It is said to have no direct effect upon the parasites within the body but is believed to possess the property of causing a reaction which results in their destruction. Malachite' green may also be employed. The combination of these substances with arsenic has been suggested. Otherwise the treatment is wholly symp- tomatic. Sleeping-sickness is a chronic condition resulting from the presence of the trypanosoma gambiense in the cerebrospinal fluid and is probably the termi- nal stage of trypanosoma fever. It occurs chiefly in negroes, less frequently is it seen in half-breeds. Pathology. The disease is a meningo-encephalitis. After death the cerebrospinal fluid is found to contain red-blood ceUs, leucocytes and try- panosomes. The capillaries of the brain and cord are surrounded by an infiltration of round cells. A mixed infection with streptococci may be observed late in the disease. Symptoms. After a prolonged incubation period, perhaps of several years, the invasion takes place and may be characterized by various symptoms referable to the nervous system such as convulsions and mental disturbances; there may be headache, dizziness and elevation of temperature. When the affection has fully developed the patient suffers from mental dulness and lethargy, from which he may be aroused to perform the bodily functions; speech is indistinct, the gait is uncertain and immediately upon being left to himself the patient faUs into deep slumber from which it becomes pro- gressively harder to arouse him. The body gradually wastes, bed sores make their appearance and death takes place either from secondary infection or in coma preceded by paralysis or convulsions. Fluid drawn by lumbar puncture contains the trypanosome. The disease may last for several years and it is beheved to be uniformly fatal in outcome. Treatment is probably ineffectual but free purgation early in the infection and the administration of arsenic in large doses and the other substances mentioned under the treatment of trypanosoma fever is advised. KALA-AZAR. Synonyms. Tropical Splenomegaly; Dum-dum Fever. Definition. A distinct chronic infectious disease of tropical regions char- KUBISAGARI. 207 acterized by persistent remittent fever, anaemia, emaciation, cutaneous pig- mentation and hepatic and splenic enlargement. Etiology. The results of recent research lead us to believe that kala-azar is a disease distinct from every other and not, as has hitherto been supposed by certain observers, in any way connected with malaria. Its specific cause is probably the so-called Leishman-Donovan parasite. This organism is a form of trypanosome and is probably to be found in the blood, particularly that withdrawn by splenic puncture, at some period in every instance of the disease. It is a fusiform, circular or ovoid body with a spherical nucleus at one side; a number of them may be grouped in the form of a rosette. Kala-azar occurs in low-lying, more or less water-logged districts of Asia and Egypt where the rainfall is heavy. Natives are most frequently at- tacked, the disease being rare in Europeans. S5nnptoms. The onset of the affection is marked by chills, fever and gastric irritability. Splenic enlargement is constant, increase in the size of the liver is frequent. The temperature is of irregularly remittent type and may persist for months; periods when the fever is absent may occur from time to time. The patient becomes emaciated and 'anaemic, haemorrhages into the skin and mucous membranes may take place and purpuric rashes and evanescent oedema may be observed. A grayish or blackish pigment may be deposited in the skin and there are muscular pains. The death rate is high, complications, particularly dysentery, being often responsible. Treatment. Isolation and quarantine should be insisted upon for it has been shown that by these means the disease can be made to disappear. Qui- nine has no specific action upon the cause of the infection but may control the temperature to some extent. The treatment consists chiefly in the employ- ment of hygienic and symptomatic measures and in combating the anaemia and bodily wasting by nourishing food and tonics. The removal of the patient from the infected district is advisable. KUBISAGARI. Definition. This is an endemic disease of northern Japan similar to the endemic paralytic vertigo of Switzerland, or Gerlier's disease. Its causation is unknown but it seems to occur in individuals who live in close association with their cattle. Males and females of all ages are attacked and the affec- tion is most common during the warm season. Symptoms. Its course is protracted and is characterized by ptosis, double vision and impairment of sight and of the power of certain groups of muscles, especially those of the back of the neck, resulting in a falling forward of the head. Paralysis, partial or entire, of the masticatory, pharyngeal or leg muscles results with interference with the performance of their functions. 2o8 THE INFECTIOUS DISEASES. In the intervals of the paroxysms the only persistent symptoms are the ptosis and falling forward of the head. The disease is never fatal. Treatment. The frequency of the paroxysms may be somevi^hat diminished by the administration of the bromides, especially potassium bromide, and the continued exhibition of potassium iodide and arsenic is said to be of benefit. LEPROSY. Synonym. Elephantiasis Grsecorum. Definition. A chronic infectious disease occurring in two forms, (a) tubercular leprosy which is characterized by the development of nodules in the skin and mucous membranes and (b) ancesthetic leprosy in which there is a nodular infiltration of the nerve trunks. The two forms tend eventually to become combined. .Etiology. Leprosy has been known since the time of Moses. At present it is endemic in certain parts of Asia, the Sandwich Islands, the West Indies, Greece and Tiirkey, and cases are not infrequently seen in Sweden, Norway, Iceland, Australia, South Africa, Mexico. Canada, and in the Southern and Northwestern United States. The disease attacks both sexes and all ages and Hutchinson believes that a diet of fish is a factor in its causation, either inducing a susceptibility by lessening the bodily resistance or by carrying the contagium in its substance. A diet lacking in proteids seems to predispose to the disease. The specific cause is the bacillus leprce a micro-organism closely resembling the tubercle bacillus in certain particulars but easily differentiated by staining. Mode of transmission. It is probable that very close association with patients is necessary to acquirement of the disease for physicians and nurses who are in close contact with sufferers are seldom attacked. The possibility of the hereditary transmission of the affection is to be considered but it is without doubt of the very rarest occurrence. It is not certain that the disease may be contracted by direct inoculation but it is probable that this is the case. The bacilli are given off in the discharges of suppurating lesions, in the saliva and nasal mucus when there are leprous manifestations in the throat or nose, and have been found in the urine and milk. They may be borne upon clothing and the disease has been transmitted by fomites. The most probable portal of entry for the contagium is through the respiratory tract, and certain observers believe that it niay be contracted during coitus in the same fashion as syphilis. Pathology. The nodes occurring on the mucous membrane and skin in the tubercular form of the disease are composed of small cells supported upon a framework of connective tissue; within and between these cells the lepra bacilli exist in large number. The nodules finally break down and form ulcers which may heal and cicatrize; in the ulcerative process fingers LEPROSY. 209 and toes may be lost and the conjunctival and laryngeal mucous membranes may be affected. In the anaesthetic type there is a peripheral neuritis resulting from the growth of the bacilli within the substance of the nerve fibres. Symptoms, a. Tubercular leprosy: An intermittent febrile movement lasting for many months may precede other symptoms; before the nodules develop there are often areas of erythematous redness upon the skin; the edges are well-defined and there may be cutaneous hypersesthesia; pigment may be deposited in these spots, which may later disappear, without the development of nodules, leaving white anaesthetic areas {lepra alba). More commonly the tubercular nodules appear and persist, it may be, for years; ultimately they, for the most part, ulcerate, but some may disappear without undergoing this process. The occurrence of nodular growths, in the face, together with the cicatrized areas may give rise to the appearance termed the fades leontina; at times the nose and ears may ulcerate away and the breaking down of nodules in the cornea or larynx may cause blindness or loss of voice. Obstruction to respiration and even death may be caused by tubercles in the nose, pharynx, or larynx. Inhalation pneumonia is not infrequent. b. AncBsthetic leprosy is evidenced by pains in the limbs, hyperaesthesia or numbness; the infiltrated nerves may be palpable under the skin and while at first tender, later become anaesthetic. Trophic disorders such as dryness or smoothness of the skin or the appearance of smaU bullae may be noted. Areas of cutaneous anaesthesia appear and may be preceded by maculae which later disappear. Vesicles form which burst leaving ulcers behind and the trophic disturbances may result in wasting and atrophy of the limbs and even the dropping off of fingers or toes. The disease may last for years without impairing the patient's functions but the finally increasing exhaustion overcomes him. The diagnosis of an advanced case of either type is very simple. In the earlier stages the areas of erythema with sensory disturbance are quite typical. In doubtful instances a section of the skin or of a tubercle should be examined for the presence of the bacillus leprce. The prognosis is not favorable as regards recovery, although this has occurred in the anaesthetic type, with, however, persistent trophic lesions. The course of the disease is chronic, lasting even 20 or 30 years; it is more rapid in the ulcerative variety. Death may take place from intercurrent disease or from the progressively increasing weakness. Treatment. Isolation or segregation should be insisted upon in all cases. This is preferable to the legalized compromise which obtains in Norway; here the indigent lepers are cared for in an institution while those whose income is sufficient are permitted to remain at home under proper care and 14 2 lb THE INFECTIOUS DISEASES. restrictions. A leprous mother should not nurse her infant and it should associate with her as little as possible. Treatment proper consists in attention to cleanliness, general hygiene and surroundings and plenty of nourishing food; certain observers consider that a diet too rich in carbohydrates and poor in proteids is a factor in the causation of the affection, consequently it would seem well to prescribe a regimen containing plenty of nitrogenous food. The internal administration of chaulmoogra oil often results in marked benefit. It may be given in begin- ning dose of 5 minims (0.33) morning and evening, the dose being increased each day by from 4 to 6 minims (0.24 to 0.40) until the patient is taking as much as 250 minims (16.0) daily in 3 or 4 doses. The drug may be given in milk, hot tea or in capsules and should be continued for 2 to 3 months. If gastric disturbance is caused the oil may be given per rectum, 2 drachms (8.0) in milk being the proper quantity, or it may be administered hypoder- maticaUy in daily dosage of from i to 2 drachms (4.0 to 8.0). An efl&cient substitute for chaulmoogra oil is sodium gynocardate which may be given in piU form; of this drug 20 to 80 grains (1.33 to 5.33) may be given daily. Giirjun oil is at present little used. Encouraging results have been reported from the employment of mercury bichloride and sodium chloride, each \ grain (0.016) in 20 minims (1.33) of distilled water. This solution is injected deeply into the muscles twice a week. Ichthyol is recommended in tubercular leprosy and may be given in doses of ^ a drachm to 2^ drachms (2.0 to lo.o) daily. Large doses of potassium iodide may be given in the hope of causing the erythematous nodes to disappear. Other drugs from which favorable results have been obtained are sodium salicylate, potassium chlorate and sodium cacodylate. Calmette's antivenene given hypodermatically in doses of 5 to 7 drachms (20.0 to 28.0) has been administered with benefit in certain cases. The injections are given every 2 days at first, then daily. Locally inunctions of pyrogaUic and chrysophanic acid and of 20 percent, salicylic acid have been recommended. The nodules before ulceration may be cauterized with the thermo- or galvanocautery after which powders such as thymol iodide or iodoform may be appHed. The latter should also be dusted upon ulcerations or a i to 20 phenol ointment, 5 percent, europhen (an organic iodine compound) in olive oil or i part of gurjun oil to 2 parts of liihe water may be employed. The frequent application to the nasal and buccal cavities of mild antiseptic solutions and of 10 to 20 percent, silver nitrate to ulcerations of mucous sur- faces is to be advdsed. The neuralgic pains may be controlled by the administration the coal tar analgesics, aconitine or gelsemine. Nerve stretching may be advisable in extreme cases. FRAMBOESIA. 211 Very recently excellent results have been reported as following the treat- ment of leprosy by means of the X-ray. At least one case seems to have been cured since the presence of the baciUi, easily demonstrable before exposure to the rays, have disappeared as a result of their application, and improve- ment in a number of other cases has been noted; whether the results are permanent, time alone will tell, Wilkinson who reports the cases believes that when a local lesion is treated the organisms in that situation are killed and their bodies are absorbed, producing an immunity against the living organism. In the treatment of patients the part which presents the greatest leprous involvement is selected and exposed to the ray usually for lo minutes at a distance of from 7 to 10 inches. The effort is made to approach as near to burning the skin as possible without actually doing so. After 2 or 3 treat- ments a blushing of the skin is noticed and there is a sensation of itching. Of the 3 cases in which the result was considered to be successful in 2 the treatments were 14 in number, in the 3d, 52. Recently rather remarkable results have been reported as due to the admin- istration of a fluid extract of mangrove (rhizophora mangle). At first 2 drachms (8.0) are given morning and evening, later this dosage is increased to from 2 to 3 ounces (60.0 to 90.0) daily. Each night the patient is given a bath at 102° to 104° F. (38.9° to 40° C.) to which enough mangrove decoction has been added to redden the water. A light diet, chiefly of fruit and milk, is prescribed together with tonics such as coca and kola; no acids nor spices are allowed. The patient is advised to sleep in a cool room and to avoid the hot sun. Ulcers, if they appear, are dressed with 30 percent, of the fluid extract of the mangrove in water. FRAMBCESIA. Synonym. Yaws. Definition. A chronic contagious disease chiefly observed in the tropics and characterized by the development of granulation tissue in the true skin. Etiology. This affection is common in Africa, Southern Asia and the islands of the Pacific. In the West Indies, Central and South America it is less frequent. It is rarely met in the United States. Dark skinned races are more frequently attacked than whites and while yaws may occur at any age children are most frequently affected. While probably of bacterial origin, the specific micro-organism of the infection has not been isolated. The disease is transmissible by direct inoculation through an abrasion of the skin and also by food and eating and cooking utensils. Symptoms. The period of incubation varies from 2 to 8 weeks. Pro- dromal symptoms such as malaise, anorexia, headache and pains in the muscles and joints, may be present, particularly in children, during this period. The invasion of the disease is marked by the appearance of the 212 THE INFECTIOUS DISEASES. primary sore which in experimental yaws appears at the site of inocula- tion. This is at first a small papule which within about 7 days becomes a shallow ulcer which in turn soon heals leaving an indurated scar. The primary lesion may be wanting in certain instances. With the initial sore the secondary eruption may appear or, more usually, it is several weeks before its occurrence. It may be preceded by a pallor of the skin with a bran-like desquamation. The secondary rash appears first on the face and soon spreads to other parts.. It consists of small papules which are particularly numerous near the muco-cutaneous junctions. The papules enlarge forming tubercles under the skin as large as a good sized pea; at the top of these pustulation soon commences, and the skin breaking, a yellowish fluid is discharged which dries, forming a tough firm crust under which the tissue is papillomatous, resembling a raspberry in appearance. From this raw surface there is an exudation of viscid yellowish pus. Pain is seldom present but there is usually an annoy- ing pruritus. Successive crops of the lesions may appear and after several months they diminish in size and scab over, the crust ultimately falling and leaving behind a spot of increased pigmentation in whites and of skin lighter than the normal in dark races. In prolonged and untreated cases a third stage may occur, characterized by breaking down of the nodules, pains in the bones and joints, periostitis and bone caries. The diagnosis. Yaws is to be distinguished from syphilis, to which it bears so close a resemblance that certain observers consider them the same or at least analogous diseases, by the lack of induration in the initial sore, of gland enlargement, of secondary involvement of the mucous membranes and of vascular thickening. Verruga bears a close similarity to yaws but is histologically a distinct disease. The prognosis is usually good. Treatment. Isolation of all cases should be practised, all abrasions of the skin should be properly treated and protected, and buildings in which pa- tients afiflicted with the disease have lived should be avoided. Constitutional treatment consists in the administration of potassium iodide; general tonic treatment, iron, arsenic, etc., are often necessary adjuvants. The external lesions should be kept clean by the application of antiseptics and, when advisable should be protected by dressings. Sluggish ulcers should receive stimulation by means of silver nitrate and balsam of Peru and the chronic nodules may be treated surgically. VERRUGA. Synonyms. Peruvian Warts; Verruga Peruviana. Definition. A chronic infectious disease characterized by a prodromal VERRUGA. 213 febrile stage, rheumatic pains and the subsequent development of granulo- matous wart-like excrescences upon the skin, mucous membranes and viscera. jSitiology. This disease occurs only in certain parts of Peru upon the western incline of the Andes. It is not contagious but is inoculable and may appear in epidemics. The natives believe that it is contracted by drinking the water of certain springs. It attacks all ages and both sexes and seems to be intimately associated with a pernicious type of malaria known as " Oroya Fever." Its specific cause is unknown but a bacillus somewhat larger than the tubercle baciUus has been held responsible by Yzquierdo. One attack usually confers immunity. Symptoms. After an incubation period of from 2 weeks to 40 days the invasion of the disease takes place; prodromal symptoms such as malaise, and a tired sensation in the limbs, persist for a few days and are succeeded by an afternoon rise of temperature. The latter becomes gradually more marked and may be either remittent or intermittent in type. There are chiUs and pains in the joints of the extremities and in the spine; the pain is more severe at night and attacks one articulation after another. Muscular contraction involving the sternomastoid and calf muscles may be observed. The patient loses flesh and becomes anaemic, there are hepatic and splenic enlargement. After about 3 weeks the eruption appears and with its incidence an amelio- ration of the other symptoms, including the fever, occurs. The rash shows itseK first upon the face, the extremities and about the joints, the hairy parts are involved but rarely the trunk; it begins as small pinkish spots, soon becom- ing papular and dark red or bluish in color. The papules vary in number from only a few to several hundred and in size from that of a small pea to that of an orange; they are vascular and bleed easily. When occurring upon the internal organs they may cause difficulty in swallowing, and bleeding from the oesophagus, stomach, bowel, bladder or uterus. The growths persist for several months and either dry into black spots which disappear leaving no trace, ulcerate or suppurate. The prognosis is much more favorable in the natives than in whites, the mortality varying from about 10 percent in the former to 70 percent, in the latter. An early incidence of the eruption augurs a favorable course and outcome, but delayed and atypical outbreaks signify a severe type of the disease. Treatment. The removal of the patient to the lower levels near the sea is always to be advised and quinine should be administered on account of the possibility of a malarial element in the infection. Tonics and stimulants are often necessary and the ulcerous and suppurative excrescences should receive antiseptic treatment. In other regards the treatment is supportive and symptomatic. 214 THE INFECTIOUS DISEASES. MEASLES. Synonyms. Rubeola; Morbilli. Definition. An acute infectious febrile disease, often occurring in epidem- ics, characterized by congestion of the upper air passages and a dusky red eruption of maculo-papular form. .etiology. The disease is commonly endemic, epidemics occurring in most thickly populated districts about every 2 years. It prevails chiefly during the cold months and appears usually in children, but adults may be attacked. Infants under 3 months seem to possess a certain degree of immun- ity. Measles is almost certain to be communicated to those not rendered immune by previous attacks and when introduced into regions where the disease has previously been unknown is extremely fatal. The specific cause of measles is undoubtedly a micro-organism, and while various bacteria have been found in the secretions of sufferers none of these has been proven to be directly causative of the infection. The contagium is given off in the conjunctival, nasal and bronchial secretions and these are infective even before the stage of eruption. Dried particles of the secretions may collect upon clothing, furniture, etc., the latter thus becoming capable of transmitting the infection. The contagium is, however, short lived. One attack usually but not always confers immunity. While mistaken diagnoses are responsible for many apparently repeated attacks, it is undoubt- edly true that susceptible individuals may suffer from the infection more than once. Pathology. The post mortem appearances in measles are in no way char- acteristic. The catarrhal condition of the conjunctival mucous membranes is not distinctive. Death is usually due to complications, especially broncho- pneumonia, and the typical lesions ordinarily found in this condition are present. Lobar pneumonia with collapse of the lung may be found and swelling of the lymphatic tissues throughout the body, tonsils, lymph nodes, and intestinal follicles, may occur. There may be slight splenic enlargement. In instances of malignant or black measles hemorrhages are present. Symptoms. The incubation period is from 7 to 14 days, rarely a few days longer. Prodromata such as malaise, sneezing and f everishness may be noted at the end of this period. Leucocytosis may be present. The period of invasion lasts 3 or 4 days, dviring which the symptoms of conjunctivitis and rhinitis are noted. The onset may be gradual or sudden and marked by chilly feelings — rarely a distinct chill — or a convulsion. The fever at first is not very high and may remit upon the 2d day. Following this the temperatiire rises to 104° to 105° F. (40° to 40.5° C). Other symptoms of the onset are cough, nausea and vomiting. The pulse is rapid and full. As the fever falls the pulse returns to normal. MEASLES. 215 The symptoms continue for about 4 days and in severe infections cerebral manifestations may be present. On the 4th day the typical eruption appears. This consists of maculo-papiiles, at first rounded, rose-colored and shghtly elevated, later tending to coalesce into crescentic shapes. The rash appears first upon the face and mucous membranes, then upon the body, the extrem- ities becoming finally involved. At first the papules impart a shot-like feeling to the finger and may be mistaken for the eruption of smallpox. The rash disappears on pressure, is fully developed in from 2 to 4 days and then DAY OF DISEASE n .|. i ' 5 6 7 8 9 10 11 12 13 14 fl 1 HOUR A M M M PA M M P A F A F M M M k A P A P A F A P f M M p A f M M A P A M M P A F A P A P M M MM 107° -•12° - -- — — L -- - 106 — 1 — -lC — — - — E ~~ - —41° - = ^ --^ = =: ;E: :E - Z£ p:__ ---'- EEE E E: EE E EE EEE '\ll EEE E= • lOa S'104 : z: --Z :__ :- ^r -=-- i" - E: :z = E EE -Z; ; z; :SE E= - -5 E og - - — -f 1, — — -- -- - — S 103 ^ - - - — -l ^" — — .__ -- - 1 — - —, --f ^/ — — -L -- - (2 "'102 w — - — -- — — -- - — - 1 — -39° 1 = zz N :E: :E z: ^^^ pz E ^ :r - ^' zz: :ee EE= 2 . a 100 z 3 =t = =: :E: 1 = Ei ^l z E= EE - = -- n; :e; M — 38°'S" — — — -.J - ~- '~~ 3 l— -- -— - - — — zz a- ^ — ~~ — ' --- rv • -ff — 98 97 —] — — — P - — - — — - — - - — — — 96 E = w z~ EE! 1 = E EEE E ZI EE E E ^ EEE g § ^ -30 Fig. 8. — Clinical chart of measles showing defervescence by lysis when the eruption is fully developed. gradually fades. In from 10 to 14 days fine desquamation, lasting from a few days to several weeks, takes place. At the height of the eruption there may be enlargement of the glands of the neck. A day or two before the eruption small red spots from the size of a pin head to that of a split pea appear on the lining of the cheeks and mouth. At the center of these is a bluish-white spot which may be made out with the aid of a strong light. The white spots may be removed by means of a forceps and being examined are shown to consist of epithelial cells in a state of fatty degeneration. These are known as Filatov's or Koplik's spots and are an important early diagnostic sign. The symptoms of the disease continue until the eruption has reached its height. On the 5th or 6th day it begins to fade and at the same time the temperature begins to fall gradually and the symptoms become ameliorated. Variations from the typical course may take place. Morbilli sine morbilUs 2l6 THE INFECTIOUS DISEASES. is the term applied to the disease when the symptoms are manifested but no eruption appears. A mild type, in which all the symptoms are sHght and recovery takes place within a few days, has been described. Malignant or black measles is a severe and fatal type, characterized by haemorrhages into the skin and from the mucous membranes, the prostration is marked and all the signs of a severe toxaemia are present. Complications. It is these which render measles a disease to be dreaded. Broncho-pneumonia is the most common and may be diagnosticated by the persistence of the cough and high temperature and by the physical signs of small areas of pulmonary consolidation. Lobar pneumonia may also com- plicate the disease. Less frequent compHcations are otitis media, laryngitis,' diphtheria, ulcerative or gangrenous stomatitis, keratitis and parotitis. Neph- ritis, endocarditis and joint inflammations and nervous complications, while fortunately rare, have been observed. Among these may be mentioned hemiplegia, paraplegia, meningitis, multiple neuritis and cerebral abscess. Piilmonary tuberculosis may develop as a sequel of measles and, in patients of suspicious diathesis, when the cough is obstinate, this possibility should not be forgotten. Diphtheria is not an uncommon complication in institu- tions. The diagnosis of measles during epidemics is not difficult. Early in the affection the appearance of the spots upon the buccal mucous membrane is an aid in differentiation. The early involvement of the nasal lining and the conjunctiva as against the sore throat and enlarged glands gf scarlatina should aid in differentiation from the latter disease. Fever for 4 or 5 days, accompanied by catarrhal symptoms, buccal spots and the appearance at the end of this period of a maculo-papular rash, tending to become crescentic, should differentiate from chicken-pox and German measles. The prognosis in uncomplicated cases which occur amid good surroundings is favorable, provided the patient's general condition is good. In epidemics under unsanitary conditions as in asylums, army camps, etc., the disease is likely to be attended by a high death rate. Poorly nourished patients and those affected with previous chronic disease are very prone to complications, especially pneumonia, and in this event sel- dom recover. Treatment. Prophylaxis consists in immediate isolation and the removal of other children from the house. The latter shoiild be kept from associa- tion with other children for at least 2 weeks in order that the disease, if con- tracted, may develop. Many parents encourage their children to expose themselves on the principle that every one must contract the disease and that it is less likely to prove serious in childhood than in adult life, but this is little less than criminal. MEASLES. 217 All discharges, dressings, clothing, the sick-room, etc., should be disinfected according to the usual methods. The contagium of measles being of feeble vitality the quarantine need be kept up not longer than 4 or 5 weeks. Measles is a self-Hmited disease and unfortunately we have no means of aborting it or shortening its course. Its treatment, therefore, is symptomatic and supportive; much also can be done in the way of preventing the incidence of complications. At the onset of the disease the patient should be put to bed in a darkened room and isolated. The apartment should be well ventilated and while its temperature need not be high, the patient should be carefully protected from draughts. The bed covering need not be heavy but should be sufficient to keep the patient comfortable. The bowels should be opened at the invasion of the disease by means of fractional doses of calomel followed by a saline and they should be kept open throughout the disease by means of laxatives. The skin should be kept active and the kidneys mildly stimulated by the simpler alkaline diuretics or spiritus setheris nitrosi. The conjunctivitis may be controlled by means of the application of cloths moistened in cold water or by dropping a few minims of saturated solution of boric acid into the eyes at intervals. The lids may be prevented sticking together by smearing their edges lightly with vaseline. Should the conjunctivitis become purulent a few drops of a 5 percent, solution of silver vitellin (argyrol) should be instilled at frequent intervals. " The care of the nose and pharynx is most important since it is by extension from these parts that the middle-ear frequently becomes involved. The nasal cavity and the throat should be frequently sprayed with diluted liquor antisepticus (U. S. P.). Following the cleansing influence of these alkaline applica- tions the inflammatory condition of the mucous membranes may be relieved by spraying with albolene, to an ounce (30.0) of which about 10 drops (0.66) of eucalyptol or thymol or both have been added. The itching and burning of the skin may be relieved by sponging with tepid water to which a little sodium carbonate has been added or by rubbing in vaseline or oleum theobromatis. The fever ordinarily needs no especial treatment; should it rise to 104° F. (40° C.) or over it may be controlled by sponging with cool water or by small doses of antipjnrine or acetphenetidine. In the early stages of the infection this symptom may be relieved by small doses of tincture of aconite — 3 to 5 drops ( 0.2 to 0.33) — every 2 or 3 hoiirs. If this drug is given the pulse should be watched and the medication should be stopped at once if any sign of cardiac depression is noted. The cerebral symptoms may be relieved by cool sponging or cool packs and by the application of an ice cap to the head, but when the pulse is weak, the extremities cold and cyanotic, warm baths with the addition of mustard are indicated. Stimulation may be necessary, especially if pneumonia is present as a complication and here 2l8 THE IXPECTIOUS DISEASES. small doses of alcohol or stryclinine should be employed. In collapse the h}'podermatic administration of camphor in aether or oil is useful. For the bronchitis simple cough mixtures containing expectorants such as ammonium chloride or ipecac in small doses, -^-ith the addition of codeine or heroine if the cough is distressing, should be prescribed. In order to prevent broncho-pneumonia it is necessary that the patient have a plentiful supply of fresh air and yet that all chances of exposure should be studiously avoided. A iiannel jacket should be fitted to the chest, the skin of which should be daily rubbed vidth olive oil to which a little turpentine or camphor may be added if desired. The administration of guaiacol carbonate is advo- cated in the treatment of the catarrhal manifestations of measles as being preventive of respirator}- complications. The various complications should be treated as when occurring independ- ently. In institutions the occurrence of diphtheria as a complication may be prevented by the administration of an immunizing dose of antitoxin to each case. According to Holt this procedure has been carried out by him with excellent results. In instances when the eruption is delayed the patient should be given a hot pack by means of a blanket wTung out in hot water. This should be wrapped about him and then covered by a rubber sheet. This procedure induces profuse perspiration and the appearance of the rash. The diet during the febrile period should be entirely fluid, consisting of milk, soups and broth. \\Tien the fever has subsided a gradual return to an ordinary regimen may be allowed. The patient should remain in bed for about a week after the temperature has reached normal and must not be allowed to use his eyes for about a month. While desquamation is taking place the skin should be kept soft by means of inunctions of oil or cocoa butter. For considerable time after convales- cence has become established the patient should be kept from exposure to sudden changes of temperature; particularly is this necessar}^ if there is per- sistence of the cough. Here the administration of codliver oil and creosote carbonate is indicated and a change of climate is to be advised, preferably to one of high altitude, slight humidity and mild temperature. In ordinary cases tonics should be administered during convalescence and the diet should be plentiful, nourishing and easily digestible. RUBELLA. Synonyms. Rotheln; German ^Measles; Roseola. Definition. An acute infectious febrile disease of mild t^'pe accompanied by a maculo-papular eruption and enlargement of the cervical lymph nodes and at times by mild catarrhal symptoms. RUBELLA. 219 Etiology. That this disease is distinct from measles and scarlet fever has been definitely proven. It occiors chiefly in children, although it may be contracted by adults. It is ver}- contagious, although rather less so than measles and appears both epidemically and sporadically. The infection is probably microbic in origin but as yet its specific cause has not been isolated. The contagium is transmitted by direct contact with the patient and by fomites and is probably active from the beginning of the disease until well into the convalescent period. One attack usually confers im- munity. Symptoms. The period of incubation is from i to 3 weeks, averaging about 10 days and while there are in many instances no prodromata, for a period of 2 or 3 days before the appearance of the eruption the patient may complain of chilly sensations, general pains and malaise, sore throat and slight fever. Mild bronchitis, tonsillar and glandular swelling in the cervical region may be present. Slightly before or S}Tichronous with the appearance of the rash, which in certain instances may be the initial symptom, the temperature rises to 100° to 103° F. (37.8° to 39.4° C). The eruption appears fust upon the face and spreads thence to the neck, trunk and extremities. At times it is confined to one part while at others it involves the whole cutaneous sur- face including the palms, soles and buccal mucous membrane. The rash is papular, rose-colored and may become confluent, the papules fusing irreg- ularly, while the surrounding skin may become h}'persemic. The papules vary in size but are smaUer than those of measles and do not fuse in crescentic shapes. When the eruption involves the various parts of the body in succes- sion it is seen in all stages at the same time. In other instances it may appear upon all parts simultaneously. It reaches its height within from 24 to 48 hours and lasts from 2 to 5 days as a rule, when it may terminate in slight desquamation, less marked, however, than that of measles. Sore throat is almost always present and swelling of the cervical glands, and even of those of the axilla and groin may occur. Slight catarrhal symp- toms referable to the mucous membranes of the eyes and nose are not infre- quent. The pulse is rapid in proportion to the elevation of the temperature; the latter falls mth the fading of the rash and the other symptoms gradually ameliorate. The coTurse of the disease is from 3 to 7 or 8 days and convalescence is rapid. Relapses may occur but complications are seldom seen. Rarely a complicating bronchitis, pneumonia, or digestive disturbance may be observed. The diagnosis in t}^ical instances is not particularly difficult. In cases indistinctly characteristic the problem is less simple. Such may be differ- entiated from measles by the absence of buccal spots and marked catarrhal 220 THE INFECTIOUS DISEASES. symptoms, by the mildness of onset, lighter colored and more diffuse eruption; from scarlatina by general mildness of course, absence of severe throat involve- ment, atypical tongue and absence of general erythematous eruption. The prognosis is generally most favorable, delicate children, those whose surroundings are unhealthful and those who are unfortunate enough to be subjected to complications may succumb to the disease. Treatment. The patient should be strictly quarantined until the diag- nosis has been absolutely assured. Confinement to bed should be enjoined and fliyd diet is necessary as long as the temperatvire remains elevated. The bowels should be opened at the onset of the disease by means of fractional doses of calomel followed by a saline and regular daily movements should be secured by mild laxatives or simple enemata if necessary. The skin should be kept active and cleansed by means of a daily sponge bath; cool bathing may be resorted to if the temperature causes anxiety. The catarrhal symptoms should be treated just as in measles and if there is cutaneous irritation this may be relieved by gently inuncting carbolized vaseline or theobroma oil. The enlarged glands may be rubbed with a 5 percent, ichthyol or compound iodine ointment. The complications are to be treated as when they occur independently and during convalescence the administration of tonics such as iron, strychnine and codliver oil may be advisable, especially in debilitated children. SCARLATINA. Synonym. Scarlet Fever. Definition. An acute infectious fever characterized by a diffuse scarlet rash upon the skin and usually accompanied by pharyngeal inflammation. .etiology. The disease occurs endemically in nearly all parts of the world and amongst all races; the natives of East India and of Japan are said, however, to be to some extent immune to the infection. At intervals epidemics of varying intensity appear. The disease is most common diiring the autumn and winter months and it affects chiefly children under the age of 10 years. Certain individuals and some families seem to be insusceptible. Nursing infants seldom contract the disease; in pregnancy and after surgical operations individual susceptibility is increased. An enormous amount of work has been done upon the bacteriology of scarlet fever but up to the present time the results have been inconclusive. In the majority of cases the streptococcus pyogenes is to be found in the inflammatory exudates of the disease but while certain observers believe this to be the specific cause of the infection it seems more probable that this bacter- ium is present as a result of mixed infection and that the true cause of scarla- tina is another micro-organism. Mallory has found a parasite in the skin SCARLATINA. 221 which has also been demonstrated in the serum of blisters by Duval and which occurs in various forms, notably in the shape of a rosette, resembling the rosette stage in the reproductive cycle of the malarial parasite. Class, whose researches have been confirmed by others, has found in the blood, urine, scales of epidermis and in cultures from the throat a diplococcus which may have some influence in the causation of the infection. With regard to the bacteriology of scarlatina it may be definitely stated that the streptococcus is an important influence in the aetiology of the septic manifestations of the disease. The contagium is much more resistant than that of measles, much less diffusible and less prone to infect those exposed. The latter fact may be due either to a natural immunity enjoyed by certain individuals or to a peculiarity of the contagium. Mode of transmission. The contagium is probably contained in the secre- tions of the throat, respiratory tract and ear and in the particles of skin exfoli- ated at the termination of the disease. The disease may be communicated by direct contact with a patient or by fomites, the infection being very resistant and remaining viable for long periods in clothing, bed linen, books, etc. While the disease may be carried by a third person, this mode of conveyance is rare. Air may carry the infection for short distances and it may also be transmitted by means of milk with which infected persons have come into contact. The poison usually affects the throat primarily, having been taken in upon the inspired air. It may also enter by means of the digestive tract. The fact that infants have been born while manifesting the disease at all stages would show that the infection may be transmitted by means of the blood. One attack usually, but not always confers immunity. Pathology. This disease presents no distinctive morbid changes. The eruption is ordinarily invisible post mortem unless it is haemorrhagic in char- acter. The throat exhibits the appearances of simple follicular or ulcerative tonsillar and peritonsillar inflammation with an accompanying lymphoid enlargement or even abscess formation in the neck in the more severe instances. The viscera, especially the kidneys, are the seat of an acute degeneration and may contain foci of necrosis. The pathology of the various complications does not materially differ from that of these conditions when they occur independently. Symptoms. The incubation period varies from i to 12 or 14 days but is usually 2 to 4. The invasion takes place suddenly or after a short prodromal period, characterized by indefinite malaise. The initial symptom is usually emesis; chills or convulsions may occur. The temperature rises rapidly to 103° to 105° F. (39.5° to 40.5° C), the pulse is proportionately rapid — no to 130 — the face is hot and flushed, the tongue dry and the throat sore. 222 THE INFECTIOUS DISEASES. The eruption appears from 12 to 36 hoiirs after the onset of the disease. The whole skin is flushed and scattered over it are numerous tiny red points; these may occur in irregular patches or they may be widely disseminated. The rash appears first upon the neck and shoulders and extends rapidly; the skin of the whole body and of the limbs may be involved within 48 hours. When the eruption is at its height the skin becomes almost uniformly red and swollen, particularly upon those parts which are protected. The redness disappears on pressure but returns instantly upon its removal. Upon the face the rash is least apparent and usually involves only the forehead and cheeks, the skin about the nose and mouth remaining pale. The eruption is present upon the pharynx. It remains at its height from i to 3 days and gradually fades as the temperature approaches normal. Variations of the eruption are not infrequent. In the severe types of the infection it is darker in color and haemorrhagic petechiae may be present. Vesicles containing turbid fluid may appear (scarlatina miliar is). The skin is often rough to the touch and itching and burning may be present. The rash usuaUy begins to fade about the 7 th to the loth day and desquamation, lasting several weeks, takes place. This exfoliation may be so slight as to be difl&cult of perception after a poorly marked rash or, following one of severe type, the skin of the fingers and toes may come away in the form of moulds and the bits of desquamated epidermis may be numerous and of considerable size. The tongue is at first red at the tip and edge with a whitish coat in its center through which the enlarged papiUae protrude giving the so-called "strawberry" or " raspberry " appearance. As the disease continues the white coating is shed and the tongue is left red, rough and even more like the surface of a strawberry or raspberry than before. The pharynx may be the seat of a mild inflammation, of a follicular tonsil- litis or of a severe anginoid condition caused by infiltration, ulceration and even pseudo-membranous inflammation of the pharyngeal structures; lym- phoid enlargement and even involvement of the tissues of the neck may be noted. The initial fever varies from 103° to 106° F. (39.5° to 41.1° C), or even higher and continues with slight morning remissions until the rash begins to fade when it falls by lysis. Hyperpyrexia may occur in severe infections. The pulse is rapid in proportion to the height of the temperature and the respirations are also accelerated. The spleen may be slightly enlarged. The urine is scanty, hyperacid, high colored and often contains a trace of albumin and a few casts. This should cause no undue alarm as the urine is likely to become normal once more; it should, however, be examined daily smce nephritis is an important and not infrequent complication. LeuCocy- tosis may be present. The duration of the febrile movement of an ordinary case of scarlatina SCARLATINA. 223 is from 3 or 4 days to 2 weeks, depending upon the severity of the infection. Irregular forms of the disease may be met. These are of 3 chief classes: 1. Anginose scarlatina which is characterized by severe pharyngeal symp- toms; the throat is markedly swollen and dysphagia is present, upon the tonsils there is a pseudo-membranous exudate which may result in abscess formation and ulceration. The inflammation may extend to the larynx, trachea, and bronchi, and is almost certain to reach the middle-ear by means of the Eustachian tube. The disease may terminate in death and sloughing of the tissues of the neck is not an unusual occurrence. 2. Malignant scarlatina is characterized by a severe toxaemia which may S*al^A°s'; n [^ pi [T] pn ^ "^ m r^ M P ^ n '~ n n n n n n HOUR K A P M M A 1* M A M A M A P P M A M P A M IV p A M P M M M p p A p p A p A M £ M P A M M 107' - r- - — - - - - - - - p — - - 106° - — - — - — — - - - - - ~ - — b E-4i° ^m; _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I104' - - It - - — — ^ ^— — — — — - — — — IT) HO g : ^ : H - ^ G ti39° g 2, |ios' «1D2' - q k - 3 d - - - I - z - z I - d H - S 101 ~ - 5 : ~ - - - 3 3 - - - - = - h E '^ §100° — - - - - -\ — -^ — - - — — - - - — - -38 3 99° - -\ - — — — - — — — - - - - - : ^' _ _ 1 1 V _ _ _ _ _ _ _ _ _ _ P_ ~ ~ I q q 5 y 5 * ^ A ^ s 7 i ^ I z z z z z z z z Z z : ^37° 97" - - - = d = = - J r ~ = = = = = - z d d = = = I I -:s° 96° \ 1 — —J 1 — 1 1 — I — 1 1 1 — 1 — 1 1 — 1 — 1 1 — 1 — 1 — 1 — 1 1 — I— 1 — 1 — LJ Fig. 9. — Clinical chart of scarlatina. overwhelm the patient and result in death even before the diagnosis is made. Hyperpyrexia is present, the pulse is very rapid, soon becoming weak, the prostration is marked and the cerebral symptoms are profound. Death takes place from adynamia. 3. Hcemorrhagic scarlatina is typified by the appearance of extravasations of blood beneath the skin and mucous membranes resulting in epistaxis, haematemesis, intestinal haemorrhage, haematuria, etc. This form of the disease is usually fatal. Complications. Of these nephritis is the most important and perhaps the most frequent. It is of acute type and must not be confounded with the albuminuria which so often occurs when the fever is at its height. It is 224 THE INFECTIOUS DISEASES. usually evidenced by the appearance of albumin and casts in the urine but instances have been noted in which renal changes have been found post mor- tem when no symptoms suggesting nephritis had been present. The condition is probably the result of the toxic action of the poison of the infection and occurs in several forms: a, A mild type with slight oedema and albuminuria and a few casts; h, a more severe type, with more marked oedema, dark urine with more abundant albumin and casts and transudates into the serous cavities, resulting in death with tiraemic symptoms, chronic nephritis or, as a rule, recovery; c, a haemorrhagic type, with scanty urine containing blood, albumin and numerous casts. Anuria may occur, vomiting and convulsions are fre- quent; the outcome is usually rapidly fatal and due to ursemic poisoning. Endocarditis is not rare. This may persist after recovery from the scarla- tina or may occur in a malignant form which is usually fatal. Myocarditis and pericarditis are less frequent but are complications to be dreaded. Pleurisy, empycema, bronchitis and broncho-pneumonia are less common complications. An arthritis may occur in one of two forms : an arthritis similar to that occur- ring in other infections such as enteric fever or gonorrhoea and involving several joints as a rule, or a suppurative inflammation affecting one or more articulations. The prognosis is good in either t^'pe. Otitis is a serious and not uncommon complication and is the result of the extension of the throat inflammation through the Eustachian tube to the middle-ear. Perforation of the tympanic membrane is frequent and mastoid- itis with all possible complications may foUow. Impairment of hearing or complete deafness may result. Adenitis accompanied by glandular enlargement in the cervical region is very common and may go on to abscess formation and necrosis in the deep tissues of the neck. Complications referable to the nervous system are rare but sometimes occiir. Of these the most important is chorea which may be associated with the arthritis and endocarditis. Hemiplegia, progressive paralysis and cere- bral thrombosis have been observed. The diagnosis of scarlet fever is usually not difl&cult in typical instances, the rash, the pharyngeal symptoms and the tongue being characteristic. Scarlatina may be differentiated from measles by its more abrupt invasion, the presence of throat symptoms, the absence of the buccal spots and catarrhal symptoms and the desquamation; from rubella by its more severe constitutional symptoms and characteristic tongue; from diphtheria by its eruption and by bacteriological examination, but it must not be forgotten that the two infec- tions may be present simultaneously; from drug eruptions by the presence of constitutional symptoms and sore throat; and from acute exfoliative dermatitis by the presence of the characteristic tongue and throat symptoms. In der- SCARLATINA. 2 2$ matitis the desquamation differs, the skin being thrown off in crusts and scales; a moist surface is frequently left. The prognosis is variable. In some epidemics the mortality is high, but as a rule the death rate in this disease is not great. It is higher in infants and in institutions. The malignant and fulminating cases are fortunately not common for they are almost certainly fatal. Complications are usually responsible for death when this occurs in the ordinary t}'pe of the disease. Relapses in scarlatina are rarely observed. Treatment. Prophylaxis is most important for by proper methods the disease may be to a great extent prevented. Isolation during the course of the disease and thorough disinfection of the sick-room and its contents are absolute essentials. The physician should always cover his ordinary clothing with a long gown while visiting the patient and upon leaving should disinfect his hands and his face and hair in so far as is possible. Only the persons immediately concerned in the care of the patient should be allowed in the sick-room, all the excreta should be rigidly disinfected and the skin, especially during desquamation, should receive inunctions or baths in some antiseptic solution to prevent dissemination of the exfoliated epidermis. The quarantine should be continued for from 6 to 8 weeks after the inception of the disease. A careful system of school inspection will do much to prevent the spread of this infection. The treatment of the disease itself consists in strict confinement to bed during the febrile period and for a week or ten days thereafter, the control of symptoms and in prevention of complications. The mild types of the disease need little or no medication. The sick-room should be light, well-ventilated and kept at a uniform temperature of from 65° to 68° F. (18.5° to 20° C). The itching and burning caused by the eruption may be relieved by inunctions of carboHzed vaseline, 5 percent, ichthyol ointment in lanolin, 5 percent, boric acid ointment in vaseline. Sponging with very weak (| percent.) phenol solution as well as dusting with talcum powder are also useful. Inunctions of colloidal silver (unguentum Crede) may exert an effect upon the septic nature of the disease as well as a beneficent influence upon the skin. Inunc- tions are particularly indicated during desquamation to prevent the dissem- ination of the scales. Baths of warm soapsuds may also be given and if the skin is irritated, bran baths may be employed. The temperature in ordinary cases may be neglected but should it rise above 104° F. (40° C.) it may be reduced by the application of an ice coil over the heart, cool sponging or cool packs. Quinine has been advocated; the only effect which it can have in this disease is to temporarily lower the temperature. For the cerebral symptoms cool sponging, the ice cap and small doses of salipyrine, salophen, acetphenetidine or antipyrine may be em:- ployed. These drugs while reducing the tendency to insomnia and restless- 15 226 THE INFECTIOUS DISEASES. ness also have an antipyretic effect. A daily sponge bath with tepid water and soap should be given for the sake of comfort and cleanliness. Stimulation in the milder forms of the infection is unnecessary but in severe cases of septic or anginose type with weak, rapid and irregular pulse it is indicated. Brandy or whiskey is usually preferable, the dose depending upon the condition in hand. Digitalis as the tincture may be given when the pulse is rapid and of low tension, the dosage for a child 5 or 6 years old being I drop (0.065) every 5 or 6 hours. Strychnine in doses of from 2'i-o to yiiy of a grain (0.0003 to 0.0006) may be given alone or in connection with other stimulants. Throughout the disease the bowels should be kept freely open, an initial course of fractional doses of calomel followed by a mild saline being indicated at the onset. As the disease progresses saline laxatives may be given from time to time or the high intestinal irrigation with hot water (112° F. — 44.5° C.) may be employed. The latter is a most excellent stimulant and diuretic and an aid of considerable value in the elimination of the poison of the infection. Pilocarpine has been recommended in the treatment of scarlatina; it is said to reduce the temperature, to improve the condition of the throat and to prevent glandular involvement. It should not be given with the coal tar antipyretics and should idiosyncrasy to the drug be present atropine will be found to be an effective antidote. The simple form of pharyngitis needs no other treatment than a mild antiseptic mouth wash or throat spray of Dobell's solution or of diluted liquor antisepticus which should be applied every 4 hours. Nasal involvement should be controlled by syringing or spraying with similar agents. The severer throat inflammations should be carefully treated in order to prevent, if possible, aural complications. Here hot or preferably cold applications should be made to the throat externally and endeavors should be made to keep the throat itself as nearly clean as possible. Frequent irrigations of hot, mildly antiseptic solutions such as ^ satm-ated solution of boric acid, o.i percent, iodine trichloride, 0.2 percent, salicylic acid, etc., are useful. The irrigation should be of considerable quantity and given while the child is lying with its head turned to one side and slightly lower than the rest of the body. It may be given by means of a fountain or ordinary syringe to which a soft rubber catheter is attached. If the swelling is marked and there is tendency to oedema, sprays containing adrenalin chloride may be employed and steam inhalations impregnated with compound tincture of benzoin or eucalyptol may be prescribed. Insufflations of equal parts of sozoiodol and sublimed sulphur are recormnended; 10 percent, phenol in glycerin may by injected into the seat of the inflammation in instances of gangrenous tonsillitis. Slight enlargements of the cervical glands usually subside without treat- SCARLATINA. 227 ment but more marked glandular involvement necessitates the employ- ment of continuous cold by means of the ice bag held in place by bandages. Inunctions of ointment of colloidal silver (unguentum Crede) are useful and a thin gauze compress impregnated with 10 percent, ichthyol ointment may be applied to the glands beneath the ice bag. The presence of pus demands immediate incision and drainage. The prevention of complications is a most important part of the treatment of this disease. While at times these occur in spite of all attempts at prophy- laxis, this fact should not deter the physician from employing every means in his power. In preventing the incidence of nephritis It is particularly necessary to watch the urine carefully, examining it at least once a day, to studiously guard the patient against exposure to draughts, to continue the fluid diet and the confinement to bed for at least a week after all febrile symptoms have disappeared and not to allow the patient to leave the sick-room too soon. It is far better to err upon the safe side in this regard than to permit the patient to go out too early. Recently the use of hexamethylene (urotropin) has been advocated as a prophylactic against scarlatinal nephritis and has seemed efficient in some instances while inert in others; it certainly can do no harm when given in proper dosage and carefully watched. The prophylactic use of digitalis has also been recommended and it would seem that the employ- ment of high rectar irrigations of hot saline solution should be effective. The treatment of scarlatinal nephritis when it occurs is identical with that of acute nephritis when occurring from other causes. The prevention of aural complications consists in the methodical and thorough treatment of the pharyngeal conditions as laid down above. The drum membranes should be inspected daily for any sign of bulging and when necessary immediate paracentesis should be done, the opening to be kept free as long as there is the slightest tendency to discharge. The discharging ear should be irrigated with warm boric acid solution in considerable quantity every 4 hours. The practitioner should never hesitate to summon the otolo- gist in consultation when the condition is in the least doubtful, for upon proper management of the aural complications of scarlatina the patient's hearing may depend. Mastoiditis, internal ear involvement, sinus thrombosis, etc., are conditions for the otologist alone and their discussion is beyond the scope of this work. The treatment of the joint complications consists in immobilization and the application of hot moist compresses. While by no means always satis- factory in its results, the administration of the salicylates should be under- taken. These may be given in appropriate dosage by mouth, or salicylic acid may be given by inunctions as suggested under the treatment of acute articular rheumatism. Acetyl-salicylic acid (aspirin), adult dose from gr. x to XV — 0.66 to i.o, may be employed. The chronic joint complications neces- 228 THE INFECTIOUS DISEASES. sitate the internal and external exhibition of the preparations of iodine. The presence of pus in a joint is an indication for immediate surgical inter- ference. The treatment of the other complications is identical with that to be insti- tuted when these occur independently. Advances have been made diiring recent years toward the serum treatment of scarlatina by means of antistreptococcus serum; this serum is used rather to combat the complications which are due to streptococcus infection than with the hope of influencing the disease itself. The results, particularly those attained with Moser's serum, would seem to justify the employment of this means of treatment. It is particularly indicated in the severer and complicated types of the infection. The serum is given in considerable amounts and acts best when administered in the early stages. The initial dose may be about 5 drachms (20.0) and a total quantity of 5^ ounces (180.0) has been given. The disadvantages of the treatment are its costliness and the large amount of serum necessary. Von Leyden's so-called convalescent-serum is reported to achieve good results. The treatment of convalescence consists in the employment of tonics and careful watching of the urine which should be examined at intervals for a considerable period. Persistent nasal and throat symptoms necessitate the employment of antiseptic sprays. The diet of the disease should be of milk — ^plain or peptonized — only throughout the febrile movement and as a preventive of nephritis for a week or ten days after the normal temperature has been reached. After this time an ordinary regimen may be gradually and carefully resumed. FOURTH DISEASE. Synonym. Dukes's Disease. This affection is considered by Dukes to be an independent disease of mild character which simulates mild scarlatina, but differs from it in that its incu- bation period is much longer, being from 9 to 21 days, and in its lack of pro- dromal symptoms. The eruption resembles that of scarlet fever except that it appears first upon the face; it is usually followed by profuse desqua- mation. Many observers doubt the existence of this disease as a separate entity, and it is certain that, before its identity can be clearly established, further study must be made of rubella. It has been suggested that this affection may be the result of a simultaneous infection with scarlatina and rubella. Its treatment is entirely symptomatic and to be based upon that of the other infectious exanthemata. VARICELLA. 229 VARICELLA. Synonym. Chicken-pox. Definition. An acute infectious febrile disease of mild type characterized by a vesicular eruption and usually seen in children. .etiology. The disease occurs sporadically but from time to time epidem- ics are observed. It is essentially a disease of children but adults who are not immune through an attack in childhood are quite likely to contract the infection. The affection is met in all climates and at all seasons and while its specific cause has not yet been isolated it is presumably a micro-organism, probably a protozoon. The contagium is found in the contents of the vesicles and the disease may be reproduced by inoculation with this. The disease is markedly contagious and is transmitted by direct contact and possibly through a third person. Symptoms. The incubation period is from 10 to 16 days and the appear- ance of the eruption may be the first noticed symptom. In other instances there may be mild prodromata such as irritability, malaise and slight fever. The invasion may be marked by a chill of slight degree followed by a rise of temperature to 101° to 103° F. (38.5° to 39.5° C), vomiting, headache and perhaps general pains. The eruption appears, without other symptoms or within 24 hours of the incidence of the invasion, first upon the upper part of the trunk, although it is usually first observed upon the face; upon the face the rash is usually scanty but the scalp is always involved. It occurs first in the form of small reddish points which quickly become rounded rose- colored macules. These become successively papules and vesicles within a few hours. These last vary from yV to J an inch in diameter and later contain turbid fluid. Usually they are not umbilicated but at times this manifestation may be observed. In about 48 hours from their original appear- ance the spots have become pustules which upon being pricked collapse entirely, which is not the case with the pustules of smallpox. The rash lasts from 2 to 5 days when the pustules begin to dry, a brownish crust resulting, which soon falls leaving no scar; in certain instances a depression is left which, however, is seldom permanent. Successive crops of the eruption appear and the rash may be seen in all stages at the same time. If the vesicles are scratched or irritated small cicatrices may remain. The rash is also seen upon the lining of the mouth and pharynx and perhaps on that of the larynx. A scarlatiniform blush may precede its appearance. The eruption of vari- cella is always discrete and in mild cases there may be not more than 10 to 20 vesicles upon the whole body. The temperature falls by lysis as the rash fades and as this occurs the other symptoms, if any have been present, disappear. The disease in children previously healthy is very mild but may be more severe in those less fortunate. 230 THE INFECTIOUS DISEASES. In the latter complications such as nephritis and paralyses have been observed. A haemorrhagic form of the disease with extravasations of blood into the eruption and from the mucous membranes has been described and gangrene of the skin about the pocks and of the scrotum has been noted in strumous children. Erysipelas and adenitis are possible compHcations. The diagnosis is not dif&cult. The lack of constitutional symptoms, the occurrence of the eruption in all stages at one time, the absence of umbil- ication of the vesicles and of a surrounding areola are characteristic. There is no sjiotty feel under the skin as in smallpox. In infants the differential diagnosis between severe t}^es of variola and mild cases of varioloid may present diflficulties. The prognosis is uniformly good, although in institutions and unsanitary districts the disease is prone to assume a severe type, and complications may occur which are likely to render the recovery of the patient somewhat uncer- tain. Immunity is usually but not invariably conferred by an attack. Treatment. Prophylaxis consists in isolating the patient if the disease occurs in institutions or other places where many children are gathered. In private, quarantine may not be necessary unless the other children in the family are unhealthy or delicate. Quarantine when instituted should be continued until the last crust has fallen, the patient may then be released and his apartment disinfected; cleaning and thorough airing will usually be found sufi&cient. The treatment of this disease is simple and consists chiefly in relieving the symptoms. The fever is seldom of a height to cause alarm and may be easily controlled, if necessary, by means of cool sponge baths. The headache may be alleviated by means of cold compresses. The bowels should be kept open and the skin and kidneys active. Cooling 'drinks may be grateful to the patient. If the eruption upon the buccal lining is painful this symptom may be relieved by rinsing the mouth with a 2 percent, to 4 percent, cocaine solution. The mouth should be kept clean by means of mild antiseptic washes; catarrhal conditions of the upper air passages and glandular involve- ment, which may be observed in strumous children, may be combated by the means suggested under the treatment of scarlatina. The itching of the skin may be, to some extent, prevented by a wash of very weak phenol solu- tion, by applications of carbolized vaseline, 10 percent, boric acid ointment in lanolin or vaseline or a 3 percent, ichthyol ointment. To prevent scratching in infants it may be necessary to tie up the patient's hands in cotton ^vrapped about with gauze. It is important that the urine should be examined at intervals during and succeeding the disease. It is best to keep the patient in bed during the febrile movement and the diet should consist of fluids. Ordinary diet may be gradually resumed after the temperature has reached normal. SMALLPOX. 231 SMALLPOX. Synonym. Variola. Definition. An acute infectious disease characterized by an eruption which appears first in the form of macules, which become successively pap- ules, vesicles and pustules, upon the last of which crusts form which finally fall and leave permanent cicatrices. JEtiology. This disease has existed in various parts of the earth since a very remote period. It invaded England during the 13th century and later was brought to America. Before the introduction of vaccination it was a com- mon and very fatal disease, epidemics being by no means infrequent. Small- pox is very contagious, almost all unvaccinated persons who are exposed conracting the disease; instances of natural immunity have, however, been observed. A single attack usually confers immunity, but cases in which 2 to 3 undoubted attacks have been experienced have been reported. The disease occurs in individuals of all ages and is especially fatal in children. Pregnancy predisposes to the infection and infants exhibiting an active erup- tion or the pock marks have been born of mothers who have contracted the disease during this period. Such instances are rare and a child born while the mother is suffering from the infection rarely contracts it if immediately vaccinated. Males and females are equally susceptible but smallpox is more virulent in dark skinned races and is rapidly disseminated and very fatal amongst aboriginal tribes. The disease is contagious throughout its whole course after the appearance of the eruption and a few moments of association with a sufferer are a suffi- ciently long time to contract the infection. The contagium may be carried to great distances on clothing, in bedding, etc., and the pulverized dry crusts retain their infectivity for several years. The contagium exists in the blood, secretions, the contents of the vesicles and pustules, in the dried crusts and probably in the excretions. Inoculation from the blood, the contents of the vesicles and pustules and from the scabs is possible but the chief mode of transmission is probably by means of the pulverized crusts w^hich are taken in upon the inspired air. The poison of the disease may be transmitted by a third person and upon the air to an unknown distance. The severest type of the disease may be contracted from a very mild case. The specific cause of smallpox: is probably a micro-organism and much research has been conducted in the hope of isolating it. A bacterium has been found both in the contents of the pustiiles of smallpox and in the lymph of cow pox which may prove to be the cause of the disease, and protozoa have been described which exist in the epithelial cells of the cutaneous lesions. Pathology. In addition to the typical eruption and its various modifica- 232 THE INFECTIOUS DISEASES. tions certain other morbid changes are found. The pustule has its origin in the rete mucosum just beneath the cutis vera. The pus focus is surrounded by a reticulum infiltrated with serum, leucocytes and fibrin. The central area of necrosis finally dries and forms a crust which falls leaving no scar if the process extends no deeper. If the papillae of the true skin are involved in the necrotic process and are destroyed, the loss of tissue results in a perma- nent cicatrix. The eruption may occur upon the mucous membranes of the mouth, phar- ynx and oesophagus, the agminated glands of the intestine may be swollen and a^ew pustules may appear in the rectum. They also have been observed upon the conjunctiva and upon the mucous membranes of the nose and larynx. The lesions when occurring in the trachea and bronchi take the form of ulcerous erosions rather than true pustules. In the haemorrhagic type of the disease there may be extravasations of blood beneath the skin and mucous membranes as weU as into the viscera, muscles, marrow and other tissues. Laryngeal oedema, perichondritis and chondritis, bronchitis and pneu- monia may be observed as associated lesions and myocardial degeneration may take place. Peri- and endocarditis are seldom seen but splenic enlarge- ment is common and the liver and kidneys are the seat of an acute degener- ation (cloudy swelling). True nephritis is rare but may occur during con- valescence. In the haemorrhagic type of smallpox the spleen is likely to be hard and dense and the liver of similar consistency or the seat of fatty degeneration. Symptoms. The disease occurs in three types: a. Variola vera of which 2 forms are described, i. Discrete. 2. Con- fluent. h. Variola hsemorrhagica of which 2 varieties have been observed, i. Purpura variolosa or black smallpox. 2. Variola hasmorrhagica pustulosa or pustular haemorrhagic smallpox. c. Varioloid or smallpox as modified by vaccination. a. Variola vera, discrete form. The period of incubation is from 7 to 15 days, usually 12. During this period there are rarely any prodromata, but at its end the invasion of the disease occurs suddenly with one or more chills. In children a convulsion is a frequent initial symptom. There are head- ache, backache, (which is characteristically intense) and general pains with nausea and vomiting and prostration. The temperature rises rapidly to 103° to 104 ° F. (39.4° to 40° C.) on the first day, the pulse is rapid and tense and nervous symptoms may be pronounced; even delirium may be present in severe infections. The skin is usually hot and dry but in certain instances marked sweating may occur. The severity of the initial symptoms is no ndication of the type of the disease. SMALLPOX. 233 About the 2d day the initial rash appears. It may be either diffuse and scarlatiniform or macular; while these eruptions may be general they usually occur only upon the lower abdomen, the sides of the chest, in the axillary region and upon the inner aspects of the thighs. Haemorrhagic petechiae may accompany them. The scarlatinal t}'pe is the more frequent. Initial eruptions are by no means the rule, since they appear in only from 10 to 16 percent, of cases. About the 4th day the characteristic eruption of the disease appears first upon the forehead along the hair line or upon the ventral surface of the wrists, whence it spreads downward over the trunk and limbs becoming general DAY OF DISEASE "^ -^ ^ [^ 5 r^ [^ H ^ ^ ^ ^ ^ p ^ n n n n n -41" HOUR M M s M M MM M A U M p p £ M p M p M s M M p M w M WW F 107' 106' E I 3 1 2 E i E I z = E E E E E E E - E z 105 1 104 1 103' ^ \ j 5 E 3 t. E E E E = E E E E z z - z E Li - X - - z =ti ^ =^ ^^ =e: -^ - E - p - - - = - - - im' — L- - — -f— ~- -^ - - -1 - J H - - — - — : c ^39° « - - j — ^— t- ^- ^ - r - - z : ; d ± 't 101" ~ z rz: p - p \- zz :-(— - _ — - - — - - - - - H - - c - 3 r = E E = y = E - ^ - 4= E I^ E - E ~ E E z E Z z g 100 99" z - z z E z 1 = = z z z z z = E E E E E z E E = z - ^38 1 z - ~ z z z z z z «— £^ = = = E fe 1 - E E E E E E E E E E E E E E : 98^ — z ~ z z - p z z z z t^ •V z z z - z z z z z z z E37° _ _ — _ _ _ _ l- _ J — , — 1 — — — — — — — — 97° — — - - - — - — - z iz z tz z z z z — z z z _ hi z z z z z : z z z t : z z z - z z z z z z z z z z z z z z z z z z - z - - - 96' — — - - — - — -J - — - - - — — — — - - - - — - — 1 1 — 1 — 1 — 1 — — 1 — 1 — 1 — 1 — 1 — 1 — 1 — 1 — 1 — 1 — I — 1 — 1 — 1 — 1 — 1 — I— 1 — Fig. 10. — Clinical chart of smallpox showing fall in temperature upon the appearance of the eruption and its rise upon the incidence of the stage of pustulation. usually within 24 hours. At first it is in the form of round pale, reddish macules which later become darker and slightly elevated. By the second day the papules have assumed firm consistency and impart a feeling as of shot under the skin to the examining finger. By the 5th or 6th day the papules become vesicles containing clear or slightly turbid serum and umbilication is present which is a characteristic of the eruption of smallpox; by the 8th day the vesicles have become pustules, the umbilication disappears and the skin and mucous membranes become tense, swollen, inflamed and painful. After the rash has persisted for from 10 to 12 days the pustules dry and crusts form which finally fall leaving no scars unless the deeper layers of the skin have been affected. In the latter event pit-like cicatrices of varying size 234 THE INFECTIOUS DISEASES. and depth persist. The rash appears upon the various mucous membranes (see p. 232) as well as upon the skin. In true smallpox there is a distinct leucocytosis. At the end of the first week a count will reveal an increase to 12,000 or 15,000, later this may fall but at the end of the second week there is a second augmentation. The temperature, upon the appearance of the eruption, falls, sometimes- nearly to normal, but when the fluid in the vesicles becomes converted into pus the fever (secondary fever) recurs and with it the usual symptoms which acconjjpany an abnormally high temperatiire appear. Not unusual symptoms of the disease are sore throat and hoarseness, due to the eruption upon the pharynx and larynx, vomiting and diarrhoea. Splenic enlargement is frequent and albuminuria may be present. As the rash drys and the crusts fall the temperature falls and all the other symptoms abate. The disease is said to possess a characteristic odor. In the confluent type of smallpox the pustules are so closely situated that they coalesce. This manifestation is particularly likely to be present upon the face. In marked cases of this type, the skin of the face and limbs is thoroughly infiltrated with pus, the temperature is high (105° F — 40.5° C.^ or more) and cerebral symptoms as well as other signs of a severe infection are observed. Salivation may be present and there is enlargement of the superficial lymph glands. The appearance of a patient affected with con- fluent variola is most revolting. In the more marked infections, from the loth to the 12th day the patient becomes progressively weaker, the cerebral symptoms increase in severity and death may take place. In cases which recover the secondary fever is prolonged, depending upon the extent of the pustulation, lasting from 3 to 4 weeks. At the end of this period the pus begins to dry and the crusts form. These, after adhering for a considerably longer period than those of discrete variola, fall. h. Variola hcBmorrhagica. The purpuric form of haemorrhagic smallpox is characterized by the early appearance of a heemorrhagic rash and of haemor- rhages from the mucous membranes. The condition is a very fatal one and the patient may die even before the appearance of the papules. Hsematuria is common and haematemesis, haemoptysis and corneal and intestinal haemor- rhages may occur. The skin may be purplish and the patient's appearance is most horrible. The temperature may not be greatly elevated, but the pulse is rapid and small, while the respirations are accelerated out of proportion to the height of the temperature. In variola hcEmorrhagica pustulosa the haemorrhages do not appear until the stage of vesiculation or of pustulation is reached. Then there are extrava- sations of blood into the areolae of the pocks and later their contents becomes bloody. Haemorrhages from the mucous membranes also occur. While this type of variola is very fatal, recoveries sometimes take place. SMALLPOX. 235 These malignant forms of the disease are much more prone to occur in the unvaccinated. c. Varioloid or smallpox modified by vaccination or a previous attack from the disease is usually much milder than the unmodified disease, although the initial pains may be severe. All the symptoms are less marked and the eruption is less diffuse. Secondary fever is slight or absent, the initial fever dropping and the symptoms clearing with the appearance of the eruption which matures rapidly. Permanent cicatrices are uncommon. This form of the infection in rare instances may be severe and even fatal. There is usually a direct ratio between the length of time intervening between vaccination and the attack and the severity of the latter. Unusual types of variola sometimes are observed. Variola sine varioUs or sine eruptione has been described and a form of the disease known as horn-wart or stone-pox in which the papules dry before the vesicular stage has been noted. Another abortive form is crystalline-pox in which the vesicular fluid remains permanently serous. Complications. Those referable to the respiratory system are oedema of the glottis, inflammations of the laryngeal cartilages, pleurisy and broncho- or lobar pneumonia. Vomiting, diarrhoea — particularly in children — and parotitis may occur. Circulatory complications are rare; myocarditis with inflammation of the coronary vessels has been observed, but pericarditis and true endocarditis are very seldom met, although during the attack of the disease an apical systolic murmur may be heard. Albuminuria is common but true nephritis is rare. Orchitis and ovaritis have been described. Cerebral complications such as persistent delirium or coma, occur during the acuity of the infection and post-febrile insanity and neuritis have been reported. Joint inflammations may complicate convalescence and skin manifestations such as painful acne, furunculosis and localized gangrene are among the most important sequelae. Formerly the neglect of the eyes was responsible for various ophthalmic complications but attention to the cleanliness of these organs has now ren- dered these less common. Otitis from extension of the pharyngeal inflam- mation may occur. The diagnosis is simple after the appearance of the characteristic eruption and in the earlier stages the severe pain in the back, the shot-like feel of the undeveloped eruption and its appearance upon the forehead about the hair- line are diagnostic points. The catarrhal symptoms of measles and buccal spots are absent which aids one in differentiating the measles-like initial rash, and the scarlatinal form of initial eruption is less persistent than that of scarlet fever. In chicken-pox the rash is present in all stages at the same time and is very rarely umbilicated. The differential diagnosis of the haemorrhagic type from epidemic cerebro- 236 THE INFECTIOUS DISEASES. spinal meningitis offers difficulties. The only safe method is to isolate all suspicious cases until the diagnosis is confirmed. The prognosis varies in different epidemics but at best smallpox is a disease to be dreaded, particularly in children. Haemorrhagic forms are generally fatal. Pregnant women are likely to abort and frequently die. Pharyngeal, laryngeal and pulmonary complications render the infection especially serious. Prophylaxis. The most strict isolation is absolutely imperative and if possible the patient should be removed to a hospital for contagious diseases. The room selected should be divested of all carpets, pictures and hangings, and all superfluous furniture should be removed. Before the door a sheet kept constantly moistened with i to 20 phenol solution should be suspended. Thorough ventilation is an absolute necessity. The nurse and physician shoiild wear, while in the sick-room, a gown covering all the other apparel and a cap which are to be removed upon leaving the patient. None but the attendants should be allowed to visit the patient. All bed linen and clothing should be immersed in i to 1000 merciu-y bichloride or three percent, phenol solution immediately upon removal and allowed to stand at least two hours before being sent to the laundry. All dressings, crusts from the eruption and sweepings must be immediately burned and the patient should be supplied with separate utensils and dishes. After death the body should be sponged with strong phenol or mercury bichloride solution, the mouth, nostrils and anus plugged with pledgets of cotton moistened with either of these, wrapped in a sheet saturated with a disinfectant, placed in a metallic or air-tight coffin and buried as soon as possible. The disposal of such bodies by cremation is always to be preferred when practicable. In the event of recovery the patient before leaving the sick-room should receive a thorough bath and shampoo with soap and hot water and then be sponged off with a i to 3000 solution of mercury bichloride or immersed in a I to 5000 bichloride solution bath. He should then be dressed in a clean night dress and removed to another apartment where he may put on other clothing. The quarantine should be insisted upon until the skin is clean, smooth and no trace of the crusts remains. Room disinfection. The disinfection of the sick-room and its contents depends upon the means at hand. If a steam disinfecting plant is conven- iently situated the bed, bedding and other fabrics should be made into bundles, wrapped in clean sheets and removed for steam disinfection. By care in transportation such packages may be transferred with little danger. The bedstead, furniture and wood work must be carefully washed with a soft cloth wet with i to 1000 mercury bichloride or three percent, phenol solution. All cracks and crevices should receive studious attention. The removal of superfluous objects greatly simplifies the disinfecting process. The walls SMALLPOX. 237 if painted should be treated in the same manner as the wood work; if papered they should be thoroughly rubbed with pieces of bread, then if practicable, the old paper should be removed and burned and the walls repapered. After attention to these details all the windows and the doors, with one exception should be closed and sealed by pasting strips of paper with common flour paste over all the cracks. The sealing process is important, for upon the tightness of the room depends, in great measure, the efficacy of the disinfection. If the cracks allow the escape of the disinfecting gas, the process is of little value. Before sealing the last door all draperies which have not been removed must be spread out and all drawers, closet doors, etc., widely opened. Sulphm* dioxide or formaldehyde gas may be used to disinfect the room. If the apartment is bare and contains little decoration the former may be employed; if the reverse is the case the latter is to be preferred. If sulphiu: disinfection is chosen, four pounds must be used for each 1000 cubic feet of room space. A simple method of generating the gas may be arranged as follows: Two or three bricks are laid upon the bottom of an ordinary wash tub and upon these is placed a dish-pan or other metal receptacle which is to hold the sulphur. The tub should contain enough water to cover the bricks and the bottom of the pan, so that there shall be no danger of fire. For this reason the vessel which holds the sulphur must never be placed upon the floor. The sulphiir is to be broken in small pieces, over which alcohol is poured and set on fire by touching a match to the mixture. The operator should stand at as great a distance as possible while applying the match. If enough alcohol is used the sulphur will be almost entirely consumed, and it is important that the pan should not contain too much sulphur, as in this case the combustion will not be complete. On this account it is better to use two or more pans for the sulphur if the room is large. To produce proper disinfection it is nec- essary that moisture be present, and to provide for this, unless the weather is damp, we must supply this lack. This may be done by boiling water over a gas stove or by pouring boiling water from one vessel into another in the room just before the disinfection is begun. Another method is to place a vessel of water a few inches above the burning sulphur. The sulphur should always be prepared so that it may be at once set on fire after the moisture has been supplied. After lighting the sulphur the room should be imme- diately closed and the door of exit sealed as described above. If formaldehyde gas is employed it may be generated from tablets in a specially designed lamp or generated from formahn in an apparatus which sends the gas rapidly through a tube passed into the keyhole of a door. The latter method is preferable but less practicable than the former. Whichever method is chosen the room should remain sealed for at least 8 hours. Even at the end of this time care must be exercised in entering the apartment and in so doing one should wrap the face in a wet towel, pass quickly 238 THE INFECTIOUS DISEASES. to a window and open it, allowing the gas to escape and the fresh air to enter. Since the discovery of vaccination by Jenner in the last decade of the i8th century we have had at our disposal a practically absolute preventive of smallpox and since that time the disease has become a rarity in districts in which the procedure has been systematically instituted. Consequently too great insistence cannot be laid upon the necessity for the routine performance of the operation. All children should be vaccinated at from 3 to 5 months of ago, every 7 years thereafter and in the intervals whenever smallpox is prevalent; at such times one should never be satisfied with one unsuccessful attempt. While vaccination does not always protect, the disease as it occurs in those who have undergone the operation is very rarely severe. Treatment. Since no means exists of shortening the disease when once infection has taken place the treatment is to be directed at the control of the symptoms and the prevention of permanent scarring. At the onset the patient should be isolated and put to bed in an airy room, the temperature of which should be kept constantly at about 65° F. (18.5° C.) and the bowels should be opened by repeated fractional doses of calomel or other mild laxative, to be followed by a saline, if necessary. The symptoms of the first stage which need special attention are the pain, the vomiting, the diarrhoea and the cerebral manifestations. The pain may be relieved by the administration of acetpheneti- dine, acetanilide or salipyrine, usually in combination with caffeine to prevent heart weakness. Morphine may become necessary in severe instances. The ice cap to the head and the application of analgesic liniments such as the following, I^ camphors, chloralis, mentholis, aa B i, may prove beneficial. The vomiting may be controlled by swallowing small pieces of cracked ice, by minute doses of phenol, hydrocyanic acid or cocaine or by frequent sips of iced champagne, and the diarrhoea by means of bismuth naphtholate or iodo- phenolphthaleinate (dose of either gr. v to viiss — 0.33 to 0.5); bismuth subsalicylate or subgallate in connection with small doses of opium may also be employed to relieve this condition. The nervous symptoms may be rendered less distressing by potassium or sodium bromide or hydrated chloral, any of which may be given per rectum as well as by mouth. Sulphonmethane is also useful and in the extreme instances the employment of morphine or opium in small doses may be necessary. Cool sponging, tepid tub baths and the ice helmet are also useful in the treatment of the cerebral manifestations. The temperature is seldom high enough to cause alarm but if necessary it may be reduced by the application of the ice coil over the precordium or by cool sponging. Rarely is cardiac weakness an early symptom but should this be the case stimulants such as caffeine, alcohol or strychnine may be given hypodermatically. SMALLPOX. 239 The dryness of the mouth will be alleviated and the activity of the skin and kidneys will be favored by frequent cold drinks which should be offered at intervals. The eruptive period. During this stage the problem confronting us con- sists of two parts, the treatment of the cutaneous manifestations and that of the constitutional condition. In the former the chief object is to prevent permanent scarring and numerous methods have been employed with this end in view. Of these the simplest and one of the most eflEicacious is to cover the skin with a thin gauze compress which is kept moist with cold i to 5000 to 10,000 mercury bichloride or i to 200 or 300 phenol solution and is covered with oil-silk. For the face a suitable mask can be made. The phenol has the especial advantage of neutralizing the unpleasant odor of the disease. The wet compresses have a certain analgesic effect and are grateful to the patient. CUpping of the hair is necessary if the eruption involves the scalp to any extent. Of other means of treating the skin the employment of wet dressings of weak thymol or potassium permanganate solutions may be mentioned. Many more drastic applications have been advocated, such as touching the eruptive points with pure phenol, painting with silver nitrate solution or ^ strength iodine tincture and even opening the pusfliles and touching them with stick silver nitrate, but none of these is likely to yield better results than the simple cold wet compress. Dusting powders have a place in the treatment of the eruption especially in its early stages. Of these boric acid, bismuth subgallate, talcum, or a mixture of phenol i part and lycopodium powder and zinc oxide of each 16 parts are to be recommended. Scrub-baths given daily are said to prevent pitting since they hinder the formation of the vesicles and pustules; they are, however, a drastic measure. Continuous warm baths have also been advocated. The administration of xylol — 100 to 120 drops (6.66 to 8.0) in divided doses every 24 hours is said to diminish the mortality, to lessen the characteristic odor of the disease and to tend to arrest the suppurative stage, thus influencing the occurrence of pitting. The variolous manifestations in the nose, mouth and throat require the external application of cold and moisture and attention to the cleanliness of the nasal and buccal cavities. Antiseptic sprays and mouth washes such as Dobell's solution or diluted liquor antisepticus are useful here and astringenl washes such as dilute solution of potassium chlorate or iron perchloride may be employed. The discomfort attendant upon the appearance of the erup- tion in the mouth may be alleviated by means of sucking bits of ice and by emollient and demulcent drinks such as thin oatmeal gruel and teas of arrow-root or marsh-mallow. If ulcers appear they may be touched with a 20 percent, silver viteUin (argyrol) solution. Localized collections of pus in the pharynx or tonsils should be immediately opened and drained. 240 THE INFECTIOUS DISEASES. The conjunctival eruption should be carefully treated by means of contin- uous compresses of cold boric acid solution (| saturated) and by instillations of a few drops of a lo percent, argyrol or of a i to 500 methylthionine hydro- chloride solution. Silver nitrate solution may be used but is painful and no more efl&cacious than the silver viteUin. If the eyehds tend to become gummed together this may be prevented by anointing their margins with vaseline, either plain or containing 5 percent, of boric acid. After the crusts have formed the patient should be advised to let them fall spontaneously for if they are removed before they are wholly loosened the pitting is apt to be more pronounced. Children should be prevented from scratching by bandaging their hands loosely in gauze. The itching during the period of crust formation may be relieved by means of the dusting powders suggested upon the previous page or by warm baths to which bran may be added and the scales may be protected from irritation by means of light dressings of carboHzed vaseline or vaseline containing 5 percent, of boric acid. If the scabs become detached for any reason before the skin beneath has wholly healed the suppurating surface should be cleansed with a mild antiseptic solution and dressed, until the skin has reformed, with borated vaseline. Exuberant granulation tissue should be touched with stick silver nitrate and dressed antiseptically. The treatment of the constitutional condition during the stage of pustula- tion offers "several problems. The strength of the patient must be maintained by proper and sufficient nourishment and the pyasmic condition necessitates the employment of measvires such as are indicated in suppurative states due to other causes. Here alcohol in the form of brandy or whiskey, 2 to 4 ounces (60.0 to 120.0), and infusum cinchonas in large doses are highly recommended. The former may be given either diluted with water or in the form of a milk punch with egg; to the latter a few drops of dilute hydrochloric acid and spirit of nitrous aether may be added with advantage. The fever seldom needs especial treatment but should it be alarmingly high the application of an ice coil to the precordium will usually result in a considerable reduction. The coal tar antipyretics should be employed with great caution if at all. The condition of the heart should be carefully watched and should stimulation be required in addition to the alcohol, strychnine and caffeine may be given in appropriate doses and should there be evidence of collapse hypodermatic injections of camphor dissolved in olive oil or aether become necessary. Ner- vous symptoms may be controlled by the bromides and chloral which may be given by rectum or by mouth as indicated. The dose of the latter must be such as to be in no danger of causing heart weakness. Tepid baths are also useful in relieving the nervous hyperexcitability. The administration of antistreptococcus serum has been suggested as a means of combating this stage of the disease and not without reason since the pres- SMALLPOX. 241 ence of the streptococcus in the contents of the pustules is common. This procedure is especially indicated in patients with grave septic symptoms; 15 drachms (60.0) may be given in 3 doses 24 hours apart or in profoundly toxic instances this quantity may be given in one day. Attempts at controlling haemorrhages may be made by giving ergot hypodermaticaUy or better by the internal or rectal administration of calcium chloride. The latter exerts a dis- tinct influence in increasing the coagulability of the blood and may also be given in hsemorrhagic forms of the eruption. Its dose is 20 grains (1.33) 3 times a day. The treatment of the complications is little different from that of similai conditions occurring independently. OEdema of the glottis may demand scarification, intubation or tracheotomy. Pneumonia should be prevented by careful management of its precursor, bronchitis, and by frequent turning of the patient upon his side to prevent hypostatic congestion of the bases of the lungs. Pharyngeal suppuration and furunculosis necessitate appropriate surgical treatment. The treatment of smallpox by means of red light has recently been advo- cated, especially by Finsen, who considers the omission of this method to be little less than criminal. The idea is not new, having been exploited by John of Gaddesden in the 14th century. According to Finsen, who excludes the ordinary daylight by means of panes of red glass, daylight and particularly its chemical rays have an injurious effect upon the course of the disease since the suppuration of the vesicles is brought about by exposure to unchanged sunlight. Upon the infection per se the Hght seems to exert no action. The avoidance of suppuration, however, is most important, since the stage of pus formation is the most dangerous epoch in the disease and many fatalities result primarily from the suppuration. The method must be properly and systematically employed, but if pus formation has already taken place or is about to begin the red light will not abort it. Finsen considers that in ordinary epidemics this treatment will reduce the death rate by one-half. Many other observers have used the light treatment with good results while still others are much less enthusiastic in its advocation. Various other methods of treatment have been recommended with enthu- siasm, among which may be mentioned that by means of intestinal antiseptics such as the phenolsulphonates, phenyl salicylate (salol), mercury bichloride, etc., and that of Talamon who applies a spray to the skin composed of mercury bichloride and tartaric acid, of each 15 grains (i.o), alcohol (go percent.) one and a quarter drachms (5.0) and aether to make an ounce and a half (45 -o)- With this the skin is sprayed for i minute 3 or 4 times a day, the eyes being protected. The surface is first washed with soap suds, rinsed with boric acid solution and dried with cotton. The treatment is begun with the appearance of the rash, and after spraying, the face is covered with 50 percent, mercury 16 242 THE INFECTIOUS DISEASES. bichloride glycerite. After 4 days the spray is used less often and after i week it is discontinued, the glycerite dressing being continued. The same observer has recommended in the confluent type of the disease baths of mercury bichloride solution lasting 45 minutes to i hour, internal stimulation being employed at the same time. The serum treatment of smallpox has thus far given no results which render its use justifiable. Further advance in the elaboration of an efficient serum therapy may be made in the future. The convalescence usuaUy necessitates the employment of tonics and of easily Higestible and nutritious food. The diet of smallpox should be carefully regulated. During the initial fever only fluids should be allowed but in the remission before the stage of pustulation semi-solids such as gruels, soft-boiled eggs, meat jellies, etc., may be given. At the onset of the stage of pustulation the patient must return to fluids; it is at this time particularly necessary to maintain his strength, conse- quently the diet should be as concentrated and nutritious as possible. VACCINIA. Synonyms. Cow Pox; Vaccine Disease. Definition. An infectious disease characterized by an eruption and pro- duced in man by inoculation with the contents of the vesicle of cow pox. Individuals who have been successfully inoculated are, with a very few excep- tions immune from smallpox, and even if able to contract the disease such subjects are affected with its mildest form, varioloid. Whether vaccine disease is a separate disease or is the variola of the human being as manifested in the cow is a moot point, opposite views being held by different observers; one point is certainly evident, however, to the un- prejudiced, and this is that could vaccination be systematically and thoroughly carried out smallpox would become an unknown disease. Unfortunately certain fanatics oppose the compulsory performance of the operation and until these experience a change of heart and compulsory inoculation is in- stitituted cases of variola wiU be seen from time to time and where a proper soil is offered epidemics will occur. That inoculation with cow pox was a sure preventive of smallpox was discovered and proven by Edward Jenner, of Gloucestershire, England, in 1796. While in all probability vaccine lymph contains a specific micro-organism which is responsible for the train of symptoms which foUows inoculation, no such body has yet been successfully isolated although much research upon this subject has been carried out. Various bacteria and amcjeboid bodies have been found in the lymph but none of these has been proven to be the essential cause of the disease, vaccinia. VACCINIA. 243 In inducing vaccinia in the human being and rendering him subsequently immune to smallpox infection two varieties of virus are employed, the human- ized and the calf lymph. The former is the pus from the pustule of a vacci- nated human being, the latter is the contents of the pustule of the cow or calf. The latter is chiefly used at present and is preferable since the human- ized virus is capable of transmitting syphiHs to the inoculated person should the individual from whom the virus has been taken be unfortunate enough to be infected with specific disease. While the possibility of the transmission of tuberculosis in the same way has been considered it has never been proven. The operation of vaccination is performed as follows: The site selected is, in the case of boys, the outer side of the arm at the junction of its upper and middle thirds. In vaccinating girls in the upper walks of life it is preferable to use the outer side of the calf. The skin over the part chosen should be steriHzed by washing with soap and water, alcohol and i to 5000 mercury bichloride solution, wiped with sterile water and allowed to dry. Then with a needle which has been steriHzed by heating in a gas flame a surface one- eighth to one-fourth of an inch in diameter is lightly scratched, care being taken not to draw blood, but merely to remove the upper layers of the integu- ment. A slight exudation of serum wiU follow this procedure and into this the vaccine should be rubbed for several moments. The surface should be allowed to dry and then dressed lightly with a compress of sterile gauze. The various shields sold to cover vaccination wounds should not be used. Different makers supply dried vaccine upon quiUs or ivory points, which may be used instead of the needle to abrade the skin. When from a reputable firm these may be employed. The health boards of certain cities furnish calf lymph put up in glass tubes and packed with a needle, a bit of wood and full directions for the performance of the operation. The symptoms following vaccination. Shortly after the inoculation there is a slight inflammatory reaction at the site of the abrasion which lasts but a short time. If the procedure is successful and the vaccination takes, after a period of incubation, occupying usuaUy 3 days, a small red papule appears, by the 5 th to the 7 th day this becomes an umbilicated vesicle surrounded by a pink areola and containing a viscid transparent fluid; by the loth day the areola is more pronounced and the fluid has become purulent. The skin surround- ing the pustule is often indurated and tender. From this time the inflammation gradually subsides, the contents of the pustule begins to dry, about the 14th day a brownish crust forms which becomes flnaUy hard and dry and falls about the 21st day, leaving a roundish depressed scar which is red at first but finally becomes whiter than the surrounding skin. In many instances constitutional symptoms accompany the evolution of the vaccinal pustule. These vary from slight malaise and irritabflity with rise of temperature about the 3d day to marked prostration with a febrile 244 THE INFECTIOUS DISEASES. movement lasting from i to 2 weeks; with this there are headache, gastric disturbances, restlessness, etc. The number of white blood cells is increased and enlargement and tenderness of the axillary or inguinal glands, depending upon the site of the inoculation, occur. The duration of the immunity conferred by vaccination varies in different individuals but it is best to revaccinate every 7 years and at other times whenever smallpox appears epidemically. After from 10 to 15 years a second vaccination is usually successful but the appearance of the pustiile and the constitutional phenomena are less characteristic. Even in first inoculations the typical result niay not be attained. In such instances the operation should be per- formed again and repeated if necessary until success crowns the effort. Generalized vaccinia is rare but may manifest itself as a pustular rash on different parts of the body, appearing on the eighth to the tenth day; the pustules are most abundant upon the vaccinated limb and may continue to appear for several weeks. The disease may prove fatal in children. Complications of vaccination. Cellulitis may occmr, especially in debili- tated children as a result of contamination at the time of operation or sub- sequently and may necessitate the employment of radical surgical measures. Erysipelas is a serious complication and great care should be used in vaccina- ting if the disease is prevalent. If the disease exists in the family of the subject about to be vaccinated the operation should, if possible, be post- poned. During the evolution of the pustule various skin eruptions may appear and in certain instances dormant disease such as tuberculosis and hereditary syphilis have manifested themselves. The occurrence of tetanus as a complication has been noted in a number of cases most of which were inoculated with lymph from one particular pro- ducer. The possibility of such contamination should render us especially careful to use lymph from reputable sources only. The treatment of vaccinia is wholly symptomatic. Mild cases need no treatment whatever. Those in which the constitutional manifestations are unusually severe should be kept in bed and on a fluid diet during the febrile movement. The bowels should be kept open and the kidneys and skin active. The local condition and the glandular swellings should be treated in accordance with proper surgical methods and for the complications the means ordinarily applicable should be employed. GOUT. 245 CHAPTER II. CONSTITUTIONAL DISEASES. GOUT. Synonym. Podagra. Definition. A painful constitutional disease, acute or chronic, due to an abnormal quantity of the antecedents of uric acid in the blood, resulting in various symptoms, of which joint inflammation is the most prominent and characteristic, together with the deposition of urates in the neighborhood of the articulation. To Wallaston's discovery in 1779 that the deposits at and around the joints were composed of urates we date our knowledge of this disease and its pathol- ogy- .etiology. In many individuals there is an hereditary tendency but the disease may also be earned. In more than half the cases a family history is obtainable. The disease is more frequent in males than in females and it is through the male line that the hereditary tendency is more likely to be transmitted. Gout is seldom seen in young subjects and usually shows itself after the age of forty. The stigmata, however, of the gouty diathesis may be detected as early as puberty. The most common causes of acquired gout are excessive eating, particularly of meats, and intemperate drinking, combined with sedentary habits, yet these factors are by no means essential to its occurrence. It is also true that not all who possess the hereditary tendency suffer for the indis- cretions of their forbears, for proper mode of living may act as a preventive. Over-drinking is a chief factor in the production of gout, but the form in which the alcohol is ingested has a certain influence on the incidence of the disease. Heavy ales and beers such as those brewed in England are more likely to bring on gout than are the lighter malt liquors produced in America and Germany. Whiskey is less to be avoided in this connection than heavy wines, such as port. It is probable that the excessive carbohydrate content of these beverages is the causative factor of the disorder, resulting, as it does, in the products of gastric acid fermentation, which, upon absorption render the blood less alkaline and less solvent of uric acid. Lead poisoning may excite an attack of gout, possibly as suggested by Haig, because it may reduce the alkalinity of the blood. Local traumatism to a joint, or even pressure from footwear may bring on 246 CONSTITUTIONAL DISEASES. an attack in the injured part. The reason of the predisposition of the disease to attack the great toe joint is unknown. Pathogenesis. With regard to the pathogeny of gout there is much differ- ence of opinion, but most authorities unite in beUeving iiric acid to some ex- tent a causative factor. Whether this substance causes the train of symptoms known as "gouty" by its increased production in the body, by its diminished excretion or both, is not certainly known. We are not unanimous in thinking that the sodium biurate which forms the tophus is the cause or the result of the pathologic process, but Sir William Roberts' theory that uric acid normally does not as such circulate in the blood, but only as a soluble quad- riurate of some base, is probably correct. In normal urine, uric acid is always present in the form of sodium, potassium or ammonium quadriurate. These are unstable salts and in the presence of the normal sodium chloride solution of blood or lymph become converted into the more stable and less soluble biurates. In health the quadriurates are too soon removed to become converted. Evidently, therefore, in gout, something delays excretion long enough for them to be changed into biurates, and this takes place in those tissues, such as the synovial fluid, the cartilage and the fibrous tissues, which contain the greatest proportion of sodium salts. The tophi, therefore, occur first where there is plentiful synovial fluid, then in the cartilages, then in the fibrous tissues. If we consider aU sorts of conditions, presenting more or less resemblance to gout, as phases of this disease we have a sort of anchorage, but one which permits of much deviation. If we examine the various statements made as to the disease we may find the following fairly representative. "In gout we have a disease which may give rise to almost any symptom or affect almost any organ or function." If we start with the patient the following has been presented: The gouty individual is one whose general metabolism is unstable and this instability may be present in one or more of the great physiologic systems (digestive, circulatory, nervous, etc.). If these statements represented the actual state of our knowledge, one might readily assume that we had abandoned our anchorage and were adrift. Recently, Woods Hutchinson has offered the foUowing statement as a solution of the difficulties which beset us, defining gout as " a disturbance of health associated with the presence of excessive amounts of urates in the urine." The merit of this definition lies in its presenting a material point from which we may start. It fails to state what the corpus deliciti is, although deductively it is not uric acid. It fails because it does not embrace within its limits those instances of undoubted goutiness in which "the presence of excessive amounts of urates in the urine" is inconstant, and it proves too much, because leucocythaemia and the renal infarcts of the newlyborn are included by the definition, but are admittedly not involved in the question, so far as the symptomatology is concerned. GOUT. 247 However, as a starting point this statement is useful and an effort will be made to find a working hypothesis upon which we may base a plan for relief of svmptoms and disabilities consequent upon disturbed metabolism. Uric acid for over a century has at once been the base and capstone of all pathologic theory with regard to gout. At present we are in better position to reach a practical working basis for therapeusis. 1. We are reasonably certain that uric acid, as such, is not toxic. This fact is now almost universally conceded. 2. The presence of a lu-ic acid sediment in the urine does not of necessity indicate a gouty tendency, for the power to hold uric acid in solution in the urine depends largely upon the amount of pigment and the percentage of salts contained in that excretion. 3. A nitrogen-free diet does not cause an abolition of uric acid excretion. And finally, 4. The excretion of uric and phosphoric acid goes on hand in hand — at least during attacks. Examining these propositions seriatim we see that while uric acid per se is not toxic it is quite possible that earlier and less oxidized bodies are probably so. Therefore the increased excretion of uric acid, signifying the increased or complete oxydation of uric acid antecedents and their ehmination as uric acid, should be accompanied by a relief of symptoms referable to the presence of these antecedent bodies in the organism. In practice this is found to be true. Next, the observation of coincidence of marked symptoms and diminished uric acid excretion with periods of relief and increased iiric acid excretion points out that delayed or imperfect excretion of uric acid is concomitant with exaggerated pathologic conditions. Since, as has just been stated, uric acid is not in itself toxic, its forbears must be responsible for the symptoms. As a nitrogen-free diet is not followed by an absence of uric acid from the urine, the formation of uric acid in the body from substances contained therein must be conceded. This uric acid is very properly termed endogenous uric acid and is independent of the character of the food ingested. It is the exoge- nous uric acid, the amount varying with the food and modified by various factors which act on digestion and absorption, when the patient is on ordinary diet, that completes the other portion of the total uric acid excretion. As uric and phosphoric acid excretion bear a fairly constant relation to one another, the clue is at once given as to the probable source of endogenous uric acid. This source is the cell nuclei and the products of their destruction are both uric and phosphoric acids as they appear in the urine. Therefore the breaking up of these nuclei gives rise to the appearance of uric acid and the xanthin bases, which, as a group, constituting the alloxur bodies are termed purins because they all contain the radical C5 H4. 248 CONSTITUTIONAL DISEASES. Since the phosphoric goes hand in hand with the uric acid excretion, it would be as logical to direct therapeutic attention to the former as to the latter. So far as the endogenous uric acid is concerned we may define gout as a toxaemia of varying causation, accompanied by the formation of an excess of urates, this excess being due to the breaking down of the leucocytes and fixed cells in the attempt to neutralize the poison. Now as to exogenous uric acid; obviously this comes from without and constitutes the source of the smaller moiety of the total output of uric acid. Here the ingestion of food, either purin free or of small purin content, must be considered. Obviously, were the attempt made to regulate the diet accord- ing to the amount of purin nitrogen found in food, various articles of food would be permitted which experience has shown to be detrimental to the patient. And after all, the patient must not be disregarded, for the metabolic reactions of the gouty are indubitably abnormal. From this it is clear that an attempt to regulate the output of exogenous uric acid by altering the intake of purin containing substances must be futile when we consider that there are factors influencing metabolism in the gouty which are important. Recently there has been a tendency on the part of some observers to return to the mechanical theory of gout. This theory advances the idea that the urates deposited in the joints and the ligamentous structures about them act as foreign bodies, obstruct the lymph vessels, cause irritation, and exert pressure upon the articular and periarticular tissues and interfere with their nutrition, thus explaining the pain, redness and swelling and accounting for the degenerative manifestations which result later. Old deposits of the biurates are not of necessity painful but it is the opinion of most observers that fresh deposits of these substances are always accompanied by painful symptoms. Pathology. While there are few organs or tissues which may not be the subject of gouty changes, the characteristic manifestation of the disease is in the acutely inflamed great toe, the swollen and reddened appearance of which has but to be but once seen to be always remembered. Less usual is a like condition of the thumb. The manifestations of chronic gout are less typical and may be difficult of differentiation from those of chronic rheumatism. Deposits of the urates, however, are pathognomonic of gout. These occur with greatest frequency in and around the joints, involving the cartilages, ligaments, tendons, biirsse and last of all the skin and connective tissue. Often we find the tophi about the finger joints or in the aural cartilages. Upon microscopic examination the cartilages are seen to be infiltrated with sodium biurate crystals. The tophi may ulcerate through the skin of the knuckle joints and they are frequently accompanied by a tendency of the fingers to be drawn to the ulnar side and of the toes toward the outer side of the foot; this latter being a late GOUT. 249 manifestation and frequent, as well, in arthritis deformans and a result of the fact that the abductor muscles are more powerful than their antagonists. The tophi should not be mistaken for Heberden's nodes which are of different origin and occur in arthritis deformans. These are, however, more prom- inent and painful in gouty subjects. Various exostoses and enchondromata or "lippings" from the cartilage covering the articular extremities of the bones, especially of those of the fingers and toes, may be observed but should not be confounded with true tophi. The kidney of gout is the granular or cirrhotic kidney and is not in any respect different from the ordinary kidney of so-called chronic interstitial nephritis. The heart is often the seat of an hypertrophy, especially of the left ventricle, and its valves may show deposits of urates upon their edges. The arteries are usually sclerosed, which fact is due to the toxic influence of the xanthin bases. Sjrmptonis. Patients in whom attacks of gout are frequent, often are able to foretell a coming attack, learning from experience that certain symptoms, which differ in different individuals, are premonitory; headache, neuralgic pains, disordered digestion, cardiac irregularity or palpitation, a tense pulse, a feeling of weariness, depression, etc., may be mentioned in this connection. Any circumstance which tends to lower vitality or intemperance in eating or drinking may bring on an attack. Usually the first symptom noted by the patient is a pain in a joint, usually in the metatarso-phalangeal articulation of the great toe. Its onset is sudden and its character is sharp and stabbing. A chill may usher in the attack. Accompanying the pain are the symptoms of local inflammation; heat, red- ness, swelling and tenderness, although there may be pain without these manifestations, or there may be local signs without discomfort. The attack usually begins at night and, if the first, it may not be typical and therefore remain undiagnosticated. As morning comes on the pain becomes less, perhaps to recur during the night following, and for from four days to a week the cycle continues — ^worse at night, better during the day. With the attack there is commonly a moderate rise of temperature (100° to 102° F. — 37.8° to 38.4° C), which may continue, with morning remissions as long as the acuity of the symptoms persists. After a few days the pain and other symp- toms subside and the skin of the affected part desquamates. The urine during the attack is scanty, high in color and specific gravity, may contain a little albumin and if allowed to stand is Hkely to show a sedi- ment of urates and uric acid. Glucose also may be present. After the attack the amount of uric acid excreted through the urine may be increased; before its onset and diiring its acuity this may be diminished. Gouty pharyngitis may be the only manifestation of an acute attack and 250 CONSTITUTIONAL DISEASES. is impossible of diSerentiation from other forms of sore throat which show only redness and slight swelling. The local symptoms of an attack of acute gout may suddenly disappear and manifestations due to derangement of the internal organs — notably the stomach, heart, brain or bladder — may as suddenly appear. In such cases the gout is described as " retrocedent " or "metastatic." The symptoms referable to the heart may be pain, dyspnoea or irregularity of action; those referable to the stomach, pain, vomiting, or diarrhoea; those referable to the brain, Various meningeal disturbances; and those referable to the bladder, those of inflammations of that organ or of the prostate gland. Skin eruptions (eczemas) have been described in this connection. Atypical Gout. Certain symptoms not distinctive of gout may appear in persons of gouty tendency and in such patients are of undoubted gouty origin. These include almost an3r mentionable symptom; of them the most usual are various muscular pains, headaches, digestive disorders, burning and tingling of the palms and soles, digitis mortui. Certain changes, not characteristic, occur in the organ of vision as a result of the disease — except rarely, in cases where there are deposits of the urates in various tissues of the eye. Chronic Gout. When a patient has continued to have numerous attacks of gout changes take place in his tissues — as described in the section on pathology — such as the deposits about the joints and in the cartilages, the deformities of the extremities and the morbid degenerations of the kidneys and blood-vessels. Treatment. The treatment of gout resolves it into the management of the acute attack and that of the gouty tendency. a. The treatment of the acute attack. When the attack occurs in a healthy person in whom there exists no reason for limiting oiu: efforts, the indication is to prescribe the drug or drugs which will most quickly relieve the patient of his misery. Colchicum will relieve the pain and in the salicylates we have agents which will hasten the elimination of the purin bodies which are the causa causans of the attack. The following capsule is recommended: I^, colchicinas salicylatis gr yiir (0.0006), methylis salicylatis /x vi (0.4); make one capsule. Signa — Take one every hour until pain is relieved. When the acute symptoms have abated the indication is to relieve the system of the accumulated purin bodies and to prevent their further retention. (See treatment of chronic gout and purinsemia, p. 252.) In patients who have suffered frequent and repeated attacks of gout and whose heart and arteries are the seat of sclerotic changes, glyceryl nitrate (nitroglycerine) TTT-51T gr. (0.0006-0.0012) and strychnine -3V to yV gr. (0.002-0.003) at the intervals required by the severity of the degeneration should be prescribed to dilate the arteries and to counteract the depressant effect of the colchicine. GOUT. 251 There is no reason why an attack of acute gout should not be cut short for there is no danger of the disease "going to the heart" unless we fail to open the arteries and to provide against the myocardial degeneration. The use of nucleinic acid in the treatment of the uratic deposits has been suggested and favorable results are reported. Nuclein substances, themselves, since they contain abundant purin bases are not suitable in this connection. Base-free thymic acid has been used in attempting to lessen the size of the tophi, which seem to diminish under its influence, while the excretion of uric acid is increased. Quinic acid, particularly quinic acid anhydride may be used in acute gout in doses of 150 grains (lo.o) per day. It is reported that by its admin- istration the pains are greatly ameliorated and the local signs about the joints are lessened. This substance regularly diminishes the output of uric acid. Certain authorities recommend hypodermatic injections of antipyrine in the neighborhood of the affected joint, since this drug, in addition to its analgesic effect is said to have a specific action in gout. The wine of colchicum seed in beginning dosage of one-half drachm (2.0) in combination with potassium iodide or sodium salicylate is frequently used in acute as well as in chronic gout, the dosage of the two last being up to one drachm (4.0) a day in divided doses. For the pain acetphenetidine (phenacetine), antipyrine salicylate (sali- pyrine), and saligenin tannate have their advocates. Hypodermatic injec- tions of morphine will always relieve but these should not be given unless absolutely necessary. The insomnia may be controlled by the bromides or chloral. The diet during the attack should consist entirely of milk and vichy, equal parts. Of this eight ounces (250.0) should be given every two to four hours. This tends to act as a diuretic and to cause the colchicum to be absorbed into the circulation rather than to be excreted through the intestine without accom- plishing the effect for which it is administered. It is very important that the patient should drink copiously of water. Local Treatment. The joint should be protected by a generous swathing of cotton, and various local applications, warm rather than cold, may be made, always remembering that it is very important that the skin should be kept intact. Painting with collodion (not more than two coats) either with or without the tincture of iodine may afford relief as may also any of the following applications: Sodium bicarbonate, i to 16 of warm water; equal parts of guaiacol and glycerin; one part of the extract of belladonna to eight of glycerin; oil of peppermint; chloroform and olive oil, equal parts; bella- donna liniment and chloroform, equal parts. Local applications are likely to afford less relief than in rheumatism and are less effective cold than warm. At times the tenderness is so marked that not even the bed clothing 252 CONSTITUTIONAL DISEASES. can be borne upon the afflicted part; in such cases the use of a frame to sup- port the sheets is advisable. PURIN^MIA. Synonyms. Lithaemia; Uricacidaemia; UricEemia; American Gout; Gouti- ness. Definition. A disease of rather indeterminate nature dependent upon the preseirce in the blood of partially oxydized food elements more especially the biurates. .Etiology. The condition is caused by intemperate eating and the abuse of alcohol, combined with too little exercise and a sedentary habit of life. The accumulation of the urates is rather due to their production within the body as a result of faulty metaboUsm than to a too great ingestion of substances which contain these bodies. Symptoms. Various indefinite symptoms characterize this disease. One of the most constant is digestive disturbance which may be manifested by intestinal fermentation, constipation, etc. Headache is frequent and may be accompanied by dizziness, ringing in the ears, insomnia, numbness and tingling of the hands and feet, neiuralgias and indefinite pains in various joints and muscles of the body. Neurasthenic symptoms are common as well as irritability of temper. Dermatoses, such as eczema, psoriasis and prtuitus ani are often observed. Palpitation, cough and loss of flesh and strength may be present. The luine usually contains less lu-ic acid than normal, and there is frequently an excess of indican due to the digestive derangement. There may be traces of albumin and a few hyaline casts. Crystals of calcium oxalate are often seen. Treatment. The keynote of treatment lies in (i) limiting all toxic influ- ences and formation of toxins, particularly in the alimentary canal, in order to minimize the retrograde metamorphosis of the body nucleins; (2) preventing the absorption of all toxic material; and (3) promoting the elimination of toxic agents. Diet. The diet should consist of purin-free foods in so far as possible; these are, milk, eggs, butter, cheese, white bread, rice, sago and fruits. Those con- taining under two-hundredths percent, of purin nitrogen are beer, stout, onions, asparagus, brown bread. Under three-hundredths percent, oatmeal, lentils, beans, peas. Under five-hundredths percent, salmon, cod, pike, halibut, mut- ton, veal, pork, ham, tmrkey, chicken. Under one percent, liver, steaks, soups. Under four percent, sweetbreads. Obviously were the attempt made to regu- late the diet according to the amount of purin nitrogen found in food, various articles would be permitted which would prove detrimental; also the patient must not be disregarded, for the metabolic reactions in this gouty condition PURIN^MIA. 253 are indubitably abnormal. Hence it is clear that any attempt to regulate the output of uric acid formed in the body by altering the intake of purin con- taining substances must be futile when we consider that there are factors influencing metabolism in our patients which are important. Finally the clinical observation that the appearance of an excess of uric acid and urates in the urine is generally coincident with the diminution or disappearance of the symptoms leads to the conclusion that the elimination of bodies antece- dent to uric acid by agents which increase the uric acid output as uric acid is also not to be forgotten. In considering endogenous uric acid, unquestionably methods whereby the toxaemia which results in nuclear destruction is obviated should be con- sidered. Metabolism, in character at least, is profoundly altered by the ingestion of various substances such as lead. Waters containing lime and iron are well known to be harmful. Indirect poisons are also potent as well as direct. The effect of alcohol in purinsemic subjects is not wholly due to the alcohol per se, but more probably to some of the more readily fermentable carbohydrates, as the aethers, esters or acetone groups which are found in the sweeter or more fruity wines used by the rich, or accessory products found in the malted beverages drunk by those in moderate circumstances. The logical inference is that substances capable of producing intestinal putre- faction, and consequent autointoxication, should be prohibited. If the endogenous uric acid is restrained as to its amount by preventing unnecessary w^aste from autointoxication, exogenous uric acid can be readily controlled. Evidently a prohibition of red meat, as has been the custom, should diminish the excretion of exogenous uric acid, but we are confronted by the fact that the ingestion of nitrogen is essential to the existence of the organism and so far we cannot make use of that contained in the atmosphere. The distinction between animal and vegetable foods is more apparent than real, for the glutens (vegetable albumins) at least, are assimilated with more difficiilty than animal albumins, and the excess of carbohydrates leads to intestinal fermentation and putrefaction. Clinically the prohibition of red meat has not been a success, and modern research tells us why this is so. To make a positive statement, it can be safely said that animal food in moder- ation is advisable. Pickled, salted and fried meats are forbidden. Fish is excellent, even oysters and lobsters are permissible if fresh. All vegetables and raw fruit, if apart from meals, are allowable. Tea, coft'ee and cocoa in moderation are permitted. Alcohol in excess and inferior wines are injurious. Malt beverages should be supplanted by cider, in quantity not exceeding a pint each day. As has been pointed out, the quantity, rather than the variety of the food, is to be limited. AU rich, highly-seasoned, greasy and twice-cooked foods, strong soups, cooked tomatoes, rhubarb, sweet cooked foods are to be avoided. Large mixed meals of animal and farina- 254 CONSTITUTIONAL DISEASES. ceous foods with fruit and wine, especially if the latter be sweet or fruity provoke the disease. Plainly cooked animal food, preferably roasted or grilled, and limited to the quantity necessary for nutrition, is eminently satisfactory. Two ounces (60.0) per day of good whiskey, well diluted, will satisfy those habituated to alcohol. Excess of water should be taken only apart from meals. Sedentary habits interfere with digestion and assimila- tion and lead to the ingestion of more food than the muscles and liver can burn up. Consequently an out-of-door life with such exercise as moderate bicycling, golf and the like is to be recommended. In fact, excessive food, improper forms and amounts of alcohol, and lack of exercise are factors which lead to gout and the purinsemic conditions which are earned rather than inherited. The last therapeutic fact which calls for comment is the method by which an excess of uric acid, and especially its forbears, is removed from the tissues. The alkalies and salicylates are our chief reliance in that they not only make these products more soluble, but also because they favor their elimination. The prolonged use of alkalies is obviously disad- vantageous so that we must rely chiefly upon the saUcylates. One of the most excellent and useful of the forms of these salts is saligenin tannate, a substance obtained from several species of Salix and Populus (nat. ord. SalicacecB). It is a decomposition product of the glucoside salicin saligenin in chemical combination with castaneotannic acid. Over salicylic acid it presents the advantage that, while equally efi&cacious, it does not disorder the digestion nor cause untoward symptoms. It is preferable to the salicylates in that it is antiseptic, while the latter are not, and it easily splits up. Over both it offers the advantage of larger dose and longer period of administration. The dose is 1 5 grains (i .0) in powder twice or three times daily after meals. The bowels should be kept open by means of sodium phosphate, cascara, podo- phyllin, etc. Piperazine water will be found useful in certain cases but the administra- tion of lithium in tablet form or otherwise is likely to peld little or no result; the bitter tonics such as mix vomica , gentian or cinchona are often useful. The headaches and other pains may be controlled by antipyrine salicylate (salipyrine) in 10 grain (0.66) doses repeated. Morphine should be used only as a last resort. In certain cases a sea voyage or change of climate will prove of benefit. DIABETES MELLITUS. Synonyms. Glycosuria; Melituria. Definition. Diabetes mellitus is a chronic disease characterized by an excessive secretion of urine, which contains glucose, and which is the result of a disordered metabolism. DIABETES MELLITUS. 255 ^Etiology. The disease is more common in males than in females, and is most frequently seen between the ages of 30 and 60, although it ma,y occur in childhood and even in infancy. Certain races, notably the Hebrew, possibly because this is an essentially dyspeptic people, are more prone to the disease than others. Heredity according to certain authorities seems to influence its occurrence and while the disease is seen more often in the well-to-do it has also been observed in those of poor circumstances. It is a rare condition but seems to be becoming more common. Its definite causation is very obscure but it is in essence a disease of incomplete oxidation and is nearly related to gout and purinsemia. The fact has been observed that diabetics often alternate between the excessive elimination of urid acic and of sugar. Pathogenesis. Notwithstanding the immense amount of research done in connection with diabetes the pathology of the disease remains exceedingly obscure; however, we may consider as recognizable three classes of the morbid condition. a. The pancreatic form. b. The alimentary form. r. The nervous form. Disease of the pancreas has for a number of years been known to be a factor in the production of glycosuria. Opie has demonstrated that partic- ular elements, namely, the islands of Langerhans in the pancreas must be affected to produce this symptom. The most frequent pathological change in these elements which results in the appearance of sugar in the urine is a sclerosis or degeneration of other form, hyaline, for instance. The glycosuria appearing in cases of cysts of the pancreas, cancer, etc., is probably the result of a temporary involvement of these so-called islands. Also the frequent association of arteriosclerosis and diabetes renders it probable that this con- dition by its interference with the nutrition of the pancreas may result in changes which lead to diabetes. Alimentary diabetes is brought about by some disorder of the digestive system producing an interference with proper carbohydrate metabolism, which results in an hyperglycaemia, which is due to the presence in the organism of an amount of glucose with which the body is unable to cope. For instance, in certain infectious diseases, exophthalmic goitre, alcoholism and lesions of the liver, the presence of an amount of sugar, of which the normal organism might easily dispose, in these conditions may result in gly- cosuria, due possibly, as pertinently suggested by Pearce, to a temporary interference with the function of the pancreas due to circulatory or toxic dis- turbances of the islands of Langerhans. The nervous type of diabetes occurs in various diseases of the central nervous system; tumors, and other lesions of the floor of the fourth ventricle; traumatic and other neuroses, acromegaly, etc. 256 CONSTITUTIONAL DISEASES. Unfortunately the facts known to us concerning this disease are few but a summing up of our knowledge would seem to show, according to Edsall, that in the pancreas resides an important influence over carbohydrate metabolism. How this organ acts is not known but it is not merely through the production of a glycolytic ferment. It is also apparent that carbohydrate metabolism is associated not only with the pancreas but with other organs> notably the liver, as weU, and that the more deeply the subject is studied the more complex does it become. Pathology. The only definite pathology so far as is at present known is showrb as a sclerosis or degeneration of the islands of Langerhans in the pancreas. Also this organ may be atrophied, the seat of an interstitial inflam- mation, of malignant growths, or cystic. The liver is often congested, cirrhotic or the seat of fatty or amyloid degen- eration. The kidneys, while they primarily have no influence over the disease, are frequently found in a state of hypergemia, catarrhal inflammation, or, more rarely, may be in a state of interstitial inflammation. The lungs may present advanced tuberculous changes or may be the seat of a pneumonia. The heart is often affected with an interstitial myocarditis, fibrous or fatty. The brain may be congested or oedematous, the seat of small haemorrhages or softened. Tumors of the pons, the medulla, or the cerebellum have been observed. Symptoms. Often the first symptom noticed by the patient is an excessive passage of iirine, the characteristic urine of a diabetic being light in color, sweetish in odor and taste, and of high specific gravity. It contains glucose in varying quantity and may contain albumin. The lu-ea and uric acid are usually increased. Excessive thirst, due to the increased elimination of fluids through the kidneys, and an abnormally large appetite are frequent symptoms. Itching of the skin, especially about the vulva in women, and the prepuce in men, where this symptom is due to the irritation of frequent urination, is common and likely to result in eczema. The breath may have a sweetish odor and symptoms of indigestion are common; vomiting may occur. The bowels are usually constipated, but diarrhoea may be present. There is often emaciation and the patient complains of bodily weakness. The lungs frequently are the seat of a chronic bronchitis and complicating pulmonary tuberculosis is common, due to the fact that the powers of resistance of the organism to the tubercle bacillus are lessened by the disease and the restriction of the diet, rather than to any direct influence of the diabetes itself. Outbreaks of boils and carbuncles are not rare; the former may occur DIABETES MELLITUS. 257 early in the disease but the latter seldom appear until the later stages. It should be remembered that during the course of a carbuncle in a non-diabetic patient glycosuria may be temporarily present. Diabetic gangrene is a symptom not infrequently met. It begins in the extremities, usually the toes, and while it may appear spontaneously from chronic proHferative endarteritis, is usually the result of traumatism, often one of vejy slight character. The gangrene is usually of the dry or senile type, though moist gangrene has been observed. Coma is a serious symptom; usually it appears in the later stages and often results in death. Its onset may be sudden or gradual. If the latter the prodromata are dizziness and irritability, the patient's condition becomes more and more stuporous and finally ends in profound coma. Convulsions and delirium are rare. While many theories have been advanced as to the causation of the coma the most probable one is that it is due to an acid intoxi- cation, the result of the continued presence of oxybutyric acid in the organism. The blood contains glucose and the red cells and hiemoglobin are likely to be diminished. Other body fluids, such as the saliva and perspiration, contain sugar and this has also been found in the transudates and exudates in diabetic patients. Peripheral neuritis has been described as a concomitant of diabetes. Abnormalities of the eyes occur such as cataract, retinal haemorrhages, choroiditis, dilatation of the retinal vessles, retinal atrophy and retinitis. The prognosis varies with the type of the disease, with the age of the patient and with the length of time which the affection has existed, without proper treatment. Patients in whom the disease begins in early adult life are seldom cured. The chances of recovery for the patient inclined to stoutness and in ' whom the disease appears in middle life or later are much better. The form of diabetes resulting from disease of the central nervous system and that due to permanent sclerotic changes in the islands of Langerhans are hopeless as regards cure but not as regards improvement. The alimentary type of the disease is most amenable to treatment. While we may consider as cured the patient who no longer excretes sugar in his urine, such a one must most care- fully guard against a recurrence. Treatment. In this the first step is to ascertain with which type of diabetes we have to deal; consequently we prescribe an absolute proteid diet in connec- tion with the drinking of plenty of the alkaline waters for five days, for diag- nostic purposes. After this period of time the patient is required to present for examination two specimens of urine, one the first passed in the morning, the other the last voided before retiring at night. If the sugar content is as when first examined it is probable that we have a diabetes due to nervous lesion. Such patients are, however, to some extent amenable to dietetic and hygienic treatment. If we find a smaller amount of glucose in the morning specimen 17 258 CONSTITUTIONAL DISEASES. than in that passed at night the diabetes is of the pancreatic variety. If we find no sugar in the morning urine while the evening specimen shows a positive sugar reaction an ahmentary diabetes confronts us. In each of these three types of cases treatment may be considered as being a, medicinal; b, dietetic; c, hygienic. Medicinal Treatment. The drugs to be preferred are those which act chemically by retarding the formation of glycogen into glucose. Of these the author prefers uranium nitrate, which may be administered in doses of i of a grain (0.016) three times daily and increased gradually up to a maxi- mum of from 3 to 4 grains (0.20 to 0.25) per day. Jambul acts in the same fashion by delaying carbohydrate conversion and thus enabling the organism to complete the process, and may be given, in powdered form, 5 to 30 grains (0.33 to 2.00) per day and gradually increased. As much as an ounce may be administered during 24 hours. This drug is said to act well in some patients and not in others and considerable difficulty may be experienced in selecting proper cases. Arsenic is another remedy, the action of which is the same as that of the two preceding, but which has the disadvantage that its prolonged administration is likely to produce digestive disturbances, neiiritis, herpes zoster and fatty liver. It may be given as Fowler's solution, 2 to 3 drops (0.12 to 0.20) 3 times a day, or as Clemens' solution (3 to 5 drops — 0.20-0.33 — 3 times a day). Opium has enjoyed extended use in diabetes and seems to have the power to diminish the excretion of glucose. Its great disadvantages are the proba- bility of engendering the habit and the constipation attendant upon its con- tinued administration. The employment of codeine obviates these difficulties and this drug may be given in doses of J to ^ a grain (0.016 to 0.032) 3 times a day, gradually increased. Given in connection with uranium nitrate its good effect may be augmented. Lithium salts act by assisting oxidation and in combination with the sali- cylates are useful in gouty patients. Aceto-salicylic acid (aspirin) in mild forms of diabetes has, according to Williamson, good effects. It should be given in acid solution — such as lemon juice — to prevent digestive disturbances — in doses of 5 grains (0.33) 4 to 6 times a day. Calcium phosphate and carbonate have lately been employed with good results, perhaps due to the affinity of sugar for calcium. Potassium iodide has achieved results in glycosm-ia due to cerebral gum- mata and should also serve in the gouty form of the condition. Antipyrine, acetphenetidine (phenacetine) and other coal tar derivatives may lessen the excretion of sugar in the nervous type of the condition because of the control which they exert over the conversion of proteid into sugar. They may also may be found useful in other varieties of diabetes. They may DIABETES MELLITUS. 259 be given in doses of 10 to 15 grains (0.66 to i.oo) three times a day in com- bination with sodium bicarbonate and preferably when the stomach is empty. Potassium or sodium bromide may be given with good results in the diabetes of neurasthenics or in that of mental disturbance. Lactic acid in doses of 75 to 150 grains (5.0 to 10. o) daily, dissolved in water, has been recommended by certain Italian physicians. Gold and sodium chloride and ergot have their advocates but are not in general use. The various preparations made from the pancreas of animals of which much was expected have so far failed to find any place in the treatment of diabetes, and the same may be said of the extract of the supra-renal body. In concluding the discussion of drug treatment it may be said that too much medication in diabetes mellitus should not be advised. Drugs should not be given when we are able to cause the disappearance of the sugar from the irrine by dietetic and hygienic treatment. , Dietetic Treatment. An exclusive diet of proteids and fats is not advisable unless absolutely necessary, for it has been proven that coma is more likely to occur in patients who are getting absolutely no carbohydrate food. When carbohydrate food is allowed a diabetic we must see to it that the organism is able to take care of it and does not excrete it as glucose. In this connection regulation of the amount of carbohydrate intake and proper exercise wiU do much. For instance, in an obese diabetic of the alimentary type who is accustomed to little exercise we may at first cut out most of the carbohydrate foods until the glycosuria has disappeared and then gradually aUow a return to a mixed diet, slowly increasing the patient's physical exercise the while so that he may be able thus to convert the steadily augmenting intake of starchy food. Thin patients of this type we can hardly deprive of carbohy- drates, since they need a certain amount of this class of food to keep up their nutrition, otherwise this deteriorates and the diet consisting of fats and proteids alone is almost certain to engender a cirrhosis of the liver. Consequently, the thin alimentary diabetic may be allowed starchy foods in certain quantity and we should be content if we reduce the quantity of sugar in his urine to 0.5 percent. With regard to the articles of diet which diabetics may be allowed it may be said that such food stuffs should be selected as contain: c, no carbohydrate whatever; h, very little carbohydrate or carbohydrate in easily assimilable form which may be converted by the organism. To the first class belong all varieties of fresh and salt meat, liver excepted, clear meat soups, poultry, fish, shell-fish, butter and eggs, fats and oils, and cheese. As belonging to the second class may be mentioned the green vegetables, such as cabbage, cauliflower, Brussels sprouts, string beans, onions, cucumbers, 26o CONSTITUTIONAL DISEASES. tomatoes, lettuce, escarole, romaine, chicory, water-cress, spinach, dandelion, beet tops, asparagus, all nuts except chestnuts, all the acid fruits, and jellies (unsweetened) prepared from meat juices and gelatin. Many of these substances contain a considerable quantity of sugar but not in the form of grape sugar. The various sugars and starches which they contain are more easily converted than glucose and consequently are taken care of by the organism. Fortunately milk sugar is of this class and milk may be freely given to diabetics. Other sugars which are likely to prove more rapidly convertible than glucose are Isevulose, the sugar of fruit and inosite^the sugar of muscle. With regard to bread it may be said that the toast of wheat bread 24 hours old is preferable to gluten or graham breads. Gluten flour may, however, be used, to make bread or biscuit for diabetics, but it is necessary to obtain a pure gluten, which is impossible in the United States. Cakes and biscuit made of flour of the soya bean are admissible and are said to be palatable. When stale they are likely to be rancid since the flour contains an oil. Bread made from aleuronat flour is highly recommended. Butter may be eaten by diabetic patients but it is best to limit its quantity. Beverages. Tea, coffee and cocoa, with cream or milk and sweetened with beet, not cane sugar are allowable. Saccharin may also be used as a sweetening but not in greater quantity than \ grain (0.016) to the cup. Gly- cerin has been employed in this connection but is inferior to the above named substances. Malt liquors, cider and other fermented liquors are not permissible since they all contain sugar or starch. Wines which contain no sugar or only a very smaU quantity, such as Bur- gundies, Bordeaux, Rhine and still Moselle wines and dry sherry, may be allowed. Whiskey, gin and brandy when unsweetened may be given if necessary. Schreiber's dietetic wines, which contain no sugar, are largely employed. The drinking of considerable quantities of water between meals is to be encouraged. Patients who dislike ordinary water often will take large amounts of mineral waters when prescribed by a physician. For such it is wise to suggest a water containing as little mineral as possible, such as Highland Spring water. The Potato Treatment. Some authorities believe that a diet of potatoes may be prescribed to advantage in almost all cases. One to two pounds (500 to 1000) of this vegetable may be eaten daily with the result of diminishing the thirst and the glycosuria and of impro\dng the general condition. If a diet containing bread is resumed the symptoms recur, only to disappear upon a return to potatoes. The reduction in the sugar is said to be due to the incomplete absorption of the carbohydrate. It is also possible that the good DIABETES MELLITUS. 261 of the potato diet may result in part from the alkaline salts which these vege- tables contain. Codliver oil may be found helpful, especially in weak and emaciated patients, and may be regarded as a food. It acts well given in connection with brandy or whiskey. Hygienic Treatment. Exercise within proper limits is a valuable factor in the treatment of diabetes, for sugar is burned in the muscles as well as in other parts of the body. Excessive bodily fatigue must, however, be avoided, since it results in the overwhelming of the system with ox}'butyric acid which is likely to be followed by coma. Patients whose bodily strength is good should be instructed to use a pedometer and walk a certain distance each day. With proper attention to the attire pedestrian exercise may be taken almost every day in the year. A moderate amount of gymnasium exercise maybe taken and such games as golf and croquet are to be recommended. The important point with regard to exercise is to take care lest it be carried to excess. Even light exercise may be impossible for the advanced and ema- ciated cases. Massage is indicated in patients unable to take active exercise and in the more vigorous it may be found a useful adjunct to the other forms of treat- ment. It is said that under systematic massage, the quantity of iirine and its sugar content may be diminished and the glucose may even be caused to disappear. Of course regulation of the diet is also necessary to produce this result. Diabetics should clothe themselves in a hygienic manner and particular attention should be paid to the wearing of proper undergarments during the colder months. Frequent changes may be necessary since the skin in this condition excretes certain irritating substances which if allowed to remain in contact with it may induce an eczema. Proper foot covering in wet weather is a necessity. Decency requires the taking of at least two warm cleansing baths per week and more than these will do no harm. A cool or tepid sponge, according to the temperament of the patient, may be taken daily. Fresh air is a necessity and the diabetic should spend much of his time out of doors and should sleep, warmly covered, if necessary, in a large, airy chamber with the window open. The various water cures and spa treatments of diabetes are often found to be valuable but their good effects are probably due to the change of air, scene and diet, together with a regulation of the mode of life, rather than to any peculiar virtue of the waters. Alkaline waters may give benefit on account of their purgative properties. Coma. When coma is feared, either from the existence of cerebral symp- toms, from a sudden diminution of the glycosuria or when acetone is present 262 CONSTITUTIONAL DISEASES. in the urine large doses of sodium bicarbonate (i to 2 drachms — 4.0 to 8.0 — 3 or 4 times a day) should be given. Coma itself should be treated by the infusion of 2 quarts (litres) of 0.9 percent, sodium chloride solution at 112° F. (44.5° C.) into the median basilic vein. If instruments are not at hand the same quantity of the solution may be given by hypodermatoclysis at 110° F. (43.3° C.) or per rectum at 116° to 118° F. (46.7° to 47.8° C). In any case the bowels should be freely evacuated in order to rid the body of toxiq substances in so far as is possible and hypodermatic stimulation should be administered as indicated. Surgery in diabetic patients. Surgical operations in diabetics are dan- gerous and often of unsuccessful outcome because of the co-existing endar- teritis proliferans. However, if the disease is of mild type and the sugar can, by treatment, be caused to disappear, operations of necessity, such as, for instance, amputations, may be performed, but with a guarded prognosis. DIABETES INSIPIDUS. Definition. A chronic condition characterized by the passage of large amounts of a urine, pale in color and of low specific gravity, but otherwise normal. etiology. Congenital and hereditary instances of the disease have been observed. It affects young adults most frequently, being rare after middle life; it may occur in infancy. Females are rather more often affected than males. Clinically two types of the condition may be described, the idiopathic and the symptomatic. The former occurs primarily and is associated with no morbid lesion; it may be met in poorly nourished children, after the drink- ing of excessive amounts of cold liquids, after an alcoholic excess, as a result of fright and in convalescent states. The symptomatic type usually accompanies cephalic injuries and such nervous lesions as cerebral tumors and haemorrhages, lesions of the fourth ven- tricle, syphilitic growths of brain and cord, etc. Diabetes insipidus may also be associated with abdominal aneurysm, tumor and tuberculosis. The pathogenesis of this condition is best explained upon the ground that it is caused by a chronic renal congestion due to some vaso-motor disorder of the blood-vessels of the kidneys which may result from direct irritation, as in lesions of the abdomen, from central disturbance, as in cerebral lesions or from irritation of the medulla oblongata. Pathology. There are no constant morbid changes found in this disease. Often the nerve lesions are impossible of discovery; when these are demon- strable they are usually at the base of the brain. In certain instances there DIABETES INSIPIDUS. 263 have been enlargement and congestion of the kidneys and bladder; the ureters and pelves of the kidneys may be dilated. Sjrmptoins. The onset of the disease is usually gradual; more rarely it appears suddenly after a debauch or an injury to the head. The most char- acteristic symptoms are the excretion of greatly increased quantities of clear, light colored urine of a specific gravity sometimes as low as 1000, and an excessive thirst. Associated manifestations which are not constantly present are a lessened perspiration and a consequent dryness of the skin, diminished salivary secretion and dryness of the mouth. The appetite is usually not abnormally large as a rule but occasionally it is increased. The digestion is sometimes impaired but in most instances the general health remains good. More rarely, and particularly when the cause of the disease is an organic one, weakness and emaciation are observed. There may be pains in the back, especially at the beginning of the affection, which extend down the thighs; diarrhoea, mental weakness and disordered sexual function may be noted and a body temperature a few tenths of a degree lower than normal is some- times a feature of the disease. The urine is often passed in extraordinary quantity, a daily excretion of 25 to 40 pints (12 to 20 litres) being not unusual and even much larger amounts have been observed. The color of the urine is light, at times being as clear as water, its acidity is low and its specific gravity diminished even to 1000. Glucose and albumin are seldom found and then only in traces; inosite may be occasionally found. The solids are usually not diminished in total amount, the urea may be increased to even several times its normal quantity. The diagnosis is not difficult as a rule, the absence of glucose in the urine and its low specific gravity easily separating the disease from diabetes mellitus. In hysterical polyuria the condition is not permanent and there are accom- panying hysterical symptoms. Chronic nephritis with greatly increased urine may be differentiated by the presence of albuminuria and casts, the presence of cardiac and arterial changes and the absence of marked thirst. The prognosis in the idiopathic instances is favorable as to the continuance of life and recovery is not impossible, many patients continue to suffer from thirst and increased secretion of urine for long periods without impairment of health. In the secondary type of the disease the prognosis depends upon that of the cerebral, abdominal or other causative lesion. Patients suffering from this form of the affection often rapidly become weak and emaciated. Treatment. In the instances due to nervous or abdominal disease the treatment should be directed at these conditions; these, however, are difficult of cure unless syphilitic in nature when they often disappear under the admin- istration of mercury and the iodides. 264 CONSTITUTIONAL DISEASES. The distressing thirst may be relieved by allowing the patient to hold bits of ice in the mouth and the employment of acidulated drinks such as lemonade. It is probable that the patient wiU do no harm by drinking sufficient water and other innocuous fluid to keep the thirst in check. The diet should be full and nourishing and the general health should be maintained by advising warm clothing, moderate exercise in the fresh air, warm baths or cold douches, depending upon the reaction obtained, massage and avoidance of exposure. Baths and frictions also aid in relieving the lessened secretion of perspiration and the dryness of the skin. Counter-irritation at the nape of the neck or over Hhe epigastrium in subjects in whom the condition is the result of nervous or abdominal disease is often useful, blisters or the actual cautery may be used and in spinal lesions especially, the galvanic current has been warmly recommended. The current should be of good strength, one pole bemg placed over the neck or lumbar region and the other over the epigastrium. Numerous drugs have been employed in diabetes insipidus. Valerian has the recommendation of Trousseau and should be given in large doses; the dose of the powdered root being about 30 grains (2.0) 3 times a day; the fluid extract, 2 to 3 drachms (8.0 to 12.0) daily in divided doses, or the tincture in drachm (4.0) doses 3 times a day may be prescribed. The ammoniated tincture may be substituted if desired. Zinc valerate also may be employed, given in pill form in increasing doses until 15 to 20 grains (i.o to 1.33) daily are taken. Ergot in doses of i drachm (4.0) of the fluid extract 3 times a day and gradually increased to double that amount is sometimes effective as is also antip}Tine in daily doses of from 30 to 45 grains (2.0 to 3.0); this latter drug should be used with caution because of its depressive influence upon the heart. Opium has been recommended but there is always the danger of habit formation to be considered. It may be prescribed either alone or with gallic acid, which latter has proved effectual in some instances; 10 grains (0.66) of the acid to J of a grain (0.022) of the opium maybe given 3 times a day. Sodium salicylate has its advocates and favorable results have been reported from the hypodermatic injection of strychnine nitrate 2T to T^ of a grain (0.0025 to 0.005). Arsenic sometimes produces good results and its use in connection with the bromides is suggested. The following formula is an excellent one. Sodi- um or strontium bromide i ounce (30.0), Fowler's solution of potassium arsenite 2 drachms (8.0), iron and ammonium citrate 2J drachms (lo.o), cin- namon water to 4 ounces (120.0). Of this one teaspoonful in a wine glass of water is to be taken after each meal. In addition it is only necessary to state that all measures, dietetic, tonic, and hygienic, which will favorably influence the patient's general condition are valuable adjuncts in the treatment of this disease. CHRONIC RHEUMATISM. 265 CHRONIC RHEUMATISM. Definition. A chronic inflammatory process, not due to bacterial infec- tion or trauma, affecting the softer structures of the joints. iEtiology. This affection is most frequently seen in individuals beyond middle age who are subject to exposure and whose conditions of life are poor. In a few instances it may follow acute articular rheumatism and it has been known to precede this type of disease. Pathology. The affected joint is enlarged and stiff as a result of the thick- ening of its capsule and of the neighboring tendons and their sheaths; the synovial membrane may be congested and the joint cartilages eroded; there is occasionally a shght effusion. In other instances even with marked symp- toms there may be little change in the joint structures. Neuritis of the nerves about the articulation may occur and with it muscular atrophy from disuse as well as from trophic disorders, and when marked effusion is pres- ent, from pressure either upon the muscles or the vessels which supply them. In the inflammations of long standing ankylosis may take place. S)anptoms. Of these the most characteristic are pain and stiffness of the joints; these are increased in cold and wet weather; motion augments the pain but lessens the stiffness; tenderness may be present with slight swelling; redness is rare. Constitutional manifestations are not common although infrequently there may be a shght rise in temperature; in the protracted instances of the disease anaemia, digestive disturbances and neuralgia are common. As the affection progresses the stiffness becomes more marked, there is crepitation on motion and ankylosis with deformity may take place. Chronic rheumatism does not tend to cause cardiac involvement but associated fibrous changes in the valves and heart muscle are not uncommon. The prognosis. While not dangerous to Ufa this disease tends to progress and complete recovery is very unlikely to take place. Treatment. Salicylic acid and its salts are of little use in this form of rheumatism although they may aid in the relief of exacerbations of the disease. The employment of drugs which benefit the patient's general condition, such as iron, strychnine, arsenic and codliver oil, is to be recommended as is the use of iodine as suggested in the section upon the treatment of arthritis deformans (p. 272). In addition guaiacol, i to 2 minims (0.065-0.13) 3 times a day and tincture of guaiac, 10 to 30 minims (0.66 to 1.33) at similar intervals are beneficial at times. The diet need be little restricted, for it is important that the nutrition shall be maintained; fats, proteids and carbohydrates in the usual proportions, together with a moderate quantity of alcoholic beverages, if these are necessary to the patient's comfort, may be permitted. Exercise out of doors should be continued as long as the condition of the 266 CONSTITUTIONAL DISEASES. patient's joints is sufficiently mobile to render it possible. This is to be insisted upon and later its lack should be supplied by properly applied massage; vibratory massage is often beneficial. For the muscular atrophy both the faradic and galvanic electric currents should be employed in connection with massage and passive motions. Local applications are very necessary; the frequent application of cloths wet in cold water and covered with oiled silk is an excellent measure. Rub- bing with hot water may also afford relief to the pain. The joints should be k«pt permanently wrapped in flannel and this protection will have an additional counter-irritant effect if occasionally moistened with equal parts of guaiacol and olive oil; dressings of lo percent, ichthyol ointment are also effectual. The actual cautery may be employed as a counter-irritant in instances of severe pain and often the application of the high frequency electric current will afford great relief. Blistering and painting with iodine tincture have been suggested. The hot-air treatment is frequently of much service. This consists of placing the affected joint in a specially constructed apparatus in which the temperature of the air is raised to 250° F. (121° C.) or even higher. Hydrotherapeutic measures are very useful; those for the well-nourished subject should be different from those employed for the weak and anaemic. For the former the best procedure is to give a full bath lasting from 10 to 15 minutes beginning at 95° F. (35° C.) and gradually raised as high as can be borne; during the bath gentle massage should be given. A course of treat- ment at one of the alkaline or sulphur hot springs often results in great benefit^ probably less from any absorption of the mineral constituents of the waters than from the regular Hfe, systematic bathing and freedom from the cares of ordinary life. Hot bathing can be perfectly well carried on at home and, if persistently and regularly employed, should be able to accomplish quite as good results as spa treatment. Aftqr the hot bath free perspiration should be induced by a pack in hot dry blankets. This bath may be taken daily or less often as the physician considers proper and in the intervals the joints may be wrapped in cold compresses as suggested above. As amelioration takes place a hot-air bath for from 10 to 15 minutes followed by a douche bath at 100° F. (37.5° C.) reduced to 90° F. (32.5° C.) and succeeded by a Scotch douche to the joints for about J of a minute may be employed. The anaemic patient should be given hot baths with great caution only. Two baths per week, followed by the sweats, are usually all that should be advised, and the weakening effect of the procedure will be better borne by the patient if a daily cool bath is given as follows: While standing in water at 100° F. (37.8° C.) in a room about 70° F. (22.5° C.) the patient is rapidly rubbed down with water at 80° F. (27.5° C.) which is reduced a degree or two each day. In treating the anaemic rheumatic subject the object MUSCULAR RHEUMATISM. 267 is to use water at as low a temperature as possible consistent with a good reaction. Scotch douches and cold and wet compresses applied to the joints are useful adjuncts to the treatment. Hot-air baths followed by douches are also excellent. Patients who can afford it should be advised to spend the cold and wet months in a warm climate. MUSCULAR RHEUMATISM. Synonym. Myalgia. Definition. A painful affection of the voluntary muscles, their aponeuroses and periosteal attachments, involving particularly the large muscles of the neck, back and limbs and the intercostals. .Etiology. The condition occurs most often as a result of exposure, espe- cially to draughts and when overheated by exercise; it is consequently more common in males. The nature of the affection is not definitely known and various theories of its origin have been advanced. It has been considered as due to a lesion of the muscles themselves, of the intermuscular septa or of the sensory nerves of the muscles. It is an interesting fact that analogous symptoms may be caused by muscular strain. Gout, rheumatism and puri- nsemie conditions predispose to the condition and successive attacks are not unusual. Symptoms. The essential symptom is pain, increased by pressure and particularly by motion. While at rest there may be a dull ache or only slight discomfort but attempts to use the involved muscles result in very sharp and cramp-like pain. Swelling may be present but there are no constitutional symptoms other than an occasional acceleration of the pulse or very slight rise in temperature. The course is often short, lasting no more than a day or two or even less; it may be protracted, however, long enough to render the term chronic not inappropriate. Recurrences are common and those pre- disposed to the affection frequently suffer from muscular pain and stiffness in damp weather. Muscular rheumatism occurs in several types, the following being most frequent. Lumbago as its name signifies is a painful affection of the muscles of the lumbar region. It is perhaps the most common form of muscular rheumatism and may be so severe as to incapacitate the patient, any movement of the back causing marked pain. Stiff neck or torticollis affects the muscular tissues of the cervical region and renders any movement of the neck so painful that the patient holds the head in the position that affords himself the least discomfort and when desiring 268 CONSTITUTIONAL DISEASES. to turn it tiirns the body; this type of the affection is frequent in the young and is usually unilateral. Pleurodynia results from involvement of the intercostal muscles and at times the pectorales and serrati magni. The pain here is very marked for respiration necessitates continuous movement of the chest. It is usually unilateral and affects the left side more commonly. It may be differentiated from pleurisy by physical examination and from neuralgia by the absence of tenderness along the course of the nerves. Cepjialodynia affects the muscles of the scalp, scapulodynia those of the scapular region, omodynia those about the shoulder. Involvement of the muscles of the abdomen and limbs may be observed. Treatment. The first consideration and one in which the patient will usually heartily co-operate is rest. The application of straps of adhesive plaster overlapping one another like clapboards and immobilizing the affected side of the thorax is often of great relief in pleurodynia. Each strip of plaster should extend about 3 inches beyond the mid-line on both back and front. The rest, especially in affections of the shoulder, should not be too prolonged for stiffness of the joint and even ankylosis may result. Dry heat applied by means of the hot water bag or by rubbing the affected part with a hot flat iron, a layer of flannel being interposed, is often effectual in relieving the pain. Hot poultices may also be used and baths of steam may be employed. Recently hot-air apparatus has been specially constructed so that it is possible to bake any part of the body and the application of hot air by this means is an excellent method of treatment; upon the same principles a Turkish bath may cut short an attack. The application of the high frequency electric ciirrent is perhaps more effective than any of the foregoing methods and when followed by vibration massage, when this can be borne, is highly to be recommended. It is difficult to explain the action of the current but possibly it so affects the nutrition of the muscle cells, or the nerves, if muscular rheumatism is a nerve disorder, as to bring about a more normal state; certain it is however that many instances, particularly of chronic lumbago may be greatly benefited by its application. The thermocautery is also useful, blisters and cups have a field of usefulness and in very severe pain we may have recourse to acu- puncture, several heavy needles being plunged into the painful muscles and allowed to remain for two or three minutes. The hypodermatic use of morphine may become necessary. Liniments may be employed but it is probable that the benefit derived is due quite as much to the accompanying friction as to the medicament. With regard to internal treatment it may be said that in a certain number of instances the administration of the salicylates may cause benefit, certainly a judicious trial wiU do no harm. For the relief of the pain antipyrine salicyl- ate (salipyrine) in 10 grain (0.66) doses given every hour for 4 or 5 doses ARTHRITIS DEFORMANS. 269 and then at longer intervals is often effective, and, empirically, good results often follow the administration of ammonium chloride, 10 to 20 grains (0.66 to 1.33) every i to 2 hours up to the limit of the stomach's toleration; this latter drug is especially effectual in lumbago and stiff neck. Persons subject to successive attacks should dress warmly and avoid over- heating and exposure of all descriptions. Their diet should be nutritious and non-irritating and tonics such as codliver oil, iron, arsenic and strych- nine should be prescribed if indicated and the iodides, nux vomica, sulphur or guaiac may be given in the attempt to combat the chronic myalgic tendency. Piu-inaemic patients should be treated in accordance with the suggestions offered under the section devoted to the management of this condition. ARTHRITIS DEFORMANS. Synonyms. Rheumatoid Arthritis; Osteoarthritis. Definition. A chronic joint disease characterized by the occurrence of changes in the intra- and periarticular structures, by atrophy of the bony structures or the development of osseous growths interfering with the joint function. -Etiology. This affection seems to be rather more common in females than in males and those whose occupations render it necessary that the hands should be much in water and thus subject to sudden and frequent changes of temperature, as well as those who are sterile or subject to uterine or ovarian disorders, appear to be predisposed to the disease. Heredity likewise has probably an setiological significance. The incipience of arthritis deformans usually takes place during the third decade of life but exceptionally the disease may begin as early as 12 or as late as 50 years of age. The monarticular type of the affection is probably a disease of the central nervous system and its lesions are the result of trophic changes. The polyarticular type has of late been attributed to infection with some as yet undiscovered micro-organism. While bacteria have been isolated from the joint lesions their specificity remains to be proven. Pathology. There are three varieties of arthritis deformans: a. The sym- metrical type in which both upper extremities are involved, h. The unilateral form in which the hand and foot of the same side are affected, c. The mon- articular type which involves a single joint and which is due to a lesion of the central nervous system. The study of the joint in this disease by means of the X-ray shows that in certain instances the changes chiefly involve the intra- and periarticular struc- tures, the former being thickened and their fringes hypertrophied and the latter swollen and infiltrated; fluid may be present in the bursal and articular 270 CONSTITUTIONAL DISEASES. cavities. In other subjects the changes involve principally the cartilages and bones; the former soften, become thin and may become wholly absorbed, leaving the joint siirfaces bare and ebumated, atrophy of the shafts may take place and nodules of bone develop at the edges of the articulations. In still a third class of cases there is bony hypertrophy; this is particularly prone to occur when the spinal column is involved and may result in ankylosis, a manifestation which is rarely met in other articulations as a consequence of this affection. Secondary trophic changes and neuritis are not uncommon; muscular atrophy, contractures and even disintegration of the ligaments with result- ing dislocation (Charcot's disease) of the joints may be observed. The extremities are deformed, the hands being often deflected to the ulnar side. Symptoms. In the type in which the involvement is polyarticular, nodules {Heherden's nodes) develop gradually upon the lateral aspects of the termi- nal phalanges, more particularly of those of the hands; at the beginning of this manifestg-tion signs of acute inflammation, swelling, pain, redness and ten- derness may be present, and these symptoms may appear at intervals during the coiirse of the disease without assignable cause or as a sequence of dietetic errors. These enlargements may be mistaken for gouty tophi but are wholly different both in causation and composition. The joint cartilages soften and the articular extremities of the bones become bare and hard. Patients in whom the disease is evidenced by the development of these nodosities are likely to escape involvement of the larger joints and are believed to be likely to enjoy long life. In polyarticular arthritis deformans of the progressive type the manifes- tations may be either acute or chronic. The former variety occurs especially in females in the third decade of life and in association with frequent pregnancies and lactation; it may also appear in children and at the climacteric. The attack is characterized by polyarticular swelling and tenderness and a febrile movement; the symptoms persist, it may be with remissions, until ultimately the permanent joint changes result. The chronic variety is usually symmetrical, is gradual in onset with pain and swelling, although an acute attack may appear intercurrently. Frequently one pair of joints after another becomes involved until the patient is wholly disabled, although quite frequently the finger joints are unaffected. The articulations may become fixed in flexion, especially those of the knees and hips, and muscular contractions are common; with these there is an atrophy which renders the articular enlargements more apparent; while the joint cavity may contain fluid it is more often dry, motion being difficult and attended with crepitus. True bony ankylosis does not occur but the immobility is due to periarticular thickening, adhesions between tlie articular cartilages and the presence of bony outgrowths. The presence of pain is not constant, ARTHRITIS DEFORMANS. 27 1 in certain instances it may be very severe, especially at night, while in other subjects the disease may develop with comparatively little discomfort. Pain on motion is the rule. Tingling and numbness of the extremities, cutaneous pigmentation and glossiness of the skin over the joints are not rare. The affection is likely to progress, accompanied by increasing weakness and anaemia until the patient is quite disabled, although at times a stationary period may be reached and continue, the patient suffering no pain and the general health remaining good, the only inconvenience being the permanent disability. Complications are not common but coincident dyspepsia and anaemia during the active stage of the disease's development are frequent. The monarticular type of arthritis deformans is observed most frequently in old men and involves especially the hip, the knee, the shoulder or the joints of the vertebrae; a history of traumatism is not rare. In the hip the condition has been termed morbics coxa. There is wasting of the muscles around the affected joint and in this respect as in others the lesions are quite the same as those occurring in the polyarticular type; indeed in certain instances the other joints may not be entirely unaffected, the corresponding articulation of the opposite side frequently showing changes of minor degree. The vertebral type is characterized by a gradual progressive vertebral anky- losis (spondylitis deformans). It occurs in two types; in the one the vertebral articulations only are affected with associated nerve symptoms such as pain, muscular atrophy, loss of sensation and ascending degeneration of the cord; in the other the nervous manifestations are less marked and there may be accompanying affection of the hip or shoulder joints. It would seem that these two forms of this type of arthritis deformans might better be merged in one as there is little reason for their separation. The condition may begin in any part of the vertebral column and at times affects the cervical region alone. It has been thought to start as a meningitis which by exerting pressure upon the nerve roots leads to paralysis of the spinal muscles and ultimate ankylosis of the spine. In children arthritis deformans is a very interesting condition, it appears before the second dentition with fever in acute instances but with merely joint swelling and stiffness in subacute cases. All the joints, including those of the vertebrae, may be affected and there are often enlargements of the cervical and other lymph glands and of the spleen. Culture and inoculation experi- ments in this form of the disease have failed to reveal any evidence of tuber- culosis. The diagnosis usually offers no difl&culty, although in subjects who present an onset with fever the condition may be mistaken for acute articular rheu- matism, but in the latter there is a tendency to successive joint involvement. The absence of tophi will distinguish arthritis deformans from chronic gout but the differentiation of the disease in its late stages from chronic rheumatism 272 CONSTITUTIONAL DISEASES. is difficult, in fact the affection is considered by some as an advanced form of this latter disorder. The prognosis as regards cure is distinctly unfavorable but the disease in no vv^ay interferes with the continuance of life. Treatment. For the patients in whom the onset is acute and resembles that of acute articular rheumatism a treatment, external and internal, similar to that of the latter disease should be prescribed. Of the chronic stage the internal treatment should be calculated to improve nutrition in every way possil^le and while we may not be able to influence the course of the affection in any great measure we can accomplish something and the patient may be encouraged with the hope that the progress of the disease may stop at any time, also with the fact that periods of remission in its development may occur. The tonics, especially iron and iodine, are indicated and the judicious admin- istration of arsenic is to be recommended. Iron may be prescribed in the form of the sulphate or if this causes gastric disturbance iron vitelhn in half- ounce doses (15.0) will prove an excellent substitute. Iodine may be given with iron in the form of syrup of iron iodide or separately as syrup of hydriodic acid of which i drachm (4.0) should be taken ^ hour before each meal in a wineglass of water. A ten percent, solution of iodine in oil of sesame may also prove beneficial; of this 10 to 20 drops (0.66 to 1.33) may be given every 3 hours. Iodine is particularly useful when there is tendency to periarticular thickening and it is probable that its administration in either of the forms above suggested wiU effect more benefit than will potassium iodide; this last, however, may be employed if desired. In the improvement of the general nutrition codliver oil is an excellent adjunct to the patient's diet which should be as generous as possible. The regimen should not be restricted except in so far as to eliminate indigestible and irritant foods. The bowels should be kept freely open. Exercise, when practicable, should be advised and should be taken, if pos- sible in the out-door air. Unfortunately in many instances the nature of the disease prevents systematic out-door exercise and it is here that massage will prove extremely useful; by its employment we successfully combat the tendency to stiffness of the joints, prevent in some measure the muscular atrophy and diminish the infiltration about the joints. Of other physical methods the treatment by means of the application of hot dry air — the so-called baking process — ^will benefit many patients and should always be tried even though in a certain number of instances it will probably be found ineffective. Electricity in the form of the continuous constant current (galvanism) is useful in diminishing the pain and is often otherwise beneficial, and the electric bath, beginning with a rather weak current may be employed. Static elec- tricity properly administered is often of great benefit. OBESITY. 273 Spa treatment and the hydrotherapeutic measures that accompany it may afford some rehef. Hot baths of water, ah- or steam are best but should be taken tentatively at first for some patients are made worse by their employ- ment, probably owing to their depressing influence upon nutrition, partic- ularly when they are taken in connection with diet restriction. It must be remembered that a full diet is one of the essentials in the treatment of this disease. Hydrotherapy at home is often practicable and hot-air baths may also be taken in the patient's own house. Hot sand or mud baths are often beneficial; the former may be conveniently taken at home. The application to the painful joints of hot wet or dry compresses is frequently effective in lessening the pain, as also may be the application of the actual cautery. Orthopaedic surgery has a field of usefulness in the treatment of this disease, particularly in the patients with spinal involvement, the acute stage of which may be greatly benefited by means of immobilization with the plaster of Paris jacket. The breaking up of the joint adhesions under anaesthesia is some- times indicated. OBESITY. Synonym. Corpulence. Definition. An abnormal accumulation of fat in the tissues of the body. .etiology. Obesity occurs in numerous instances as a result of hereditary influence, it usually does not appear until after middle life but is not seldom seen in children in whom it is met as a result of improper feeding. In these subjects it is often associated with rickets. While many corpulent persons enjoy excellent general health a superabundance of fat is frequently observed in chlorotic girls. Obesity by no means signifies that the sufferer is an exces- sive eater for it is a notable fact that many fat persons are abstemious in this regard, perhaps not so much as a result of self-denial as of lack of appetite. Gout is an aetiological factor which is not to be neglected but the most important cause is the association of over-eating and too little muscular exer- cise. Women, possibly because of their greater proneness to a sedentary mode of life, seem to be more subject to obesity than men. The excessive use of alcoholic drinks, especially the malt beverages, has a direct influence in the production of this condition. The tendency of obesity to appear after the menopause and with the decline of sexual activity in the male would seem to show that sexual indulgence lessens the predisposition to its occurrence. Fat may be derived from any one of the three classes of food and usually obese persons are those who eat largely of carbohydrates, fats and proteids, the carbohydrates, in the light of our present knowledge, being less responsi- ble for fat production than was formerly believed. Symptoms. These in the corpulent subject who is otherwise in good health consist merely of the familiar appearance, large, round visage, multiple 18 274 CONSTITUTIONAL DISEASES. chin, great girth, etc., which one sees so frequently. As the obesity increases, dyspnoea and the symptoms due to fatty infiltration of the heart muscle and arteriosclerosis, such as weak heart action and tendency to venous congestion with oedema appear. Enlargement of the Hver due to fatty degeneration of the organ is common and digestive disorders are frequent. Women often suffer from gynaecolog- ical complaints and the occinnrence of intertrigo where, as a resiilt of the excessive development of fatty tissue, two skin surfaces come into contact, as in the groins, about the labia and under the breasts, is often observed. Treatment. Prevention is necessary in subjects who show hereditary or other tendency to become corpulent; these should be advised against over- eating and the starches and fats in the dietary should be diminished. Exer- cise in the fresh air should be systematically prescribed; cool baths are a nec- essary adjunct to the other measures if the patient's reaction is satisfactory. Various dietetic treatments have been exploited most of which bear the names of their originators. Of these it must be said that no stated method is applicable to every instance of the disease but each patient should be managed in accordance with the existing indications. Perhaps the best known system is that of Banting which consists in the ehmination from the diet of carbohy- drates and fats and allowing considerable amounts of proteid food in the form of lean meat; green vegetables are also permitted. Water and alcoholic drinks are not forbidden. Ebstein's dietary restricts the quantity of food ingested but aUows fats and carbohydrates in considerable amount, sweets and potatoes, however, are forbidden. Oertel's system insists upon a diminution of the ingested fluids, only a pint (500.0) or shghtly more, of water being allowed; fat is permitted in moderate amount but not so freely as by Ebstein while the proteids and carbohydrates are less restricted than by this clinician. The fluids are restricted on the ground that they increase any circulatory difficulty which may be present. The following table gives certain dietaries expressed approximately, com- pared with the generally accepted requirements of an average adiilt at moder- ate work; the solid constituents are reckoned as being free from water. Dietary. Proteids. Fats. Carbohydrates. Calorie Value. Fluid as Beverage. Normal - - - oz. 3^2 (los.o) oz. 3 C90.0) oz. 14 (420.0^ 3,000 Pts. 3-4 (1,500-2,000) Harvey-Banting Oertel - - - - Ebstein - - - Von Xoorden - 6 (180.0) 5^2-6^2 (165.0-195.0) 3^ (105.0) 5^2 (16S.0) ^3 (10.0) 1-1^2 (30.0-45.0) 3 (90.0) I (30.0) 2^3 (7S.o) 2^2-3^2 (75.0-105.0) i\ (52.0) 3^2 (105.0) 1,100 1,200-1,600 1,300 I.3S0 2 (1,000) 1-1^2 (500-750) 3 (1,500) 2 (1,000) OBESITY. 275 Dujardin-Beaiimetz recommends the following regimen: Breakfast at 7 A. M. to consist of 6 J drachms (25.0) of bread; 12^ drachms (50.0) of cold meat without fat and 6 ounces (180.0) of weak tea. Luncheon at noon con- sisting of 12^ drachms (50.0) of bread, the crust being preferable to the soft part; 3 ounces (90.0) of meat or two eggs; 3 ounces (90.0) of green vege- tables; a salad; 3 drachms (12.0) of cheese and for dessert cooked fruit of any desired variety. Dinner at 7 P. M. No soup; 12^ drachms (50.0) of dry bread; 3 ounces (90.0) of meat and vegetables, salad, cheese and fruit as at luncheon. The fluids are reduced and pastry and sweets are forbidden. Starches are cut down to a minimum and the only alcohol allowed is half a glass of a Hght white wine with the two principal meals. AlkaHne waters are also permitted and the patient may take a small sup of black coffee after dinner. Still better than to take fluids with the meals is to omit them at these times and to drink about two hours after eating a glass of white wine mixed with two parts of water, or, if preferred, a large cup of weak tea without sugar. With some patients it may be more advantageous to give small quantities of proper food in the intervals of the meals lest the reduction of the diet produce weak- ness. The importance of institutional treatment in connection with diet regulation cannot be over-rated for the systematic exercise, bathing, etc., that can be carried on at a hospital or sanatorium are very essential adjuncts to the successful management of patients suffering from obesity. The oxidation of the fats of the body may be accelerated by stimulation of the skin by means of massage although in some instances this procedure is not successful in reducing flesh. Hydrotherapeutic measures are also indicated, cold fresh or sea baths being preferable for some patients while others are more satisfactorily treated if Turkish and steam baths are pre- scribed; the latter should be followed by douches and massage. Obese subjects should, when possible, take regular muscular exercises such as walking, bicycling, horseback riding or gymnastics. Too much sleep predisposes to corpulence and most patients will do well to limit their slumber to six, or at most eight hours. It is often wise to stimulate the hver, which in many instances is sluggish in its action; this may be accomplished by prescribing Carlsbad or Kissingen salts or even sodium or magnesium sulphate. The spa treatment as carried on at Carlsbad, Marienbad and other like resorts is often successful in reducing the weight of over-fat subjects and many such, after a few weeks' sojourn, wiU exhibit marked improvement evi- denced by amelioration of the unpleasant symptoms of the obesity as well as by loss of body weight. This is probably the result of the systematic and regular mode of life combined with the use of laxative waters and a reduced diet. The management of obesity by means of a few weeks' stay at a resort, while, during the rest of the year the patient regulates his habits to suit him- 276 CONSTITUTIONAL DISEASES. seK, is far less to be recommended than a slow and continuous method of treatment. The administration of thyroid extract in conditions of obesity has come into vogue during recent years and it may bring about a loss of weight in certain instances in which, perhaps, the corpulence is the result of disordered function of the thyroid gland. The dried extract is the preparation to be preferred and its usual dose for an adult is from 3 to 5 grains (0.2 to 0.33) three times daily. It is not, however, a drug to be carelessly used and its effects should be watched (see the treatment of myxcedema). The administration of iodine with the alkaline iodides has also been sug- gested and these may be prescribed in the following formula. Metallic iodine ij grains (o.i), potassium iodide 22J grains (1.5), water to i ounce (30.0); of this a teaspoonful should be taken 3 to 4 times a day. The alkaline salts of Uthium, potassium and sodium may also be given thus: potassium carbo- nate 1 1 parts; Hthium carbonate 2 parts; sodium bicarbonate and potas- sium iodide of each 6 parts; water to 300 parts; the dose of the mixture being 2 to 3 dessertspoonsful daily. SCURVY. Synonym. Scorbutus. Definition. A disease characterized by ansemia, general weakness, a spongy condition of the gums and a tendency to haemorrhages from the skin and mucous membranes. .Etiology. Formerly scurvy was very common among sailors upon long voyages where it was impossible to arrange a dietary containing fresh vege- tables and from this fact the incidence of the disease was considered to be due to the lack of these articles of food, particularly, as with the better methods of preserving food and with the quicker voyages which are in evidence to- day, the affection has all but disappeared. However, since it has been shown that scurvy occurs epidemically, endemically and sporadically, independently of dietetic conditions and that it may not appear when nothing but meat is eaten for months at a time, the theory that the disease is due to a lack of vege- table elements in the food has been greatly shaken. That it may appear as a result of a diet from which vegetables are wholly or in part absent is probable imless a large number of reported cases in individuals who have subsisted for considerable periods upon such articles as meat, bread, tea and coffee have been coincidences. Certain observers have attributed scurvy to the deficiency in the diet of the potassium salts and others to the lack of the alkaline carbonates derived from the vegetable acids. Another theory of the causation of the disease is that it results from some SCURVY, 277 toxic substance produced by the decomposition of food. This hypothesis is supported by the fact that an affection analogous to scurvy has been induced in apes by feeding them upon sHghtly decayed food. A third view of the aetiology of scorbutus is that it is an infection and due to a micro-organism which is as yet not isolated. A bacterium has been found occurring in instances of the disease which when cultivated and inocu- lated into lower animals causes symptoms and lesions resembling those of scurvy; the relation of this organism to the disease is not yet definitely proven. As predisposing causes we may mention over-crowding under unhygienic conditions such as obtain on ships, in army camps, asylums, etc., exposure to cold and wet, and mental and physical over-work. The principal factor is, however, the eating of improper food for a considerable period. Pathology. The changes in the blood are not characteristic of anything more than marked anasmia; there is no increase in the number of leucocytes. The blood itself is dark and fluid. Haemorrhages in any part of the body may be observed; into the skin, mucous membranes, muscles or other tissues; they may take place even into the joints. Bleeding into the liver, kidneys and muscles may be accompanied by degenerative changes. The spleen is enlarged and softened and there is swelling of the gums, in some instances so pronounced that the teeth fall. Symptoms. The onset is usually gradual with increasing emaciation and weakness; the skin is pale, the tissues about the eyes are swollen and bluish. Dyspnoea on exertion with palpitation may be present and the patient may complain of muscular and joint pains. The gums become soft, swollen and spongy, they bleed easily, may be ulcerated and the teeth may become loose and drop out. The breath is foul and the tongue red and swoUen; rarely there may be necrosis of the jaw. Petechial haemorrhages are noticed first upon the legs, later upon the upper limbs and body. As the disease progresses the haemorrhages become larger; they are dark red, rounded, and when directly under the skin may cause circumscribed tumors. They are less common in the mucous membranes but may take place under the periosteum and into the serous membranes. Sub- periosteal haemorrhages, especially in the legs, may break down into sluggish sores. Bleeding results from the least traumatism; epistaxis is common but hsematuria and bloody stools are less frequent; haemoptysis and haema- temesis are very seldom noted. (Edema of the ankles is common and the urine may contain albumin. The patient suffers from weakness; mastication is painful and the appetite poor. The bowels are usually constipated. The heart is irregular and feeble and the functional murmur of anaemia may be heard over the second left space close to the sternum. The temperature is seldom elevated. Hasmorrhagic infarcts of the lungs or spleen may occm*. 278 CONSTITUTIONAL DISEASES. Mental symptoms such as depression and insomnia are common; delirium is a late symptom; meningeal haemorrhage, convulsions and paralyses have been observed, as have hsemeralopia and nyctalopia. The diagnosis is simple when a number of instances of the disease appear at the same time and place. The haemorrhages and spongy condition of the gums are fairly characteristic and when these occur in connection with an improper diet and disappear when proper food is prescribed the diagnosis is assured. The prognosis in the early stages is good but later the tendency to serious complications such as infarct, pleural or meningeal haemorrhage, nephritis, etc., i^enders it less favorable. Treatment. Prophylaxis consists in so regulating the supplies taken by ships on long voyages that there shall be a sufficient amount of fresh vegetable food; this has been done by law. Free ventilation and avoidance of damp- ness are to be advised. The treatment of the disease is chiefly dietetic. The juice of two or three lemons or oranges should be taken daily in connection with a regimen con- taining plenty of fresh meat and green vegetables, such as lettuce, water-cress, spinach, onions, cabbage, celery, etc., and will cause a rapid amelioration of all the symptoms. If the digestion is so impaired that careful feeding is nec- essary the fruit juices should be given together with milk, beef juice, scraped beef, gruels and other easily digestible foods until a tolerance for ordinary articles is established when eggs, potatoes and the substances mentioned above may be gradually allowed. A sluggish digestion may be stimulated by giving the vegetable bitters, strychnine, quinine, etc., and it is often advisable to add iron in order to assist the regeneration of the blood. An excellent preparation is the elixir of strychnine, quinine and iron of the national for- mulary. Necessary adjuncts to treatment are moderate exercise, bathing and regulation of the general hygiene. The various symptoms should be treated as they occur. For the gingivitis ♦astringent and antiseptic mouth washes should be prescribed. Swabbing the gums with 2 percent, tannic acid or 5 percent, silver nitrate is an excellent measure. A saturated solution of potassium chlorate is serviceable if ulcers are present and potassium permanganate i to 5000 or Dobell's solution makes a useful mouth wash. For the haemorrhages surgical means should be employed when necessary, and the administration of calcium lactate or chloride in 20 grain (1.33) doses 3 times daily is a very effective measure in checking these manifestations, owing to the influence of these salts in increasing the rapidity of the coagu- lation of the blood. The injection of solutions of gelatin has also been suggested in haemorrhage but is less to be depended upon than the adminis- tration of the calcium salts. The same may be said of other internal haemos- tatics; these, however, may be used if desired. INFANTILE SCURVY. 279 The constipation may be controlled by means of intestinal irrigations. Ulcerations upon the limbs require siirgical treatment as does separation of the epiphyses which sometimes occurs. The complications, cardiac, pulmonary, renal, etc., should be treated as when occurring independently. INFANTILE SCURVY. Synonym. Barlow's Disease. Definition. A disease of infants analogous to scurvy as observed in adults and often associated with rickets. .etiology. Infantile scorbutus is due to improper feeding; in most instances the disease occurs between the 6th and the 15th month and it is often seen in the best class of private practice. Exactly what the cause of the affection is, it is at present impossible to state, we merely know that it is the result of a lack of something in the food which is essential to normal nutrition. The condition is most frequently observed in infants who have been fed upon proprietary foods, sterilized or condensed milk; it has also been reported in breast-fed babies. As a rule several months of improper feeding are nec- essary to the development of the disease. Pathology. The most constant and characteristic lesions are haemor- rhages beneath the periosteum, especially that of the bones of the legs. Inter- muscular and periarticular extravasations may also be present. There may be epiphyseal separations in extreme instances of the disease; changes in the bones analogous to those of rickets may be observed. Haemorrhages into the skin, mucous membranes, the serous sacs and the viscera are sometimes found. Symptoms. The onset is usually gradual with loss of flesh, increasing paleness and fretfulness. Soon tenderness and pain upon motion of the limbs is noticed; at first this is observed only when the child is handled, later it becomes constant; swelling above the ankles may be present. The gums are swollen, spongy and tend to bleed upon irritation or even spontaneously; they are purplish in color and may obsciire the teeth. Ecchymoses in the neighborhood of the large joints may appear. The increasing muscular weakness may be mistaken for paralysis. Ultimately the patient becomes anaemic, cachectic and emaciated; haematemesis, melaena or haematuria may occur and late in the disease there may be a slight febrile movement and exophthalmos due to orbital haemorrhage may be noted. Epiphyseal sepa- rations are late symptoms and usually result from trauma. Albuminuria with casts is not infrequent and most scorbutic children suffer from gastric and intestinal derangement. The diagnosis. Infantile scurvy may be differentiated from rheumatism 28o CONSTITUTIONAL DISEASES. by the age of the patient, the condition of the gums and the history of the dietary, and from poliomyelitis by the pain and tenderness. The prognosis when the disease is recognized early in its course is good, the recovery under treatment being very rapid; only very rarely are permanent lesions left behind. Unrecognized instances may terminate fatally in three to four months from cachexia, heart failure or intercurrent disease. Treatment. The patient should be immediately put upon cow's milk properly modified in accordance with its age and digestive ability. In addi- tion fresh fruit juice, preferably that of the orange, should be prescribed; this should be given about haK an hour before feeding and in total daily quantity of J ounce to 4 ounces (15.0 to 120.0) depending upon the age and tolerance of the child. Even when diarrhoea is present the fruit juice is not always contraindicated, this manifestation often being a symptom of the scurvy and one which becomes rapidly ameliorated under this treatment. The expressed juice of fresh beef may also be given, and, if the patient is of proper age, fresh vegetables are valuable adjuncts to treatment. The anaemia and poor general condition often render advisable the admin- istration of codliver oil, the syrup of iron iodide, and other tonics; these should seldom be prescribed before the scorbutic symptoms have disappeared. Epiphyseal separation necessitates orthopaedic treatment in connection with the measures above suggested. Fortunately the separations are seldom permanent. RICKETS. Synonym. Rhachitis. Definition. A disease of infantile nutrition characterized chiefly by anom- alies in the development of the bones and consequent deformities. .etiology. Rarely the affection is congenital. It occurs far more fre- quently in cities than in the country and is more common in Europe than in America. It is particularly frequent in the Italians and negroes of the United States, probably because the native habitat of these races offers a warmer climate than ours. It occurs especially amongst the children of the poorer classes because of the vitiated hygienic conditions in which these unfortunates are compelled to exist. In Russia it is said to appear commonly in the families of the well-to-do, the climate of this country, in its northern part at least, being such as to render free ventilation uncomfortable. Dense crowding and lack of sunlight seem to be important predisposing causes. An unsuitable or insufficient diet is the most essential aetiological factor and consequently the disease is more often observed in artifically fed infants than in those fed from the breast; it does, however, appear in breast-fed children when the milk is not of good quality and also when the child is not weaned at a proper time. Infants fed upon sterilized or condensed milk or upon proprietary RICKETS. 281 foods are especially prone to the affection which seems here to be due to a lack of sufficient fat and proteid matter in the dietary, in consequence of which there is for some reason a defective assimilation of the calcium salts. Syphilis may co-exist with rickets but the latter is not a manifestation of the former disease although it may be mpdified by it. Sex has nothing to do with the incidence of rickets; the disease usually shows itself between the 6th and 15 th month but the so-called late rickets may not appear until the loth or 12th year of life. Pathology. The lesions are chiefly of the osseous system, particularly the bones of the cranium, the long bones and the ribs. The skull tends toward the cubical in shape, the vault and occiput being flattened while the frontal and parietal eminences become more pronounced. The head is enlarged and the forehead bulging. The closure of the fontanelles is delayed, even until the third year, the margins of the bones being thickened and soft. Foci of delayed ossification which yield to pressure may be present in the parietal or occipital regions. The epiphyseal cartilages of the long bones are enlarged as a result of the rapid thickening of the zone of proliferation, which is bluish in color and soft and spongy. The periosteum is easily detachable revealing a spongy bone markedly deficient in the lime salts. The bones bend easily, producing deformities which are particularly evident in the tibiae as a result of the pres- sure of the body weight or are produced by sitting cross-legged. The femora also may be bowed outward or forward. The humerus is often bent and the radius and ulna may be twisted out of shape. Exaggeration of the normal curves of the clavicle is not infrequent. The chest is characteristically deformed; a vertical groove may be present between the 4th and 8th ribs upon its lateral aspects producing the chicken- breast. Accompanying this deformity the so-called Harrison's groove may be observed; this is a transverse depression extending from the xiphoid cartilage toward the axilla. The "rickety rosary" is also frequent. This term is applied to the bead-like nodules which appear at the junctions of the ribs with their cartilages. Spinal curvatures are common, the normal dorsal convexity and the lumbar lordosis being accentuated. Scoliosis, also, is not rare. Thickening of the scapulas and the well-known rhachitic deformity of the pelvis are often ob- served, the iliac bones being distorted, the anteroposterior diameter of the true pelvis diminished, and the pubic arch narrowed. The bony deformities are due to the tension of the muscles or to the pres- sure of the body weight. Upon chemical analysis the bones in rickets are found to contain a super- abundance of organic matter and a greatly diminished proportion of the lime salts. 282 CONSTITUTIONAL DISEASES. The muscles are small and poorly developed and the abdomen is usually enlarged and prominent. Various lesions of the viscera are common. Collapse of the lung may be present beneath the lateral grooves of the thorax; bronchitis and broncho- pneumonia are frequent and mild gastric and intestinal catarrh with dilata- tion may be observed Splenic enlargement (simple hyperplasia) is often noted and the liver may be increased in size. Enlargements of the lymphatic glands often occur but are merely an associated lesion. Symptoms. Many of these have been dealt with in discussing the pathology of the disease. The onset is usually gradual and as a rule appears before the 15th month; one of the earliest symptoms is sweating of the head, espe- cially at night and often so profuse as to wet the pillow; the child sleeps rest- lessly, and may exhibit a slight febrile movement and digestive disturbances such as nausea, regurgitation of food, flatulence and constipation. He is poorly nourished, dentition is delayed and the teeth when they appear are often poorly formed and decay quickly. Tetany and laryngismus stridulus are not infrequent and rickets is a very important predisposing cause of infantile con\'ulsions, these being usually excited by some digestive disorder. Tenderness over the epiphyses may be present causing the child to cry when lifted or otherwise distiu-bed. The first symptom to appear referable to the osseous system is the beading of the ribs and is a very constant manifestation. In very young infants as an early symptom soft spots may be observed over the occipital or parietal bones which crackle somewhat like parchment upon pressure. This condition is termed cranio-tabes and may occur in congenital syphilis both with and without rickets. The other bony deformities have been described in the section devoted to pathology. The fontanelles are late in closing, often persisting until the child is 2^ years old, the forehead is protuberant and the face relatively small and of a prematurely aged expression; the veins of the scalp are often conspicuous and the hair over the occiput is thinned owing to the friction of the pillow. The ligaments, especially those of the large joints, are loosened and stretched, causing the weak ankles, the backward bowed knees and the abnormal mobility of other articulations which are so often seen in rickets. The muscles are flabby and small and their consequent weakness causes walking to be delayed and interferes also with standing and sitting upright. The lack of power in the ill-developed muscles may be so marked as to render the differentiation from a true paralysis impossible except by testing the reaction to electricity. The lack of muscular tone is also in great measure responsible for the prominent abdomen and the constipation. Rhachitic children are usually fat but their flesh is not firm and they are anaemic; they frequently exhibit lymphatic enlargements, hypertrophied RICKETS. 283 tonsils and adenoids and fall an easy prey to any acute disease, being par- ticularly prone to all affections of the mucous membranes of the respiratory or digestive tracts. The condition of the blood is not typical; anaemia is usually present in varying degrees and the leucocytes may or may not be increased in number. The liver and spleen are often palpable either as a result of enlargement or of the downward pressure of the thoracic deformities. The diagnosis is seldom difficult. Rickets is to be differentiated from syphilis by the facts that in the former disease the bone affections are at the epiphyses rather than in the extremities or shafts, that necrosis never occiirs and that the enlargements are of the bones themselves, while in syphilis they appear rather like soft swellings over the bone. In scurvy there are the typical gum lesions and the haemorrhages, and the various paralytic condi- tions may be separated from rickets with extreme muscular weakness by testing the electrical reactions, the patellar reflexes and studying the cerebral condition. The spine of rickets is flexible, the curves are less acute than those of Pott's disease and disappear when the patient is laid flat. The other symptoms of rickets are present, and these with the absence of the characteristic mani- festations of tuberculous hip and congenital dislocation render the differ- entiation of the former affection from the two latter conditions a simple matter. The prognosis is favorable, rickets alone never resulting fatally. There is always danger that the child may fall a victim to complicating disease. The course is chronic, the symptoms often continuing for months. Their prog- ress usually ceases at the age of about one and a half years probably because the diet by this time has become more general and the child is allowed more in the open air. Under proper treatment gradual improvement takes place. The health of the patient is not permanently impaired unless there is marked deformity of the chest, although the bowing and shortening of the legs may prevent him reaching normal stature. Treatment. Rickets being to a great extent a preventable disease and due to improper feeding and unhygienic surroundings, the prophylaxis consists in the avoidance of these factors in the causation of the affection. When previous children have suffered from rickets those who follow are markedly predisposed to the affection and upon this account should be the more carefully guarded. Treatment proper consists primarily in diet regulation. Breast-fed babies when rickety should be artificially fed with properly modified cow's milk unless a wet nurse whose milk is of normal composition is available. Older children who are able to take food other than milk should be given a diet consisting chiefly of proteids and fats, carbohydrates being excluded as far as possible; 284 CONSTITUTIONAL DISEASES. milk, cream, beef juice, eggs, red meat and fresh fruit, either raw or stewed, should make up the greater part of the regimen. Farinaceous foods and par- ticularly the proprietary infant foods should be interdicted. Hygienic treatment is at least as important as diet regulation and often more difficult to arrange. Fresh air, sunshine and out-door life are absolutely essential, consequently city children should if possible be removed to the country, or if this is impracticable the patient should spend as much time as possible in the parks or upon the roof where oftentimes a sort of play-ground can bet:onstructed. Free ventilation of Hving and sleeping rooms is essential and the mother may be assured that if properly clothed and protected from draughts the child will be in no danger if the window of the sleeping room is kept open. Flannel night drawers with feet, and warm coverings are to be advised and as a hardening measure a quick sponge off with water at from 65° to 70° F. (18.5° to 21.5° C.) after the daily bath is excellent. With regard to drugs it may be stated that codliver oil — which is a food as well as a drug — is our chief reliance. It may be given in doses of a drachm (4.0) or less, to ^ an ounce (15.0), 3 times a day unless it disturbs the stomach when it should be administered by inunction either pure or mixed with lanolin in the proportion of i to 3 or 4. In very hot weather it is often wise to temporarily discontinue treatment by means of this agent. Phosphorus has been much used in rhachitic conditions and may be given combined with olive or codliver oil in doses of -j^-q to y^'o of a grain (0.0003 to 0.0006) 3 times a day after meals; larger doses may cause digestive disturbances. The following formula is a useful one: phosphorus ^ grain (0.008), oil of sweet almond ^ ounce (15.0), acacia 2 drachms (8.0), syrup 2 drachms (8.0), distilled water to 4 ounces (120.0). Dose, i teaspoonful 3 times a day after meals. Lecithin may be substituted for phosphorus, its dosage being i to 2 grains (0.065 to 0.13) 3 times a day in codliver oil. Calcium has been prescribed in the hope that it would supply the lack of mineral matter in the bones but this hope is probably vain for it is believed that any Hme taken into the organism in excess of that provided by the food is excreted through the ahmentary tract. Calcium, however, has a certain tonic effect in some instances and may be exhibited as the following formulae suggest. Calcium phosphate 75 grains (5.0), calcium carbonate 2^ drachms (lo.o), milk sugar 3! drachms (15.0), to be divided into 30 powders of which 2 to 4 may be taken daily. Codliver oil, lime water and syrup of calcium lactophosphate equal parts; one teaspoon- ful 3 times a day. Iron in the form of the syrup of the iodide may be prescribed in anaemic patients. Arsenic is also useful. Upon the theory that the disease is the result of a disorder of the thymus gland the administration of the fresh calf thymus in dose of 15 grains (i.o) for each month of the age of the patient has been suggested, or, if desired, RICKETS. 285 thymus tablets may be substituted for the gland substance. Atropine in doses of -jio of a grain (0.000012) for a child of i year will lessen the tendency to sweating. In preventing the deformities it is necessary to avoid lifting the child as much as possible and to discourage any inclination on the part of the patient to support himself in the standing position; he should not be allowed even to sit up unless supported. The deformed chest may be brought nearer into normal shape by ordering systematic respiratory exercises and gymnastics, children even as young as 3 years may be taught simple calisthenics, and the use of the pneumatic chamber has been suggested. The tendency to spinal curvatures may be lessened by keeping the patient upon a hard bed without a pillow under the head, but, if necessary, a thin pad under the lumbar region, so that this part of the back shall be raised slightly higher than the shoulders and buttocks. Daily placing of the child in the prone position and over- correction of the deformity by lifting the buttocks, the lumbar region being held stationary meanwhile, is useful. In advanced instances orthopaedic ap- paratus may become necessary. The curvatures of the legs may be corrected manually and when slight they may even be outgrown; the child should never be allowed to sit with the legs crossed beneath him or habitually in ally position because of the tendency of the limbs toward deformity. Braces may become necessary but any treatment of this sort after the age of 2^ years is usually futile on account of the firmness of the bones; osteotomy is necessary after this period but should usually be delayed until the child is at least 4 years old and the bones have become whoUy hardened. Knock knees, bowlegs and curvatures of the radius and ulna may be corrected by this operation. The flattened pelvis in women may necessitate Csesarean section or symphy- seotomy during childbirth. In the management of rickets it is necessary to remember that constitu- tional treatment should be undertaken as early as possible and that it is usually of little use to continue it after the beginning of the i8th or 20th month, for by this time the active stage of the disease is past and merely the results of the affection remain. 286 THE INTOXICATIONS. CHAPTER III. THE INTOXICATIONS, INCLUDING THE EFFECTS OF EXPOSURE TO HIGH TEMPERATURES. LEAD POISONING. Synonyms. Plumbism; Saturnism. w^tiology. This is a common condition and one of which the sources are numerous. The most important are: the use of soft water, carbonated waters and alcohoHc drinks, especially beer, which have passed through lead pipes or have been stored in receptacles lined with lead; the occupations of painters (colica pictonum), plumbers, typesetters, gold miners, white lead workers, potters, glaziers (Devonshire colic), because the laborers do not employ ordinary cleanliness and neglect to wash the hands before eating; the use of lead hair dyes and face powders, biting leaded white thread, eating certain canned fruits (lead solder), sheet lead (tin foil) about tobacco or sweets, filling holes in mill- stones with lead, playing with tin (lead) soldiers by children, the use of lead carbonate on burns, of diachylon plaster as an abortifacient or of lead and opium pills in dysentery, lead bullets in the flesh, the use of white or red lead in the vulcanization of rubber, false-tooth plates of lead, and the use of baking powder adulterated with lead chromate to give buns an attractive yellow color, have all been followed by chronic plumbism. Lead is, perhaps, the best example of a poison which is comparatively harmless when taken in a single large dose, but of which most minute doses, if taken for a sufficient period, result fatally. The lead enters the organism through the skin, respiratory tract or the alimentary system; in most instances of poisoning the toxic substance has been chiefly taken in through the mouth. Elimination takes place through the skin, kidneys, intestinal tract, saliva and milk. Pathology. Normally a small amount of lead is present in the body and it is not very unusual for minute traces of the metal to be excreted by the urine. In plumbism lead is demonstrable in the organs and tissues. The muscles are the seat of fatty and fibrous degeneration; the nerves are in a state of degenerative neuritis, sometimes fatty changes are also present. The ganglion cells of the anterior cornua of the cord may be in a condition of atrophy similar to that found in anterior poliomyelitis. In acute intoxica- tion the lesions of intense enterocolitis may be found. LEAD POISONING. 287 Symptoms. Acute poisoning is most frequently due to taking lead acetate, a very large amount of which is necessary to produce a fatal eilect, particu- larly since a great part of that ingested is generally vomited. Gastro-intestinal symptoms such as salivation, thirst, dysphagia, abdominal pain, emesis and diarrhoea result and the vomitus consists of a whitish fluid containing curd- like matter; in consequence of the astringency of the lead the purging is less intense than that caused by other irritant poisons, constipation being some- times observed. The stools may be blackish owing to the presence of lead sulphide and these and the vomitus may contain blood. These symptoms are followed by weakness, coldness of the extremities and collapse. After recovery the patient may suffer from chronic plumbism. A subacute form of intoxication is sometimes observed in which, after a short exposure to the effects of the metal, the patient suffers from anaemia, acute neuritis and even epileptiform convulsions and delirium similar to that caused by alcohol. Chronic poisoning, it is said, may sometimes be detected by painting the skin with ammonium sulphide or sodium thiosulphate; three or four coats should be applied to a patch of skin several inches square and in the presence of plumbism this area will turn dark in about 24 hours due to the formation of lead sulphide. The presence of lead is also demonstrable in the urine. In the form of the sulphide lead is sometimes deposited upon the edge of the gums producing the characteristic "lead line," this is black in color and due to the presence of hydrogen sulphide produced by the action of bacteria; if the teeth are sound and kept clean this manifestation is usually absent. The Une is also observed in some instances at the junction of the anal mucous membrane with the skin. The most prominent of the peripheral nerve effects of plumbism is lead colic, a phenomenon which is due to violent contraction of the intestinal muscles, probably resulting from stimulation of the nerve endings. As it is greatly relieved by the nitrites and other vaso-dilators it may be inferred that a primary vaso-constriction is one of its causes. With the colic the intestinal spasm forces the blood from the splanchnic area and the general blood pres- sure is raised, the pulse being slowed and rendered hard and tense. The pain, which is extreme and grinding in character, is chiefly located in the umbilical region, and the abdomen is retracted and hard; paroxysms of the most acute agony are often succeeded by intervals of comparative ease. The colic is usually preceded by constipation and may be accompanied by vomiting. The paroxysms may last for several days or a week, and then disappear to recur at intervals. Other nervous symptoms apparently of peripheral origin are anaesthesia of various parts, lasting perhaps one or two weeks, and lead arthralgia, which consists of sharp lancinating or boring pain in the joints, bones, or the 288 THE INTOXICATIONS. muscles about the joints; this latter usually appears and disappears quite suddenly. Neuralgias are sometimes observed; these may be of central origin or due to peripheral neuritis. Lead amblyopia is a rare phenomenon; the sight may be lost entirely or merely somewhat impaired. This manifes- tation may be due to optic neuritis, which if allowed to continue leads to atrophy of the nerve, to uraemia with effusion into the optic sheath or to albuminuric retinitis. In what is termed encephalopathia saturnalis the disorders observed are for th| most part of cerebral origin, although the lower portions of the central nervous system are also involved at times. The cortex is chiefly affected and an irritation is produced which is followed by paralyses, both sensory and motor, although the latter, are the more pronounced. There are usually muscular contractures and later choreic movements. Sometimes convulsions occur as a result of uremia due to the nephritis which invariably follows chronic plumbism, sometimes they are due to the lead itself. The motor stimulation is ultimately followed by paralysis. In addition there is deHriimi, succeeded by depression and coma which latter may be urgemic. On the motor system the efl'ects produced by the lead are neiiritis, paralysis and atrophy. The usual site of the lesion is probably in the peripheral nerves and muscle cells, though in certain instances the central nervous system seems to be involved. A common characteristic of lead poisoning is the ''drop-wrist" or "painter's palsy," which is probably attributable in part to paralysis of the extensor muscles and partly to the active contracture of the opposing flexors. A characteristic of lead palsy is that the supinator longus is not involved and the electrical response of the affected muscles is less than in other t^-pes of peripheral neuritis. The patient afflicted with chronic plumbism is always anaemic; this con- dition of the blood is at first due to the constriction of the peripheral vessels and later to diminution of the haemoglobin and red corpuscles in the blood. There is granular basophilic degeneration in many of the red cells and the presence of this condition is of some diagnostic value. Nucleated red ceUs are often found even if the anaemia is not of severe grade. Jaundice may result from the breaking up of red corpuscles and the liberation of large amounts of haemoglobin. The leucoc}-tes are often increased in number. The results of lead intoxication upon the circulatory system consist in the production of arteriosclerosis which is early evidenced by a high tension of the pulse and an accentuation of the 2d aortic sound. These manifestations may be demonstrable before either colic or palsy is observed. Cardiac h}^er- trophy is common and the wall of the organ may be in a state of fatty or fibrous degeneration. In the kidneys lead causes marked irritation in the process of its elimi- nation, consequently nephritis is frequent in instances of acute poisoning LEAD POISONING. 289 and is uniformly found in chronic plumbism both as a result of this irritation and of the arteriosclerosis induced by the presence of lead in the organism. A remarkable circumstance in connection with lead poisoning is the fre- quency of gout in its subjects; this coincidence is much more common in England than in America. In districts where the ordinary type of gout is rare it is said that the disease is seldom induced by lead. The prognosis depends upon the degree of the intoxication; it is favorable in early instances. Atrophic paralysis is likely to prove difficult of cure and the mental symptoms of lead encephalopathy may be permanent. The arterial lesions and those of the viscera which are evidenced by degenerative changes are usually incurable. Treatment. Prophylaxis is of the greatest importance and the public should be more fully instructed concerning the dangers of lead. Special precautions are required in lead works, paint factories and in exposed trades. Dust should be avoided as much as possible, and, where this is necessarily present, thorough ventilation is an absolute essential. The necessity of fre- quent bathing and thorough washing before eating cannot be too strongly im- pressed upon the workman. The addition to the bath of sodium hypochlorite or potassa sulphurata has been suggested upon the ground that the sulphur neutralizes the lead by forming insoluble compounds with it. Food should not be permitted upon the premises and the clothing should be changed before leaving the works. The systematic use of milk in large amounts as a food is to be recommended. Sulphuric acid lemonade is generally employed as a prophylactic but is not particularly reliable. Weak or anaemic individuals should not be employed as workers in lead and it is advisable that women should be altogether excluded from such occupations. In treatment the first indication is to remove the patient from the danger of further poisoning. In general, reliance is placed upon potassium iodide, saline purgatives, diuretics and the use of hot baths and massage to promote elimination, and upon the employment of appropriate measures to improve the patient's nutrition and strength. Potassium iodide is in universal use and appears to have a beneficial effect though the manner of its action is not clearly understood. It has been supposed to accelerate elimination through the kidneys, but it has recently been denied that the drug has any influence upon excretion by the urine or by the intestinal tract through which most of the lead escapes from the body. Baths of sulphurated potassium are efficient, especially if the patient is well soaped afterward and then thoroughly rinsed and rubbed with a rough towel. For the colic opium or morphine is often necessary, alum in 2 grain (0.13) doses is of great service and dilute sulphuric acid is also useful. The constipation may be relieved by a combi- nation of magnesium sulphate and dilute sulphuric acid and the lead cachexia is greatly benefited by the latter, given in connection with quinine and ferrous 19 290 THE INTOXICATIONS. sulphate. In certain instances of chronic plumbism cathartics fail to act unless morphine is given to overcome the intestinal inhibition produced by the irritation resulting from the lead. Opiates may also be required for the relief of the joint pains. For the paralyses strychnine may be administered but our chief reliance is placed upon electricity and massage (see the section upon the treatment of multiple neuritis). If the muscles contract in response to the faradic current this should be employed, but if not the galvanic current should be used. Nephritis and gout due to lead intoxication should be treated in the same way as when resulting from other causes and the cerebral symp- toms must be dealt with according to the special manifestations which present themselves. ARSENICAL POISONING. Acute Arsenic Poisoning as a result of the ingestion of Paris green, or of one of the various rat or vermin poisons which contain this substance (cupric arsenite), is common. Symptoms. These as well as the pathology of the condition closely resemble those of Asiatic cholera. Large doses often cause no distress for a considerable period, but, within a half hour or perhaps longer, the patient experiences dysphagia with a sense of faucial constriction. Epigastric pain, quickly becoming extreme and general over the abdomen, follows; with it are associated nausea and excessive emesis and later there is profuse watery diarrhoea with tenesmus and thirst. The vomitus and stools may contain blood and there are muscular cramps, headache and dizziness; collapse ensues, with coldness of the extremities, pallor, small, feeble pulse and sighing respiration. Coma follows, and death, sometimes preceded by convulsions, takes place. Rarely the only symptoms noted have been collapse and coma. Death may occur within 24 hours but usually the patient lingers for several days. If recovery takes place the symptoms of chronic arsenic poisoning may develop. Treatment consists in immediately emptying the stomach by lavage or by emetics such as zinc sulphate, 20 to 30 grains (1.33 to 2.0) or a tablespoonful of mustard to a tumbler of warm water. After the gastric contents have been removed the organ should be repeatedly washed with warm water on occount of the insolubility of the arsenic. At the same time large amounts of freshly prepared ferric hydroxide with magnesium oxide or dialyzed iron, one ounce (30.0) should be given. The former mixture may be prepared by using 150 grains (10. o) of magnesiimi oxide to which is added sufficient water to make a thin magma which is slowly poured into a solution consisting of ferric sulphate. 10 drachms (40.0) and water, 4 oimces (120.0); the product is then shaken until a smooth mixture results. If either of these antidotes is ARSENICAL POISONING. 29 1 unobtainable light magnesia mixed with water may be substituted. The antidote must be repeated at intervals as long as acute symptoms persist. If neither magnesia nor the iron preparations are available, dependence may be placed upon large doses of castor oil and water. The collapse should be combated by means of subcutaneous injections of brandy or aether and warm applications made to the abdomen and extremities. Chronic Poisoning. The medicinal administration of arsenic in too large doses may induce slight toxic symptoms such as abdominal pain, anorexia, nausea, indigestion, mild diarrhoea, puffiness of the eyelids, conjunctival injection and watering of the nose and eyes. Cutaneous eruptions are some- times caused, and, while these may be in part a result of circulatory disorders, they are believed to be due chiefly to a direct action of the drug upon the skin. They may be erythematous, papular, vesicular or pustular and may be asso- ciated with a swelling resembHng that of erysipelas. Prolonged administration of arsenic, it is said, may cause herpes zoster. Arsenic is extensively used in the arts, especially in the manufacture of wall papers and fabrics, and consequently accidental poisoning among w^orkers in arsenic is not rare; it may also occur in individuals who use articles con- taining the drug. The evidence regarding chronic poisoning from occupancy of rooms decorated with arsenical wall papers is contradictory but the facts favor its probabihty. Quite as often the poisoning is due to the arsenic which contaminates aniline dyes as it is to arsenical pigments, consequently chemi- cal examination should be depended upon rather than color. Epidemic arsenic poisoning has occurred from the use of beer in the manufacture of which contaminated glucose has been employed. Symptoms. In addition to the manifestations mentioned above, chronic arsenic poisoning is evidenced by a catarrhal condition of the nasal and phar}Tigeal mucous membranes, vnth sneezing and coughing; the various cutaneous eruptions appear and in some instances there is a pigmentation of the skin (arsenic melanosis); eventually the hair and nails fall. Enlarge- ment of the liver with jaundice is sometimes observed and the later phases of the disorder are characterized by localized sensory and motor disturbances, chiefly in the hands and feet, resulting from polyneuritis. There are acute pain and sensations of formication in the extremities, followed by sensory paralyses with symptoms analogous to those of locomotor ataxia. These symptoms are followed by motor paralysis, as a rule confined to the limbs, but in some instances involving the trunk. The paralysis is usually symmet- rical and the affected muscles, which are more often those of the extensor than flexor groups, become atrophied. Herpes zoster of the face or trunk is common. In very protracted cases the patient may sink into an apathetic semi-idiotic state or epilepsy may supervene. After death, in addition to the lesions in the digestive organs and nervous system, a condition of fatty 292 THE INTOXICATIONS. degeneration of the viscera, especially the liver, kidneys, stomach and heart, as well as of the muscles, is found. A more full discussion of the nervous symptoms of chronic arsenical poison- ing will be found in the section upon multiple peripheral neuritis. Treatment consists in the discontinuance of arsenic if this is being admin- istered, or if the condition is the result of arsenical surroundings, a removal from exposure. Elimination of the drug should be accelerated by means of laxatives, diuretics, diaphoretics, and the administration of potassium iodide. ^ The treatment is otherwise symptomatic; the management of the paralyses will be discussed under the treatment of multiple peripheral neuritis. Tonics and plenty of nourishing and easily digestible food are indicated. Recovery usually takes place. MERCURIAL POISONING. Synonym. Mercurialism. Acute Mercury Poisoning from corrosive sublimate or white precipitate is not unusual. Merciiry bichloride in toxic dosage at once causes a metallic taste in the mouth, extreme pain in the pharynx and stomach, rapidly followed by intense retching and emesis. The vomitus soon becomes bloody and violent purging occurs, the stools being at first serous in character, later hsemorrhagic. The urine becomes scanty and contains albumin, casts and blood; the pulse becomes weak and rapid, the temperature falls below normal, all the vital energies are depressed and death may take place within a short time. The post mortem lesions are usually those of a membranous colitis and a parenchymatous and heemorrhagic nephritis, with general degeneration of the tubal epithelium; more rarely there is a peculiar deposit of calcium phos- phate. Treatment. The stomach should, if possible, be emptied immediately by means of the stomach tube, or if this is not at hand emesis should be provoked by faucial irritation, draughts of mustard and warm water or by the hypo- dermatic injection of apomorphine hydrochloride in dose of ttt of a grain (0.006). Albumin in the form of the white of egg, that of one being suflScient antidote for 4 grains (0.24) of corrosive sublimate, the albuminate redis- solving in an excess, or milk and flour should be given. Tannic acid is also useful since it protects the mucous membranes of the gastro-intestinal tract from the action of the drug. Chronic Mercziry Poisoning is less frequently observed than formerly when the administration of large doses of the drug was common. Workers in the metal are sometimes affected, the most profound instances of intoxi- cation being due to the prolonged exposure to its fumes. MERCURIAL POISONING. 293 Symptoms. The first evidences of mercurialism are referable to the mouth. At first there is sUght foetor of the breath, later an unpleasant metallic taste and tenderness of the teeth when they are forcibly brought together are noted. These are followed by stomatitis, sponginess of the gums and sahvation. If the ingestion of the mercury is continued the amount of saliva secreted becomes enormous; it is irritant and contains mercury. The breath becomes very foul, the gums are intensely inflamed, bleed at the lightest touch and are marked at the junction of the teeth by a dark red line. The teeth are loosened and may faU, the tongue and lips become involved in an obstinate inflammation which proceeds to ulceration, and, extending as gangrene to the cheeks, may produce frightful facial deformity. Even the maxiUary bones may undergo necrosis. Nervous symptoms such as tremors, erythism, and haUucinations may appear and the faculties may be dulled. There is general muscular weakness and paralysis with areas of partial anaesthesia and joint pains may occur. The peripheral neuritis of chronic mercm-ialism is a much later manifestation than that of plumbism and even after the develop- ment of the palsies the muscles retain their irritability and do not undergo atrophy. The reflexes are usually unaffected; rarely they may be exag- gerated. General nutrition is impaired and metabolism is profoundly affected, anaemia and marked cachexia resulting. With the cachexia the heart becomes weakened, the respiration rapid and shallow and the mentality impaired; the memory is imperfect, the temper irritable and melancholia and even mania may ensue. The special senses are affected as evidenced by deafness, dimness of sight and impairment of taste and sensation. Treatment consists in acceleration of the elimination of the mercury through aU possible channels. Elimination through the skin is favored by baths of sulphur and ordinary hot water and diuresis should be induced by causing the patient to drink as much water as can conveniently be borne and by the administration of diuretic drugs. Free evacuation of the bowels is necessary but if marked diarrhoea is present it may call for treatment by means of opiates and other remedies. The pain may necessitate the employment of opium. The common belief that potassivun and sodium iodides have an effect in causing the elimination of the metal has been disputed but never disproven; at any rate the proper administration of these drugs can do no harm; care, however, should be taken that the doses are not too large, for the combination of iodine with mercury in the tissues produces a soluble salt which is very active and may, at times, cause secondary systemic merciirial poisoning. Belladonna is sometimes required to diminish the excessive secretion of saHva and in aU instances a mouth wash of potassium chlorate solution is useful in the relief of the salivation and stomatitis; tincture of m)Trh may be added to it and a mouth wash of tannic acid may also be employed. Careful atten- tion should be given to the general hygiene and the cachexia should be com- 294 THE INTOXICATIONS. bated by plenty of nutritious food and such tonic and other remedies as may be indicated. The treatment in other regards is symptomatic; for the neuritis the methods and means of treatment suggested in the section upon multiple peripheral neuritis should be employed. Prophylactic means such as those indicated in the prevention of plumbism should be recommended in estab- lishments where mercury is used. ■y ANTIMONIAL POISONING. Acute Antimonial Poisoning resembles in its symptoms acute arsenical intoxication, the chief manifestations being those of intensely acute gastro- intestinal irritation. At autopsy the mucous membrane of the stomach and intestine is found in a state of hj^ersemia and tumefaction; erosions and ecchymoses are usually present. There are often pustules in the mouth, oesophagus, stomach and small intestine and pulmonary congestion or inflam- mation may be demonstrable. Treatment. The vomiting caused by the drug itseK usually obviates the employment of emetics but if free emesis has not taken place gastric lavage is indicated or apomorphine hydrochloride, tV of a grain (0.006) hypoder- matically or zinc sulphate, 20 to 30 grains (1.33 to 2.0) by mouth should be administered. The bowels should be cleared of the poison in this situation by a purge. The antimony in the stomach may be precipitated by tannic acid in doses of 30 grains (2.0); the tannate thus formed should be washed out. If the acid is unobtainable a strong infusion of hot tea may be substi- tuted. The gastric irritation may be alleviated by mucilaginous drinks and milk. The cardiac depression should be combated by means of hypoder- matic injections of alcohol, aether or strychnine and hot applications to the abdomen and extremities are indicated. Chronic Antimony Poisoning is of rare occurrence and difl&cult of diagnosis, the symptoms being of indefinite character. They consist of headache, vertigo, depression, impaired vision, nausea, vomiting, gastric disturbance with pain, diarrhoea, albuminuria, emaciation, weakness, exhaustion and ultimate collapse. The resemblance of the symptoms to those of catarrhal gastro-enteritis renders the diagnosis of chronic antimony intoxication, when the drug is given with homicidal intent, very difficult. After death antimony is said to be found in the liver, spleen, kidneys, bones and muscles; fatty degeneration of the viscera is also observed. The pro- tracted administration of tartar emetic is stated to produce pustular erup- tions. Treatment consists in stopping the drug and in the employment of symp- tomatic and stimulative measures. lODISM. 295 lODISM. lodism, the term applied to the train of symptoms resulting from the pro- longed administration of the iodides, is induced by all these salts; the basic ion does not appear to be concerned in the effect produced. Owing to the fact that iodine is more readily freed from it, ammonium iodide is said to be more likely to cause iodism than the other salts. Symptoms. These may be separated into two groups, (i) Frequently there is catarrh of the respiratory passages which commences in the nasal mucous membrane and is evidenced by a profuse watery discharge; the inflam- mation extends upward and downward producing conjunctivitis and perhaps severe headache due to involvement of the frontal sinuses. Accompan^ang this there is faucial swelling and irritation, the tonsils may become inflamed, and laryngitis and bronchitis may result. Laryngeal oedema may occur and cause death unless relieved. Somewhat later an eruption may appear, con- sisting of erythematous patches or papules which may become pustular; other eruptions have been observed. (Edema of the face is met in some instances and there may be albuminuria. Nervous manifestations such as neuralgia, tinnitus aurium, convulsive movements, disturbed inteUection and rarely atrophy of the mammje and testes, have been described. (2) Iodic cachexia, in which rapid emaciation takes place, is a late phenomenon and intense cardiac palpitation and ravenous appetite may develop. The local manifestations of iodism can sometimes be prevented by the administration of alkalies and hence it is thought that the variation of their extent in different individuals, or in the same person at different times, may be explained by a varying degree of acidity. A tolerance may be established and sometimes the symptoms disappear while the drug is still being taken. Even though the manifestations may be intense they usually cease soon after treatment is discontinued and the chewing of pellitory will hasten the elimi- nation of iodine in the chronic forms. WTien iodic cachexia has occurred the symptoms may not disappear for a considerable time. BROMISM. This term has been given to the toxic symptoms resulting from the pro- longed administration of the bromides. The condition is rarely caused by hydrobromic acid although this substance contains a relatively large propor- tion of bromine. ^ Symptoms. The first of these is usually a papular acneiform eruption appearing chiefly upon the face and back. In marked instances the papules become pustules which may coalesce, forming small abscesses which at times become ulcers. At other times the rash resembles eczema and sometimes there is an erythema or a brown pigmentation of the skin. The tongue is 296 THE INTOXICATIONS. coated and there are digestive disturbances; frequently there is a coryza which may be associated with increased bronchial secretion and mild conjunctivitis. These manifestations are attributed to a local irritant action partly due to the salt action of the bromine salt and partly to decomposition of the bromide, with liberation of bromic acid and bromine by the free acids in different situa- tions, as hydrochloric acid in the stomach, carbon dioxide in the air passages, etc. This action takes place more readily in old age and if renal insufficiency is present. From the influence of the drug on the nervous system the cuta- neous sensibility and the sensitiveness of the faucial mucous membrane are distinctly reduced while the sexual desire becomes diminished. There is indisposition on the part of the patient to any exertion, he is easily fatigued, his gait is uncertain and there is often marked muscular tremor. The intel- lect is dulled and the memory impaired, the patient takes little interest in his surroundings, his speech is slow and he may stammer, mispronouncing words or omitting several from a spoken sentence. The facies is apathetic and stupid and the eyes are heavy and without lustre. Mental excitement, confusion and sometimes delirium may follow the continued use of mioderate doses, especially of the potassium salt. The habitual user of bromides is unable to sleep without them, and a gradual increase of the dose is required to induce slumber, consequently the systemic effects are usually disastrous. In addition the patient's powers of resistance to disease are lowered and inter- current affections, such as pneumonia or even bronchitis, may result in death. Notwithstanding the severity of the symptoms of bromism, they soon dis- appear after the withdrawal of the drug and its elimination from the system. Treatment consists in stopping the administration of the bromides and in the employment of measures calculated to relieve the symptoms and to support the patient. BORISM. The continued internal use of too large amounts of boric acid or borax (sodium biborate) results in a train of symptoms which has been denominated borism. In some instances even moderate doses of these substances have a mild aperient action while in large amounts they are gastro-intestinal irri- tants and cause emesis and piirging. Other symptoms produced by toxic quantities are dryness of the pharynx and dysphagia, intense muscular weak- ness, pain in the back and vesical tenesmus with albuminaria and sometimes haematuria, impairment of sight, headache, insomnia and nervous depression, which may be followed by fatal collapse. A rise of temperatiire is frequently observed and in the course of 2 or 3 days, if death does not supervene, scaly, papular or eczematous eruptions appear upon the skin. The symptoms are evidenced more rapidly when the drugs are taken by mouth but mani- festations of the same character may result from their free application in the ALCOHOLISM. 297 rectum, vagina or other parts. Boric acid and borax are rapidly absorbed from the mucous membranes and from abrasions, and serious instances of poisoning have been reported as due to the use of the acid as an antiseptic dressing. In chronic poisoning the symptoms are often very similar to those of acute intoxication, the cutaneous manifestations are, however, more prominent and may constitute the only positive evidence of toxic effect, although there are usu- ally indications of more or less gastro-intestinal and renal irritation. CEdema of the face and extremities may occur as a result of the latter, and consequently it is advisable to keep a careful watch of the condition of the urine whenever these drugs are administered. The hair often becomes dry and falls, and the eruption upon the skin may resemble a seborrhoeic eczema, appearing as reddish patches which desquamate like psoriasis, or papules attended with marked pruritus. The most common eruption is said to be scaly, assum- ing the form of a seborrhoeic dermatitis, but usually associated with much more oedema. Sometimes the skin and mucous membranes are dry, the lips become fissured, the nails are striated and a blue line similar to that of plumbism may appear upon the gums. The question of the effect of the con- tinued and habitual introduction into the organism of boric acid or borax as employed in the preservation of food, is of considerable interest. The results of careful experimentation conducted by the Bureau of Chemistry, United States Department of Agriculture, show, on the whole, that 7^ grains (0.5) daily is too much for a normal man to receive regularly; on the other hand a normal individual may take this quantity of boric acid or borax, ex- pressed in terms of boric acid, for a limited period of time with slight danger of injuring the health. The chief objection to the employment of these sub- stances as food preservatives seems to rest upon the fraud in permitting inferior goods to be marketed as high class products. This applies especially to meats and milk although the addition of small quantities of these substances may be beneficial since it delays the souring of the latter. If larger amounts are used with fraudulent intent, the milk is apt to be kept too long, to be of poor quality and the quantity of the preservative may be sufi&cient to injure infants who take the milk as a routine. Treatment consists in stopping the ingestion of the adulterated food stuffs and the employment of means calculated to relieve the existing symptoms. ALCOHOLISM. Acute Alcoholism. Definition. The result of the imbibition of a considerable amount of alcohol in any of its forms and within a short space of time. The quantity necessary to produce drunkenness varies greatly with the individual. 298 THE IXTOXICATIOXS. Sjrmptoms. These are chiefly referable to the nervous system, and while the sequence of their appearance is not constant there is usually a primar}^ stage of excitation during which the subject's face becomes flushed, his eyes brightened and his tongue garrulous; the speech is at first coherent but soon becomes senseless; muscular co-ordination is disturbed as e\-idenced by the staggering gait. Locomotion soon becomes impossible and finally alcoholic coma super\'enes. Other individuals are differently affected; instead of the priman' excitement being evidenced by jollit}' and good nature it may be characterized by moroseness and the subject may be incited to violence and even murder by very slight provocation. The stage of narcosis, however,. ultimately ensues as in the pre\nously described t\^e of alcoholism, if suffi- cient liquor is taken. Alcoholic coma is not always easy of diagnosis. The face is usually flushed but may present a cyanotic appearance, the pulse is strong and fuU, respira- tion is deep, slow and sometimes stertorous. The temperature may be subnormal, at times even below 90° F. (32.2° C). The urine and faeces may be passed involuntarily the pupils are dilated and muscular twitchings may be present. The individual may be temporarily aroused in most instances by pressing upon the upper margin of the orbits at the junction of their inner and middle thirds — the points of emergence of the supra-orbital ner^^es. There is usually an odor of alcohol upon the breath. One of the most common of the mistakes to which the young ambulance surgeon is liable is the con- founding of basilar fractures of the skull for alcoholism. This mistake is rendered a particiilarly easy one by the frequence with which the two condi- tions co-exist. In fracture the coma is usually deeper, the respiration stertor- ous and the pupils are often unequal. Bleeding from mouth, nose or ears is very characteristic. The difficulty of differentiation is often so great that it is always the part of wisdom to give the patient the benefit of ever}' doubt and to consider aU dubious instances of coma as proper for admission to a hospital. Cerebral apoplexy may be separated from alcoholic coma by its deeper unconsciousness, pupiUar}' inequality, the evidences of cardiac or vascular disease or of partial paralysis. In urcRmic coma the taint of alcohol upon the breath is lacking, the pulse is likely to be of high tension and the patient may exhale a urinous odor. The pupils are variable; the urine when dra-^m by catheter shows the pres- ence of albumin and casts. A consideration of acute alcoholism is not complete without mention of the ver}^ serious effects of indiilgence in diluted methyl alcohol {wood alcohol). This liquid is often drunk by confirmed alcoholics when it is impossible to procure ordinary liquors. The effects of this form of alcohol are more pro- longed than those of ethyl alcohol, lasting from 2 to 4 days, while those of the CHRONIC ALCOHOLISM. 299 latter seldom persist for more than one-quarter of this time. The most per- manent effect is upon the optic nerves, blindness, which may last for a long time, and optic neiiritis are common sequences of the ingestion of this sub- stance. Treatment. Recovery from the acute effects of alcohol is usual even if no treatment is administered; the event may, however, be hastened by thoroughly washing out the stomach, or, if the patient is able to swallow, by giving an emetic consisting of 20 grains (1.33) each of powdered ipecac and zinc sulphate, or of warm mustard water — 2 drachms (8.0) to 8 ounces (250.0). The hj'po- dermatic administration of tj to to of a grain (0.0044 to 0.006) of apomor- phine hydrochloride is an efficient method of relieving the stomach of its contents and at the same time bringing about a diminution of violent nervous symptoms if these are present. These latter may be usually controlled by the administration of hydrated chloral in dose of 10 to 20 grains (0.66 to 1.33) with I or 2 drachms (4.0 to 8.0) of sodium bromide. If stimulation is nec- essary the patient may receive a drachm (4.0) of aromatic spirit of ammonia and if there is any tendency to collapse, frictions and hot applications should be employed. "W^en convulsions are present, which is rarely the case, a little chloroform should be given by inhalation until the sedatives given by mouth have had time to exert their effect. Chronic Alcoholism. Definition. A condition resulting from the habitual and intemperate use of alcoholic beverages. What constitutes the "intemperate use" of alcohol cannot be definitely stated, for certain individuals are able to take without apparent harm quantities of this substance which would exert, in more susceptible subjects, most marked untoward effects. Dipsomania is a form of chronic alcoholism, the tendency to which is hereditary, which is characterized by a periodic desire for alcoholic excess and is evidenced by debauches at varying intervals, the subject being wholly free from the craving during the intervening periods. Effects of Chronic Alcoholic Poisoning. Among the common results of chronic alcoholism are chronic gastritis, gastric dilatation, especially in beer drinkers, hepatic cirrhosis, delirium tremens and mania. Many other diseases have been attributed to the effects of the chronic use of alcohol among which may be cited gout, peripheral neuritis, pachymeningitis, organic heart disease and chronic nephritis; in fact, but few organs and tissues are not changed in some way in chronic alcoholism and its results. Of the changes met in this condition two groups are described, namely sclerosis and steatosis, WTiile these anatomical alterations are in process of development the exterior of the body assumes characteristic appearances. The individual may be 300 THE INTOXICATIONS. either pale and flabby, but fat, with a heavy and imbecile expression or he may have a dusky red or purplish, pimply and bloated skin, with swelling under the eyes, yellow and injected conjunctivae, and blue and thickened lips. Alcoholics are especially likely to contract pneumonia, tuberculosis and other infectious diseases, and when attacked by them show less resisting power than do previously healthy persons. They are also bad subjects for surgical operations and bear anaesthesia poorly. The^post mortem changes in the organs and tissues of alcoholic individuals show no characteristic changes, there is often found, however, in patients dead from mania a potu an oedematous condition of the brain and its mem- branes, the so-called wei brain. Symptoms. These are referable to the various organs and systems whose functions have been impaired and whose structure has been altered by the effect of the alcohol. The Digestive System. Chronic catarrhal gastritis is an almost constant affection in the chronic alcoholic. It is evidenced by anorexia, foul tongue and breath, constipation, nausea and vomiting, especially before eating in the morning, the so called "water brash." Often these symptoms are relieved by the day's first potation. The liver is subject to definite changes partly as a result of chronic over- indulgence in alcohol and from accessory products used in manufacture or from additional substances introduced in "blending." From these arise symptoms in accordance with the existing conditions of cirrhosis, fatty degeneration, etc. These changes by no means always occur but are fre- quent and as a result of the compression of the portal circulation, due to the cirrhosis and consequent contraction of the new interstitial tissue, various manifestations appear such as those due to congestion of the gastric mucous membrane, hemorrhages from the alimentary tract, haemorrhoids, splenic enlargement, etc. The characteristic facies of the alcoholic with its dilated veins, reddened nose — which is often the acne rosacea of the dermatologists — the swellings beneath the eyes and the icteric conjunctivae, usually accom- panies the disorders of the digestive tract and liver. From the changes in the circulatory system the symptoms due to cardiac, renal and arterial disease result. Of these vertigo, apoplectic seizures and the various other manifestations of arterial degeneration are most important. The Nervous System. Such symptoms as tremors of the hands and tongue and unsteadiness in the control of muscular acts are very common; the mental- ity is sluggish, the patient is irritable, restless and deteriorates morally; the memory is impaired and the intellect becomes weakened generally; finally dementia and insanity may supervene. Multiple peripheral neuritis is fre- quent and will be considered elsewhere. Epilepsy may also occur as a sequence CHRONIC ALCOHOLISM. 30I of chronic alcoholism but is likely to disappear with the resumption of proper habits. At times there develops with an alcoholic neuritis, and sometimes by itself, a peculiar condition characterized by hallucinations of sight, labial tremors, thickness of speech, impairment of memory, disordered ideas of time and space and imaginative explanations of actual incidents, to which the term psychosis polyneuritica or Korsakoff's disease has been applied. Changes in the nervous system are found after death but are not charac- teristic; of these hsemorrhagic pachymeningitis, thickenings and opacities of the pial and arachnoid membranes, and even, in advanced instances, en- cephalomeningitis with meningeal adhesions should be mentioned. Treatment. Chronic alcohoHsm can hardly be treated satisfactorily at the patient's home; success is far more readily attained at an institution where outside influences can be excluded, alcohol cannot be obtained unless con- sidered advisable by the physician in charge and the patient can be kept under the strict supervision of attendants. An excellent substitute for insti- tutional treatment is a prolonged sea voyage or a sojourn in the woods such as is afforded by a hunting or fishing trip where no alcohol is taken and the inebriate is associated with one or more congenial companions who are not drinkers. It is the present uniformly held belief that an entire withdrawal of the alcohol is better than a gradual "tapering off" unless the abstention results in an attack of delirium tremens, when it is usually necessary to aUow the drug in varying amount. The substitution of narcotics such as chloral, cocaine and the like for alcohol is to be unhesitatingly condemned. Sleepless- ness and nervousness may be controlled by the administration of the milder hj-pnotics such as the bromides, sulphonme thane (sulphonal), sulphon- ethylmethane (trional), veronal and paraldehyde. Morphine should not be used unless the patient's condition renders it absolutely necessary and other sedatives have failed. Even then it should not be prescribed as a routine but occasionally only, for the danger of acquiring the habit is great. Hyoscine hydrobromide has recently been advocated as an excellent means of allaying the desire for alcohol and the nervous symptoms which follow its suspension. It may, if necessary, be given to the physiological limit even to the production of dr\Tiess of the mouth and delirium. Doses of yw of a grain (0.0006) may be administered h}'podermatically every 2 or 3 hours until the nervous manifestations are relieved. These may be kept in a state of abatement by less frequent doses until the drug finally is entirely stopped. The much exploited gold cure and other advertised institutional treat- ments possess no special recommendation. The addition to the liquor taken by the patient of apomorphine or other substances and the hypodermatic administration of the former drug after drinking may produce a distaste for alcohol. It has also been asserted that hypodermatic doses of y^^-o" of a grain (0.0006) of atropine sulphate given 302 THE INTOXICATIONS. several times a day will shortly render alcohol distasteful to the patient and productive of emesis vi^ithout the addition of nauseating drugs. During treatment the patient's digestion should be kept in as good condition as possible, the bowels should be regulated by means of mild laxa- tives or by occasional purgation with fractional doses of calomel followed by a saline, and stomachic bitters together with such tonics as strychnine and cinchona are usful. Any tendency to circulatory failure must be combated by the ordinary means, strychnine, digitalis, etc. Acute syncope or collapse necessi|0,tes the hypodermatic administration of diffusible cardiac stimu- lants such as camphor and aether and of the aromatic spirit of ammonia or the compound spirit of aether by mouth. The diet should be nourishing, abundant and easily digestible. Tea and coffee, on account of their stimulant properties may be allowed. Delirium Tremens. Synonym. Mania a Potu. Definition. An effect of the prolonged use of alcohol characterized by delirium with hallucinations and extreme prostration. Symptoms. The syndrome delirium tremens is a result of the prolonged action of alcohol upon the cerebral cells but is often induced by a sudden withdrawal of the drug. Alcoholic excess in a temperate individual does not bring on an attack but a debauch may be followed, in the case of a chronic alcoholic, by typical mania a potu. Alcoholic subjects are very prone to attacks when prostrated by acute disease, particularly pneumonia. Delirium tremens is also a frequent consequence in alcoholics of a mental shock or physical injury such as a fractiured limb or other result of traumatism. Prevention may be possible, in the latter instances, by allowing these patients alcohol in moderate quantity. The onset of an attack is marked by sleeplessness, restlessness and depres- sion; these symptoms are shortly succeeded by a delirium characterized by hallucinations of sight and hearing. Talking is continuous and incoherent and restraint may be necessary, for the patient may desire to leave the house on imaginary business. The delusions of sight may take the form of animals rats, mice, snakes, insects, etc., which the patient imagines are pursuing him or crawling about his bed or over his body. The fear induced is intense and constant watching is necessary to prevent attempts to escape. The hallu- cinations of hearing are less usual but conversations with imaginary persons may be carried on, imaginary voices and noise may be heard. Muscular tremor is marked and sleep is impossible. There is extreme weakness and the pulse is soft, frequent, compressible and, perhaps, irregular. The tern- DELIRIUM TREMENS. 303 perature is elevated to 101° to 103° F. (38.3° to 39.5° C.) unless acute com- plications are present, when it is higher. The diagnosis is simple. The patient should be thoroughly examined when first seen for surgical injuries and daily physical examination of the lungs is necessary, for congestion at the bases is frequent and may develop into pneumonia; on the other hand pneumonia, especially that at the pulmonary apices may be accompanied by a delirium resembling that of mania a potu. Meningitis, a serous form of which {wet brain) is often present, simulates in its symptoms delirium tremens, but may be differentiated from the latter condition by an absence of alcoholic history and the patient's appearance. The prognosis varies, but, if there are no complications present, recovery usually takes place within a week, the hallucinations, sleeplessness and tremors gradually disappearing. In hospitals, however, the type of alcoholic subject generally observed is in a weakened and debilitated state and the death rate is consequently high, the patient gradually falling into the typhoid condition with feeble and dicrotic pulse, dry and cracked tongue, and low, muttering delirium; death from cardiac failure supervenes in a great number of instances. In patients who recover recurrences are common. Treatment. The patient should be put to bed in a quiet darkened room; alcohol should be withdrawn unless its administration is necessary to combat adynamia; even if there is marked cardiac weakness in many instances it is preferable to stimulate by means of ammonium which is best administered as the solution of the acetate (liquor ammonii acetatis) in doses of J an ounce (15.0) repeated every 2 or 3 hours if necessary. The aromatic spirit is also useful and may be given in doses of | to i drachm (2.0 to 4.0). Strychnine sulphate, -3V of a grain (0.002) or more if indications are present may be employed as well. The reUef of the sleeplessness is most important and may be accomplished by the administration of the bromides and chloral, J drachm (2.0) of sodium bromide with 10 to 15 grains (0.66 to i.o) of hydrated chloral often being sufficient. Chloral, however, should not be employed if there is tendency to heart weakness. The writer has obtained excellent results in his service in the alcoholic wards of Bellevue Hospital with paraldehyde in doses of 2 drachms (8.0) frequently repeated if necessary. Sulphonethylmethane (trional), in doses of 10 to 20 grains (0.66 to 1.33), is also useful and often acts well when given in combination with 5 grains (0.33) of veronal. If the delirium is uncontrollable by other means hyoscine hydrobromide — xio^ of a grain (0.0006) — may be given hypodermatically. Morphine should be administered with caution if at all; when all other measures fail it may he given hypodermatically in doses of j of a grain (0.016) but should seldom be repeated more than twice, the effects being watched with great care. Cold 304 THE INTOXICATIONS. baths and hot or cold packs, repeated if necessary, are often useful in the relief of the restlessness. If there are S3'mptoms indicating meningeal involvement (wet brain), such as stiffness and rigidity of the neck, etc., the ice helmet should be appHed. Restraint is often necessary to keep the patient in bed and here the employ- ment of a folded sheet placed across the body and pinned under the mattress is to be preferred to straps. At the beginning of the treatment the bowels should be freely moved and throughout the course of the affection the channels of elimination should be kept open by means of frequent draughts of water and laxatives when neces- sary. The patient's strength should be maintained by means of frequent feeding with easily digestible and assimilable foods such as milk, peptonized if pre- ferred, and nourishing soups. As the symptoms ameliorate a gradual return to ordinary diet should be allowed. CHLORALISM. The chloral habit is very easily acquired by individuals who have employed hydrated chloral in ordinary doses for even a short time for the relief of sleep- lessness or any other pm-pose, and, once established, produces serious results and is difficult of cure. Symptoms. The patient suffers from digestive disturbances and diar- rhoea, extreme mental and physical weakness with sudden flushings due to vaso-motor derangements, cardiac palpitation, and from erythematous eruptions, usually purplish in color, and especally affecting the face; sometimes they are found upon the mucous membranes. In some instances bed sores and ulcerations appear. Dyspnoea, due to depression of the heart action and the respiration and the general bodily weakness, is a marked symptom; the temperature is often subnormal. The patient sleeps only when under the influence of the accustomed hypnotic and death in collapse may at any time follow an over-dose, since by reason of the cumulative effects of the poison in the system the vital functions are greatly impaired and elimination is ren- dered impossible. Sudden withdrawal of the drug may cause symptoms analogous to those of deHrium tremens; such a condition is dangerous, as fatty degeneration of the heart is likely to be present. Treatment should be carried out upon the same lines as those to be described in dealing with the morphine habit. Isolation and careful attendance are necessary; stimulation of the heart by means of ammonia, strychnine and digitalis is indicated; the sleeplessness may be controlled by the bromides, sulphonmethane (sulphonal), sulphonethylmethane (trional) or veronal. SULPHONMETHLIXE (sULPHONAL) POISONING. 305 a combination of the t-n-o last consisting of 10 or 15 grains (0.66 to i.o) of trional to 5 grains (0.33) of veronal is often quite effectual. Morphine may be employed only as a last resort. Tonics, plenty of nourishing food and congenial occupations, together with electricity and massage are useful adjuncts to treatment. SULPHONMETHANE (SULPHONAL) POISONING. Fatal instances of poisoning by sulphonal have been reported as occiirring from small doses of this drug continued for long periods. The excretion of this substance seems to be slower than its absorption and consequently there is a tendency to a cumulative action. This may lead to gastritis, renal disease and certain not very clearly understood changes in the blood. As a result of the last there is a characteristic discoloration of the urine due to the presence in it of a reddish-brown pigment, hsmatoporphyrin, which is an iron- free product of tlie decomposition of hEemoglobin. This occurs chiefly in women and is associated with constipation, vomiting and gastric pain, weakness and ataxia, confusion and partial paralysis; eventually suppression of the urine, collapse and death may result. Though the continued use of the drug may not induce these grave manifestations it may be attended by severe functional distiorbances such as mental, moral and physical deterioration, indigestion, impaired nutrition and cutaneous eruptions. Enormous single doses have been known to cause paralysis of the sphincters, anuria, subnormal temperature and, as a late symptom, respirator}' depression. Treatment. The untoward effects of sulphonal can usually be avoided by intermitting its administration from time to time and by the daily use of the alkaline mineral waters either still or carbonated. ^Vhen toxic symptoms have appeared the drug should be stopped at once. The treatment otherwise is symptomatic and supportive. SULPHONETHYLMETHANE (TRIONAL) POISONING. The symptoms resulting from the continued use of trional are analogous to those of sulphonal poisoning. They consist of hebetude, drowsiness, anorexia, and muscular weakness; the frequency of the pulse is diminished and, in marked instances, vertigo, ataxia and more rarely hallucinations and delirium may be obser\-ed. Haematoporph}Tinuria occurs and upon its appearance the administration of the drug should be stopped. Treatment consists, as in sulphonal intoxication, of the employment of means to favor elimination and to support the patient. The symptoms should be combated as they arise by the indicated measures. 20 3o6 THE INTOXICATIONS. VERONAL POISONING. A few instances of poisoning due to this drug have been reported. In one patient its administration resulted in a febrile movement which lasted about a week, dryness of the mouth, a morbilliform rash upon the face, chest and arms, which later became confluent and was followed by a vesicular and bullous eruption upon the mucous membrane of the mouth and pharynx, conjunctivitis and aural pain. A dose of 24 grains (1.66) has produced the sympto9is of narcotic poisoning followed by a universal cutaneous erythema which recurred after a second dose and in addition the patient suffered from periodic delirium. The prolonged employment of veronal may result in the appearance of cerebral dulness, drowsiness, a staggering gait, nausea and vomiting and haematoporphyrinuria. Treatment consists in stopping the drug, alternation with hypnotics of other types, the administration of alkaline mineral water and securing a daily movement of the bowels. MORPHINISM. Synonyms. Morphino mania; The Morphine Habit, The morphine habit is often acquired by patients for whom the drug has been prescribed by a physician to control obstinate pain or sleeplessness, or more frequently from self-administration or certain patent medicines. It is particularly frequent among women who are affected with painful con- ditions and among physicians themselves. Individuals of neurotic tendency are more subject to the contraction of the habit than those whose nervous systems are stable, and heredity is a recognized predisposing aetiological factor. Alcoholics often become morphine habitues, the drug being first taken as an aid in the attempt to overcome the craving for liquor. The morphine is taken either by mouth or h)^odermatically, and, while certain subjects continue to take the same small quantity of the drug, the tendency is to gradually increase the amount until 30 grains (2.0) a day or even more are employed. In the East opium eating and smoking are as common as the use of tobacco is with us but the oriental constitution seems much better able to withstand the effects of the drug than does that of the Caucasian. Symptoms. The continued use of small doses of morphine may for a long time result in no marked manifestations other than a craving for the drug, but sooner or later the functions of both body and mind become affected. While under the influence of the morphine the patient may feel well, but as the effects disappear mental disquietude, depression, nausea and perhaps MORPHINISM. 307 colicky abdominal pain follow, which can be relieved only by further recourse to the drug. The character of the morphino maniac becomes deteriorated and is typified by lack of self-control and of moral sense — the subjects of the habit being notoriously untruthful — there is an irritability of temperament, sleeplessness is frequent, the appetite is poor and nutrition becomes impaired; the pulse is weak and rapid, sweating and itching of the skin are common and constipation is the rule. The appearance of the patient is somewhat typical, the skin being sallow, the pupils dilated and the facies prematurely aged; oedema of the limbs may be present. When under the influence of the drug the pupils are contracted and the mental and physical condition usually seems much more normal. Morphine habitues finally become subject to muscular tremors, and, women particularly, are likely to exhibit hysteric and neurasthenic symptoms. The deteriorated constitution becomes an easy prey to disease and usually the end comes as a result of intercurrent affection or of weakness induced by the lack of the maintenance of nutrition. Certain subjects live to moderate old age and even, though the habit is continued, are able to transact the usual duties of life; these, however, are generally the rare individuals who get along upon a small and not increased quantity of the drug. The prognosis is variable, depending upon the strength of character of the patient and upon his surroundings. Relapse is very common. Treatment. Much may be done by the physician in the way of prevention of the morphine habit. The indiscriminate prescribing of the drug cannot be too strongly condemned and it is a positive crime to put a hypodermatic syringe into the hands of a patient to be used in the control of pain or sleep- lessness. When morphine is indicated it is an invaluable drug, but it is best not to tell the patient that he is receiving it, and all prescriptions should be marked " not to be refilled without order of the physician." In the treatment of morphinism institutional seclusion is an absolute essen- tial, for the closest watchfulness upon the part of attendants cannot prevent the patient from procuring the drug if he is in his own home; even in institutions it is often dif&cult to prevent his access to morphine for friends may be per- suaded and servants bribed to obtain it for him. The treatment is one offering immense difficulties at best, on account of the degraded moral condition of the habitue and is very frequently unsuccessful in effecting a cure. Isolation is necessary and the patient should be watched with the utmost vigilance to prevent him from securing the drug surreptitiously. The morphine must not be withdrawn suddenly, since this is likely to be attended by collapse and aggravated mental disturbance, but the quantity should be gradually diminished until it is considered wise to stop it altogether, which can usually be done at the end of about a week. The withdrawal of the morphine is followed in many instances by diarrhoea, insomnia, irritability and extreme 3o8 THE INTOXICATIONS. mental and bodily depression. Medication is often necessary to combat these symptoms. Stimulation of the heart for weakness, if this is present, by means of ammonium, strychnine, digitahs or caffeine may be indicated; alcohol should not be employed on account of the possibility of inducing its habitual use; cocaine is contraindicated for the same reason. The gastric symptoms should be relieved by appropriate methods, and the same is true of constipa- tion and diarrhoea. The intestinal atony which is the cause of the former is best combated by the administration of physostigmine salicylate in doses of TTo" of a grain (0.0006) twice a day; the diarrhoea may be controlled by bismuth salicylate in 20 grain (1.33) doses every 4 hours or by other salts of this metal with vegetable astringents. The appetite may be stimulated by means of the vegetable bitters and by palatable and highly seasoned food, plenty of nourishment being an important consideration; plenty of milk and rich broths should be given. The insomnia and nervous irritability may be relieved by the bromides, sulphonmethane (sulphonal) in doses of 20 grains (1.33) in warm milk, sulphonethylmethane (trional) or veronal in doses of 10 to 15 grains (0.66 to i.o), chloral formamide (chloralamide) in doses of 15 grains (i.o). Hydrated chloral may be employed in emergency but the possibility of habit formation must not be forgotten; this drug is contraindicated in the presence of cardiac weakness. Hyoscine hydrobromide and morphine itself are sometimes necessary. The mental excitement may often be controlled by warm or cool baths or packs. Within the past few years treatment by means of the systematic admin- istration of hyoscine hydrobromide has been advocated. The patient is placed under the careful supervision of attendants, the morphine is stopped and hyoscine is given h^-podermatically in large quantity, even as much as Tw of a grain (0.0006) every 2 or 3 hours, until the restlessness and nervous irritability are under control. Sleep may not ensue but a condition of semi- stupor may be produced during which the patient often talks incoherently. The physiological effect of the drug as evidenced by dryness of the mouth may not be noticeable. The patient is kept under the influence of the hyoscine for several days until the more acute craving for morphine has disappeared, the effects of the drug are then allowed to wear off and in fortunate instances the patient may have been weaned from his habit. If there are signs of cardiac failure stimulation by means of strychnine is indicated. Rather remarkable cures have been reported as resulting from this treatment, but relapse is as common as after other forms. In conclusion it may be asserted that no known drug appears to possess any specific effect in controlling morphino mania; no reliance can be placed upon any of the advertised cures; most of these contain morphine and are consequently ineffectual, the others are made up of inert drugs and are frauds. HASCHISCH (cannabis INDICA) POISONING. 309 HASCHISCH (CANNABIS INDICA) POISONING. Haschisch is largely employed in the Orient as a stimulant of the psychic functions and its moderate use does not seem to be attended by injurious effects. When taken to excess it leads to tremor, loss of appetite, muscular weakness and sometimes to mania and dementia. In some severe instances convulsive attacks have been observed and among the natives of India cata- lepsy is said to occur at times. The drug, if employed by Caucasians, would probably cause more serious results than are usual among Orientals. Death from acute poisoning is rare, and recovery has taken place after very large doses. Shortly after the administration of the drug the patient experiences most pleasurable emotions, everything seems to amuse him, he becomes hilarious and indulges in actions which he realizes to be ridiculous; double consciousness is well marked. The patient is on the best of terms with those about him and passes into a dreamy, semi-conscious state in which he experiences ideas upon the most magnificent scale; time and space appear to be indefinitely extended. He may say brilliant or witty things but there is little relevance in his thought which changes rapidly from one subject to another. He experiences delightful visions; true hallucinations may be present. The general sensibility is much diminished and even complete anaesthesia may be noted. The pupil is usually somewhat dilated; later the dreams alternate with conscious periods and ultimately the patient falls into a quiet slumber from which he awakes without any sensation of depression, but refreshed and hungry. The effects of cannabis indica vary greatly in different individuals as a result of personal peculiarities or of variations in the strength of the drug. Dryness of the mouth, thirst and strangury are occasional untoward symptoms. Treatment. The treatment of acute poisoning by cannabis indica consists in emptying the stomach by lavage or emetics and the bowels by a purge; other- wise the management of the condition is symptomatic. In chronic haschisch intoxication the use of the drug should be stopped. Otherwise the treatment of the condition is symptomatic, eliminative and supportive. COCAINISM. The habitual use of cocaine is not at all infrequent. To it physicians are particularly prone, acquiring a desire for the effects of the drug as a result of its employment as a nasal or pharyngeal application. The habit may also be induced by the substitution of cocaine for morphine in the treatment of morphinomania. Cocainism is said to be quite common among the negroes in certain parts of the South. Neurotic individuals are more susceptible to this and other drug habits than persons of normal mental balance. 3IO THE INTOXICATIONS. Symptoms. The victim of cocainism rapidly becomes emaciated and is subject to attacks of syncope. Circulatory disturbances, a feeble, thready pulse, insomnia, ocular disorders such as amblyopia, mydriasis, and nystag- mus, mental failure and delusions not unlike those of chronic alcoholism may be observed. Visual and other hallucinations, usually of disagreeable char- acter are often present and one symptom which is regarded as typical of sub- acute or chronic intoxication with this drug is a sensation of crawling worms -or insects ("cocaine bugs") under the skin. Sometimes there is delirium or acute mania. There seems to be a degeneration of the central nervous system similar to that which occiurs in chronic morphinism. The moral deterioration which results is fully as marked as that observed in morphinomania. Cocaine is usually taken by hypodermatic injection; more rarely the powder itself is used as a snuff. Treatment. Cure is often difi&cult, particularly if the habit is associated with morphinism or alcoholism. Relapses are frequent. The most impor- tant point in treatment is the withdrawal of the drug; it must be remembered, however, that sudden stopping of it may cause profound collapse. The result is seldom successful unless the patient is confined in an institution for consid- erable time and placed under the care of competent and faithful attendants. Tonics and stimulants are indicated just as in the treatment of chronic mor- phine poisoning. Plenty of nourishing food is necessary and the nervous manifestations should be controlled as in morphinism. TOBACCO POISONING. The symptoms which result from the over-use of tobacco by smoking, chew- ing or snuff taking are chiefly referable to the digestive and nervous systems. The tongue is coated, the breath is foul and there is chronic catarrh of the pharynx and larynx; nausea, vomiting, flatulence and constipation are com- mon. Insomnia, muscular weakness, tremors and even ataxic symptoms mav be observed. Amblyopia and scotoma may develop and cardiac palpita- tion and irregularity {the tobacco heart), sometimes with anginal and asthmatic attacks, are frequent. In prolonged instances the skin becomes saUow and the body emaciated. Treatment consists in the absolute interdiction of the tobacco; this may cause marked nervous irritability and the craving for the drug for a few days is often very difficult to withstand. The sleeplessness and nervousness should be controlled by the bromides, sulphonmethane (sulphonal) or sulphon- ethylmethane (trional) and the cardiac condition may be relieved as sug- gested in the sections upon the treatment of cardiac irregularity and palpi- tation. The fluid extract of cactus grandiflorus made from the green plant, CARBON BISULPHIDE POISONING. 3II 30 drops (2.00) thrice daily usually relieves the latter symptom. Tonics and nom-ishing food are useful adjuncts to the treatment. The employment of apomorphine hydrochloride in doses of sV of a grain (0.002) every 2 hours, gradually increasing the amount until nausea is experi- enced, has been suggested. CARBON DISULPHIDE POISONING. This substance is employed in the arts and especially in the vulcanization of rubber. Individuals exposed to its fumes may become emaciated and affected with headache, vertigo, nervous excitement, incoordination of move- ment and depression of the special senses with impairment of sensation and motility. Insanity is said to result in some instances. Chronic intoxication may be evidenced by a neuritis with paralysis analogous to that occurring in plumbism. Carbon disulphide when directly inhaled excites violent coughing, and causes general anaesthesia with intense muscular rigidity. The drug is a powerful heart depressant, and even in small doses by mouth produces severe nausea and vomiting, with a burning sensation in the epigastrium, and a weak and rapid heart action. Treatment. Something may be done toward the prevention of carbon disulphide poisoning by effecting free ventilation of the rooms in which the substance is used. Inhalers have been suggested, but, unless they are so constructed as to separate the toxic fumes from the inspired air, can be of little value. The treatment of the affection is whoUy symptomatic. Phos- phorus may be employed to combat the nervous manifestations, LACQUER POISONING. Workers in lacquer, which is manufactured from the balsamic gum of Rhus vernicifera, are subject to a distressing poisoning, the manifestations of which are cutaneous. This form of intoxication is observed chiefly in China and Japan and occurs both as a result of contact with the lacquer in its raw state and from inhalation of the air of apartments in which newly lacquered articles are exposed. The symptoms appear within a few hours after association with the poisonous substance and are evidenced by intense pruritus of the skin of the face, arms and legs; cutaneous oedema follows and papules appear which later become vesicles containing a yellowish sero- ptirulent fluid. Coalescence of the vesicles may take place. A rise of tem- perature is observed in severe instances. If the eruption upon the face is intense in character the mucous membranes of the lips and conjunctivae may 312 THE INTOXICATIONS. be involved as well. The eruption is said not to appear upon the trunk, only the face, limbs and scrotum being subject to this manifestation. Treatment consists in the application of lotions calculated to allay the irritation. Of these lime water and a solution of sodium thiosulphate, I part to 8 should be effective. Dressings of the national formulary solution of alum-acetate may be applied if the pustulation is marked. FOOD POISONING. Various forms of food when decomposed, contaminated or improperly prepared may cause toxic symptoms. In great measure the symptoms pro- duced are caused by the presence of substances generated in the decom- position of organic matter. These have been termed ptomaines and occur in different types, some poisonous, others harmless; certain ptomaines may be innocuous under some conditions and under different circumstances markedly toxic. Meat 'Poisoning (kreotoxismus) follows the ingestion of decomposed flesh. The most frequent form is sausage poisoning (botulismus or allantiasis) and is probably due to the employment of improper methods of preparation. Ham poisoning sometimes occurs and other meats have been known to cause toxic symptoms. Among these may be mentioned beef, veal, mutton, fowl, etc. Cured meats are responsible as times, and while the tin or zinc hydrochloride derived from the cans may be at fault sometimes the meat itself is often at the bottom of the evil. Symptoms. These appear after an interval of from a few hours to a day or two and are evidenced by the manifestations of severe gastro-intestinal irritation. There are nausea, vomiting, abdominal pain and diarrhoea. The temperature is often elevated, and dryness of the mouth, thirst, dysphagia, headache, dizziness, dimness of sight and pupillary dilatation may be present; even delirium is observed at times. In instances which terminate in death the patient passes into a condition of collapse with muscular twitchings, coldness of the extremities and cardiac and respiratory depression. Poisoning by Fish (ichthyotoxismus) and Shell Fish. Certain fish are known not to be fit for food, while others, edible at ordinary times, are poison- ous during the spawning season. Diseased or decomposed fish, which in its normal condition and fresh is good to eat, may produce toxic symptoms under the former circumstances. SheU fish, particularly mussels, may also cause poisoning. In the latter instance the term mytilotoxismus has been applied to the condition. The poison is found chiefly in the liver of the bivalve and it is not known whether a certain species is always toxic or ordinary mussels become poisonous under special circumstances. GRAIN POISONING. 313 Symptoms. Fish poisoning is marked by similar manifestations to those of meat intoxication. The symptoms are often intense and a generalized scarlatiniform rash may appear. Mussel poisoning is evidenced by marked gastro-enteric irritation and fre- quently by the development of an urticarial eruption which may become vesicular; marked oedema of the eyelids is not uncommon. In frequent instances nervous symptoms such as convulsions, paralysis, delirium and coma are observed; death is not rare and in another type of case may be pre- ceded by rapid respiration and heart action, numbness and coldness of the extremities, dilated pupils, and collapse. Poisoning by Dairy Products. Milk intoxication (galacfotoxismus) may follow the ingestion of decomposed milk, and poisoning from cheese and ice cream (tyrotoxisnius) may result from the presence of a ptomaine (tyrotoxicon) which has been isolated by Vaughan. Symptoms. These are those of marked gastro-intestinal irritation anal- ogous to that of meat poisoning. Treatment of Food Intoxication. The first indication is to remove the poisonous substance from the digestive tract. The vomiting induced by the presence of the offending food is usually sufficient to relieve the stomach of its contents but if not we should have recourse to gastric lavage. The intestine should be emptied by repeated fractional doses of calomel followed by a saline. The abdominal cramps may be relieved by the application of hot water bags or compresses and by the hypodermatic injection of morphine if necessary. The tendency to collapse should be combated by the hypoder- matic administration of alcohol and strychnine and, when the gastric irrita- tion has passed, by stimulants by mouth. Feeding should be begun with care, milk diluted with one of the carbonated waters being first allowed. The treatment in other regards is symptomatic. GRAIN POISONING. The employment of various kinds of diseased or decayed grain as food is a common source of intoxication in certain countries. Ergotism occurs among the lower classes in Europe where, after poor har- vests, the indigent are obliged to use bread made with rye contaminated with the sclerotium, an intermediate stage of development of the claviceps purpura, a fungus which attacks the rye grain. The disease is less common now than formerly. Symptoms. Two types of ergotism are recognized, (i) The gangrenous jortn, which is characterized by an onset similar to that of the convulsive type, which is to be described in a later paragraph. In from a few days to 314 THE INTOXICATIONS. a month a redness, akin to that of erysipelas, appears in the fingers, toes or upon the nose or ears. Subsequently a dry gangrene usually develops, but in certain instances the wet type of the affection appears. The process may involve an entire extremity or affect merely a finger or toe. The gangrene is due to vascular contraction with stasis of the blood current and coagula- tion and hyaline thrombosis. (2) The convulsive form. The difference in the varieties of ergotism are explained by the different actions of the constituents of the ergot and by the fact that they may act in part directly upon the blood-vessels and in part directly upon the central nervous system. In some epidemics both the gan- grenous and convulsive forms have been observed but usually one has been much more prevalent than the other. The onset of the affection is marked by anxiety and weariness, gastro-in- testinal irritation, and sometimes by a slight rise in temperatiu-e. There is a sensation of formication, itching and tingling of the surface, chiefly on the fingers and toes; these manifestations are followed by numbness and local anaesthesia. Sometimes anaesthesia and hyperaesthesia are found at the same time in different parts or even in the same part; these symptoms begin in the extremities and spread thence over the whole body. The sensory disturbance may affect the digestive tract so that there may be present either voracious hunger or anorexia. At the same time there are marked weakness and depression, often with severe headache and vertigo as well as central disturbances of the special senses, such as impairment of sight and hearing. Convulsions may follow, usually clonic in character and often epileptiform; subsequently contractures in the muscles of the limbs and sometimes in those of the trunk may develop. Formerly the disease was immediately fatal in a large proportion of cases and when recovery took place it was likely to be associated with more or less loss of intellectual power and, in some instances, with complete dementia. Treatment. Ergotism may be wholly prevented by inspection of the rye used for flour and by destroying all suspicious grain. The treatment consists in stopping the unwholesome food and substituting that which is wholesome. The symptoms should be treated as indicated. For the muscular contrac- tures massage, hot bathing and electricity are useful. Pellagra is due to the use of diseased maize as a food. Not only does the affection result from eating the grain itself but it may also follow the use of products made from the corn. A ptomaine which causes analogous symptoms in animals has been extracted from the meal of diseased maize and from the fungi which affect the grain a body which will also cause the s}Tiiptoms of pellagra has been isolated. Pellagra occurs in Italy, Hungary, Southern France, Spain, Mexico and Yucatan. Adults are chiefly attacked although children may also be affected. Alcoholism is believed to be a very potent GRAIN POISONING. 315 predisposing factor. Poor general condition and malaria also predispose to the affection. Symptoms. The disease, in most instances, is first evidenced by weakness, malaise, indigestion, and pain in the head and back; sleeplessness is common and there may be mental disorder. These symptoms usually appear in winter and with the appearance of spring the typical manifestations of pellagra show themselves. These consist of an erythematous eruption which is fol- lowed by scaling and wrinkling of the skin, particularly that of parts which are not covered by clothing; the usual duration of the rash is several weeks, desquamation then takes place leaving the skin thickened and scaly. With the cutaneous symptoms there are digestive disorders such as salivation, loss of appetite, flatulence and diarrhoea. With the incidence of summer amelioration takes place but there is a recurrence of the symptoms with the following spring. The sequence of improvement in summer and relapses in the spring continues until the patient becomes affected with a chronic cachexia with which various nervous manifestations are associated; spastic paralyses of the lower limbs with atrophy and contractures occur and the deep reflexes are exaggerated. Dorsal and cephalic pain, girdle sensations and tingling and itching of the skin are observed. The special senses are impaired. Mental symptoms are common; the patient is melancholic and may attempt suicide, mania is sometimes noted and the final stage of the affection is a permanent dementia. In the protracted instances of the disease the patient has the appearance of premature old age with marked cachexia. The prognosis as to recovery after several successive attacks is unfavorable; the course of the affection may be prolonged for 12 or 15 years. Treatment. As a preventive measure no diseased corn should be used as food or in the manufacture of other products. A rigid inspection of all maize should be instituted and suspicious grain should be destroyed, Alcohol should be forbidden. Strychnine and quinine in large doses and especially arsenic are recommended. The symptoms referable to the motor system necessitate the employment of hot baths, massage and electricity. The affected cutaneous areas should be anointed with oily substances to prevent, if possible, the thickening and stiffening of the skin, and the itching may be relieved by the application of various antipruritics. Lathyrism, Lupinosis or Chick-pea Disease is an affection due to the use as food of chick-peas or vetches, particularly the varieties lathyrus sativus, lathyrus cicera and lathyrus clymenum. The peas themselves cause the disease, decay being of no influence in its production. The intoxication is observed in Italy, France, Algiers and India where meal from the chick-pea is mixed with the flour of barley or wheat. Exposure to cold and wet is considered to be a predisposing factor in the causation of the affection. Symptoms. There is sometimes a prodromal stage characterized by gastro- 3l6 THE INTOXICATIONS. intestinal irritation with gastric disturbance, diarrhoea and a rise of tempera- ture; following this there is pain in the back and legs with tremors and weakness. Later a condition of spastic paralysis, which may continue to complete para- plegia, develops. There are no disturbances of sensation and the sphincters are rarely involved. The reflexes are increased. The arms are not affected. Lathyrism seldom results fatally but the course of the affection is pro- tracted and the paralysis is, as a rule, permanent. Treatment consists in the avoidance of chick-pea meal as a food and in the employment of means calculated to relieve the symptoms. Strong counter- irritation over the lumbar region is recommended. Atryplicism is the term applied to poisoning resulting from eating the coast orach. In China the atriplex augustissima and the atriplex serrata are used by the natives as food, either raw or cooked in dough. The intoxi- cation is characterized by the appearance, within 12 to 24 hours, of numb- ness, coldness and tingling in the fingers and dorsa of the hands. Pruritus and oedema foUow and spread to the elbow. Later the face is affected. The symptoms persist for several days and are foUowed by desquamation. In marked instances vesicles which may ulcerate appear and gangrene of the fingers has been observed. The resemblance of this condition to erythromel- algia has been remarked. Treatment. The offending substance should be removed from the intes- tinal tract by inducing free movements of the bowels. The local manifes- tations may be relieved by the application of soothing lotions. THE EFFECTS OF EXPOSURE TO HIGH TEMPERATURES. HEAT EXHAUSTION. Definition. A condition of prostration characterized by a tendency to syencop, vasomotor paralysis and subnormal temperature and resulting from over-exertion under high temperature. Exposure to the direct rays of the sun is unnecessary in the production of this affection since it may be due to the influence of artificial heart, such as that of the stoke holes of steamships. It may occur in infants during hot weather. Symptoms. These consist of intense bodily weakness and in the more marked instances, of syncope, pallor, vertigo, impairment of vision, and cold- ness of the surface. There is a clammy perspiration. The unconscious- ness which often results is usually followed by sleep from which the patient wakes within an hour or two in a normal condition. In intense cases the collapse is more marked, the heart action is depressed, the perspiration continues and is accompanied by restlessness and even delirium. The temperature may fall as low as 95° F. (35° C). SUN-STROKE. 317 Heat exhaustion is easily differentiated from true sun-stroke by the fact that in the former condition the bodily temperature is below the normal, In an ordinary attack of fainting the drop in temperature is less extreme. Treatment. The patient should be placed upon his back with the head only slightly if at all elevated. Stimulation may be administered by mouth or, if the condition necessitates its more immediate action, hypodermatically. The diffusible stimulants are to be preferred, alcohol and ammonium usually being quickly available; strychnine also may be employed. For the lowered temperatiire frictions should be instituted and hot-water bags or hot com- presses should be applied to the body and extremities. SUN-STROKE. Synonyms. Thermic Fever; Insolation; Siriasis; Coup de Soleil. Definition. A condition caused by exposure to extremes of heat and char- acterized by prostration and high fever. .Etiology. Sun-stroke is comnion in the United States during the hot months among those whose occupations necessitate prolonged exposure to the rays of the sun or who are employed under shelter where the temperature is markedly high, as in the fire-rooms of steamers, bakeries, sugar refineries, laundries, etc. Soldiers on the march are frequent sufferers. Alcoholic individuals and those of plethoric habit seem especially prone to the affection. The infectious origin of sun-stroke has been suggested upon the ground that it occurs in epidemics in certain localities and more particu- larly in those unaccustomed to extraordinary temperatures. Pathology. The genesis of thermic fever is explained upon the ground that when exposed to the effects of high temperature the heat center is so affected that it cannot rid the organism of the rapidly accumulating heat. As a result of this impairment of the elimination of heat the body temperature rises. Finally the heat center becomes exhausted in its effort to control heat production, or paralyzed by the action of the excessive temperature already reached; all at once the tissues begin to form heat with great rapidity, the bodily temperature suddenly rises and the organism is overwhelmed. After death the body retains its heat for a considerable time; rigor mortis and decay occur rapidly and the blood seldom coagulates. There is universal venous congestion, this being particularly marked in the cerebrum and lungs. The left ventricle of the heart is contracted and the right is in a condition of dilatation. There may be parenchymatous degeneration of the liver and kidneys. Symptoms. The initiatory manifestations are usually a sensation of in- tense heat, headache, vertigo, oppression and sometimes nausea, vomiting and diarrhoea. Colored vision {chromatopsia) may be experienced. Uncon- 3l8 THE INTOXICATIONS. sciousness with marked restlessness and even delirium may follow. The skin is flushed, hot and dry, the temperature ranges from 104° to 112° F. (40° to 44° C.) or even higher, the pulse is rapid and fuU, the respiration difficult and perhaps stertorous. There is pupillar}' dilatation in the early stages, later contraction is present. In most instances the muscles are re- laxed, but twitchings or even epileptiform convulsions are sometimes observed. Perspiration may reappear as a late symptom but has no influence in lessening the height of the temperature. The urine is diminished and may contain albumjn. In favorable instances a faU in the bodily temperature is accom- panied by a remission of the other symptoms. Complete recovery may ensue or the patient may be left -^dth nerv'ous and mental disturbances varying from simple loss of memor}^ to insanity. A common sequel is an inabihty to endure even slight degrees of heat; individuals possessing this idiosyncrasy may become very uncomfortable at as low a temperature as 80° F. (26.7° C). In fatal sim-stroke the temperature remains high, the unconsciousness becomes more profound, the heart weakens, the respiration becomes rapid and shaUow and death supervenes, usuaUy in from 12 to 36 hours. In another tj-pe of the affection the patient may die suddenly or within a short time after the onset with the symptoms of cardiac failure such as rapid and almost imper- ceptible piflse, marked dyspnoea and coma. The "continued thermic fever,'^ " Florida fever, ''^ '^country fever" or " fievre inflamtnatoire" which occurs in warm and tropical climates is a continued fever which has been attributed to prolonged exposure to a high temperature although of late its septic origin has been suggested. The condition may be difficult of separation from enteric and malarial fevers. The prognosis varies with the t}-pe of the affection; the milder instances almost invariably recover under proper treatment. Treatment. Prevention of sun-stroke consists in the avoidance of extremes of heat and abstinence from alcohol, over-eating and over- work; plenty of water should be taken, frequent baths are advisable and the clothing should be light. In treating thermic fever the first indication is to lower the temperature as rapidly as possible. If a bath tub is available the patient should be immer- sed in cool water and rubbed vigorously with lumps of ice in the hands of at least t^'o attendants. If no tub is at hand the patient should be placed in the shade, if in the open air, and cool water should be dashed upon him. If tubbing is impossible for other reasons ice water enemata or the ice pack may be substituted for this procedure; sprinkle baths from a watering can held at a considerable height or from a hose are often beneficial, probably from the stimulation effected by the impact of the water against the body as well as from the reduction of temperature which results. The tempera- ture should be taken at frequent intervals and when it has reached 102° F. SUN-STROKE. 319 (38.9° C.) the hydriatic measures should be stopped, for otherwise the tem- perature is likely to fall to a subnormal level and collapse may result. The patient should now be put to bed, given a cathartic and catheterized if nec- essary; he should remain in bed and on a light diet for a few days. Subse- quent rises of temperature may be controlled by cold sponging or tub baths if necessary; the coal tar antipyretics may also be employed. Syncope may be controlled by hypodermatic injections of brandy or whiskey; aether, ammonium and strychnine may also be employed. Artificial respiration is sometimes necessary. In the rapidly fatal instances with symptoms of asphyxia, venesection should be performed. Convulsions should be controlled by chloroform inhalations. The treatment of the consequences of thermic fever is symptomatic. 320 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. CHAPTER IV. DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. , DISEASES OF THE MOUTH AND TONGUE. Of the more usual forms of stomatitis, since the treatment of all is practi- cally the same, mycotic stomatitis will be taken as a type. MYCOTIC STOMATITIS. Synonyms. Thrush; Parasitic Stomatitis; Sprue. Definition. An inflammation of the buccal and phar}mgeal mucous mem- branes characterized by whitish deposits. ^Etiology. The inflammation is due to the gro'Rl;h and development upon the lining of the mouth and pharynx of a fungus, the oidium albicans or the saccharomyces. Thrush occurs chiefly in nursing children and is especially predisposed to by poor physical conditions, unhealthy surround- ings and the use of unclean nipples and nursing bottles. Pathology. The oidium albicans grows upon the mucous membrane in the form of numerous scattered tiny grayish- white spots. These may coalesce and form areas covering, in rare cases, almost the entire buccal lining and involving the oesophagus. Around these whitish spots is a reddened areola and they are somewhat adherent to the mucous membrane but may be detached, leaving a surface intact or eroded. Symptoms. These consist of the presence of the aheady described spots and of those of the accompanying physical condition. The mouth is likely to be dry and should there be any doubt about the diagnosis it can readily be assured by recourse to the microscope. The Treatment of Stomatitis. Infants in almost all cases may be prevented from acquiring stomatitis by proper attention to the cleanliness of rubber nipples, nursing bottles, etc. The nipples should be boiled daily in a solution of washing soda and should be kept in a boric acid or sodium salicylate solu- tion. The child's mouth should be cleansed by means of the finger vsrapped about w^ith a bit of absorbent cotton and moistened with saturated boric acid solution or a solution of baking soda. Such methods should prevent the occurrence of sprue. When the disease is present the above mentioned means shoiild be employed and in addition the lining of the mouth should be gently painted 3 or 4 times a day with a camel's hair brush dipped in a i to 3 percent. GANGRENOUS STOMATITIS. 32 1 solution of silver nitrate, or a 5 percent, solution of alum. In obstinate cases it may be well to give the mouth a few days complete rest and feed through the nasal tube, at the same time employing local treatment as above. The various forms of stomatitis in adults, including the mercurial variety, should be treated by strict attention to the hygiene of the mouth; the abuse of alcohol and tobacco shoiild be stopped, the teeth should be frequently brushed and otherwise properly cared for. The frequent use of mildly anti- septic fluids such as liquor antisepticus, etc., is to be recommended. Tincture of myrrh is a pleasant mouth wash used in strength of 2 teaspoonsful to the tumbler of water and a saturated solution of potassium chlorate is useful for the same purpose. The ulcers of aphthous stomatitis may be painted with 3 percent, silver nitrate solution or gently touched with the silver nitrate stick. In the treatment of the various forms of stomatitis the general bodily con- dition must not be neglected. Proper food, exercise, fresh air, etc., should be advised; tonics such as iron, nux vomica, codliver oil and the like may be necessary. In mecurial stomatitis the administration of the mercury should be stopped and treatment, such as that described above, instituted. GANGRENOUS STOMATITIS. Synonyms. Noma; Cancrum Oris. Definition. An inflammation usually affecting the cheek at the angle of the mouth and spreading outward. It is characterized by infiltration, followed by necrosis and gangrene of the tissues involved. .Etiology. The disease is probably of microbic origin; it is usually seen in young children who have been brought up in unsanitary surroundings and are in poor physical condition. It is rarely primary but as a rule is secondary to attacks of measles, scarlatina or other acute infectious diseases. Pathology. The process consists first of a brawny infiltration of the tissues, followed by a slowly spreading gangrene which may go on to perforation of the cheek or involvement of the jaw. Rarely does the gangrenous tissue separate spontaneously, the process usually advancing until terminated by death. Symptoms. The first local manifestation is a dark spot upon the lip or cheek, but usually the condition is well advanced before the diagnosis is made. There is a characteristically foul breath and the odor of the sloughing surface is often very foetid; as the disease advances the eye or ear may become involved and the neighboring lymph ganglia are enlarged. The pain of noma is usu- ally slight. When the disease is well established in its course the temperature is typical of sepsis, the pulse rapid and weak, and the appearance one of great prostra- 32 2 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. tion. There may be gastro-intestinal disturbances due to the swallowing of the discharge from the inflammatory area, or septic pneumonia due to its inhalation. The course of the disease is rapid, lasting about a week or ten days. The mortality is high^ 75 percent, of cases ending fatally. Treatment. The prophylaxis of noma consists in the proper treatment of the ordinary forms of stomatitis and attention to the condition of the mouth during the course of all infectious diseases. The neglect of this latter is inexcusable, and too great stress cannot be laid upon the necessity for the frequent use of cleansing and antiseptic solutions upon the mouths and tongues of patients suffering from scarlatina, diphtheria, measles and the other infec- tions. Gases of noma should be isolated and the treatment of the disease itself must, from the start, be most radical. Total excision of the inflammatory area with the knife, or cauterization by means of the Paquelin cautery are methods which have been in common use and in a combination of the two we have the most efi&cacious means of treatment. The excision should be performed with the patient under a general anaesthetic and the excision should be extended well beyond the diseased area. After excision the cautery shotfld be applied to the edges of the wound. The use of nitric acid or scrap- ing away the diseased tissues is not to be recommended when the more rad- ical procedure is possible. The treatment otherwise than by operation consists in stimulation as indicated, keeping the sloughing surface and the mouth cleansed by means of antiseptic solutions such as hydrogen dioxide, potassium permanganate, etc., and instituting a nourishing diet. The serum therapeusis of noma is as yet not upon sufficiently firm basis to be employed to the exclusion of surgical measures, although cases have been reported in which antidiphtheritic and antistreptococcus serum have been used with favorable results. GEOGRAPHICAL TONGUE. Synonyms. Pityriasis of the Tongue; Eczema of the Tongue. This condition is evidenced by one or more grayish, slightly elevated spots upon the mucous membrane of the tongue. These areas may be of varying size and usually involve only the dorsum of the organ, they tend to spread peripherally, producing patches which may unite and, bounded as they are by a slightly elevated border, have given rise to the map-like appearance known as the "geographical tongue." The patches at times heal and disappear but seldom fail to recur from time to time. The symptoms are not marked, itching and burning sensations being, as a rule, all that causes the patient to complain. There may be an accompanying increase in the salivary secretion. LEUCOPLAKIA BUCCALIS. 323 Treatment. The disease is not of malignant character although it is difficult of treatment. The general condition and especially the digestion of the patient should be looked to and proper diet and mode of life insisted upon. Tonics are useful in enfeebled conditions. Arsenic may be given and the use of astringent and antiseptic applications is indicated. Silver nitrate (3 percent.), chromic acid (i percent.) and weak iodine solutions may be applied by means of a brush, and mouth washes of weak boric acid or tincture of myrrh may be employed. An ointment of boric acid and balsam of Peru in vaseline has been recom- mended, and Unna advises applications of sulphiir either in the form of a natural water containing this substance, or, preferably, in his opinion, washed sulphur in an emulsion. LEUCOPLAKIA BUCCALIS. Synonyms. Lingual Ichthyosis; Lingual Psoriasis; Leucoplasia; Smoker's Tongue; Chronic Superficial Glossitis. Definition. A disease of the mucous membrane lining the mouth charac- terized by whitish patches of irregular size, which at times are thickened and tend to fissure. ^Etiology. The actual causation of this condition is not known; while it has been ascribed to syphilitic disease it has been known to occur in non- luetic individuals; the existence of mercurial stomatitis, excessive smoking, uncleanly buccal and dental conditions and gastro-intestinal diseases seem to be predisposing factors. Leucoplakia is most often seen in males beyond middle-life, and is said to predispose to epithelioma. Symptoms. The first indication of the disease is a hardly noticeable reddish or bluish patch, which may be sensitive to hot or irritating foods. Very slowly and gradually the reddish spot develops into a rounded or irregular patch, whitish or pearly in color. Several of these, while small at their incep- tion, may coalesce as they increase in size. The affected areas become thick- ened and stiff, have a hard surface and may become fissured. The dorsum of the tongue is most usually the site of the lesion but it may occur upon other parts of this organ, upon the lining of the cheeks or even upon the lips. Treatment consists in establishing a cleanly condition of the mouth, stop- ping the use of tobacco, and proper care of the teeth. Antiseptic and astrin- gent mouth washes are indicated and the patches should be touched with a 10 percent, silver nitrate solution, or better with the lunar caustic, once every ten days or so. The galvanocautery has been used with benefit as also has a 20 percent, solution of pure chromic acid. A paste consisting of resorcinol 4 parts, zinc oxide i part, benzoated lard to 8 parts applied to the plaques will cause them to exfoliate and is recommended by certain dermatologists. 324 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Syphilitic treatment accomplishes little in the treatment of leucoplakia buccalis proper but when the diagnosis is in doubt the employment of mercury and the iodides is indicated. Treatment calculated to correct any accom- panying digestive or assimilative disorder which may be present should benefit the buccal condition. DISEASES OF THE SALIVARY GLANDS. , PTYALISM. Ptyahsm or increased secretion of the saliva occurs as a symptom in poison- ing by mercury, iodine, gold and copper. It may also be produced by jabor- andi, muscarine and tobacco. Excessive salivary secretion is often a symptom of various forms of stomatitis and in children may occur as a neurosis. The treatment consists in the proper management of the astiologic condi- tion if due to stomatitis and in the stopping of whatever drug may be causative of the disturbance, together with measures calculated to remove whatever of the substance may be retained in the system. Such are the administra- tion of saUne purges if the salivation be due to mercury, or sodium bicar- bonate if it be the result of iodism. Mouth washes, such as a saturated solu- tion of potassium chlorate, are useful and atropine may be given with a view to the diminution of the activity of the salivary glands. DRY MOUTH. This condition, sometimes also called xerostomia, is usually seen in febrile conditions but may occur independently. It is met most frequently in hyster- ical women and may appear after nervous shock. The symptoms are dryness of the mouth and a smooth, shining condition of its mucous membranes which are redder than normal in color. The treatment is that of the nervous condition, as a result of which the xerostomia has appeared, and the use of mouth washes containing lemon juice. ACUTE PAROTITIS. Infectious parotitis has been discussed in the section upon the infectious diseases. Inflammations of the parotid gland, other than mumps, may occur as a complication of the acute infectious diseases (especially typhoid fever), pneu- monia, pyaemia and syphilitic disease, associated with diseases or injuries of the pelvic or abdominal viscera or genital organs; accompanying neuritis of the facial nerve and in poisoning by sulphuric acid. The inflammation is usually the result of microbic infection which may be transmitted through ludwig's angina. 325 the blood current or directly through the duct of the gland. The parotitis accompanying facial neuritis is in all probability the result of some vasomotor abnormality. The symptoms of the condition are localized pain, tenderness and swelling. The salivary secretion may be increased. Abscess formation may ensue with an accompanying temperature of septic type and increased pain and prostration. Treatment consists in the attempt to prevent abscess formation by means of leeches, the ice compress or coil. The coal tar analgesics, especially anti- pyrine salicylate (salipyrine) may be given to relieve the pain and aconite may be administered unless the circulation is depressed by the causative infection. As soon as abscess formation is evident an incision should be made and the pus evacuated. Chronic or subacute inflammations of the gland which may occur as accompaniments of mercurial or lead poisoning, in syphilis, or following acute inflammations, should be treated by inunctions of blue ointment, 10 percent, ichthyol in vaseline, compound iodine or iodine vasogen ointment. LUDWIG'S ANGINA. Synonyms. Angina Ludovici; Cellulitis of the Neck. This condition is an inflammation of the floor of the mouth beginning in or about the submaxillary gland. It begins usually on one side, later spreading to the other and is usually a complication of one of the acute infectious diseases; rarely it may be primary. It is a pyogenic infection and spreads through the tissues of the floor of the mouth and the throat. Sloughing of the soft parts or abscess formation may follow; in rare cases spontaneous resolution may take place. The symptoms are pain, tenderness and swelling in the floor of the mouth, later in the neck, and dyspnoea if the larynx or trachea is pressed upon by the tumor. (Edema of the glottis may occur. The abscess may point either externally or internaUy and the constitutional symptoms are those of pus infection in general. The treatment consists in the early application of leeches or cold in the form of compresses or the ice coil. Surgical measures are likely to be sooner or later necessary and consist in free incision and evacuation of the pus. DISEASES OF THE TONSILS AND PHARYNX. ACUTE CATARRHAL PHARYNGITIS. Synonyms. Angina; Sore Throat. Definition. A catarrhal inflammation of the mucous membrane lining the pharynx. -Etiology. Certain persons appear to have a predisposition to frequent 326 DISEASES OP THE DIGESTIVE SYSTEM AND PERITONEUM. attacks of sore throat. The exciting cause is usually exposure to cold and dampness, although the condition may be caused by the inhalation of irrita- ting dust or vapors. The inflammation often occurs in individuals of gouty or rheumatic tendency, and is frequently associated with acute inflammations of the nasal mucous membrane and tonsils. Pathology. As in all acute inflammations of mucous membranes, the pharyngeal lining and the uvula are at first dry, congested and swollen, after a number of hours or a day or two there is an excessive secretion of mucus which may be either thin and watery or thick and viscid. S3miptoms. There is usually a considerable rise in temperature, preceded by chilly feelings and general pains; the local symptoms consist first of a dry- ness of the throat, with discomfort or actual pain on swallowing. If the inflammation involves the larynx or Eustachian tubes there will be hoarseness and slight cough, or fullness in the head and varying degrees of impairment of the hearing. On examination the throat is seen to be red and swollen; or covered by the excess of mucous secretion. Accompanying the inflam- mation various tonsillar conditions may be observed. Treatment. If seen early the patient should be given a Dover's powder, his bowels should be freely opened by repeated small doses of calomel (J to ^ a grain — 0.016 to 0.032) followed by a saline and he should be put to bed. The general bodily pain may be relieved by antipyrine salicylate (salipyrine) in doses of 10 grains (0.66) every 2 or 3 hours until efficacious. This drug also will have in addition an antipyretic effect and the fact that it contains the salicyl radical ' makes it especially advantageous in rheumatic patients. Phenyl salicylate in doses of 5 to 10 grains (0.33 to 0.66) every 3 or 4 hours and salicin are also useful in this connection. Aconite is of use in controlling the fever and also benefits the local condi- tion. The tincture may be given in 4 minim (0.25) doses every hour or two or 4^0^ of a grain (0.00016) of aconitine may be administered every 4 hours. These drugs should be stopped as soon as their physiological effect is evident, as manifested by numbness and tingling of the fauces. The pain in the throat may be lessened by the application of frequently changed hot or cold compresses, flax seed poultices or in severe cases by a mild mustard paste. The pharyngeal discomfort and the local inflammation are amenable to treatment by various means such as tablets to be dissolved in the mouth, gargles, direct applications and sprays. Tablets. I^, potassi chloratis gr. xv (i.o), olei menthae piperitse fx iii (0.20), extracti kramerise gr. XV (1.0), extracti glycyrrhizse 5iss (6.oj; massa fiat et div. in trochiscos no. XXX. I^, codeinse gr. iii (0.20), extracti gambis gr. xx (1.33), extracti glycyr- rhizag 5iss (6.0); massa fiat et div. in trochiscos no. xx. I^, cocainse hydro- chloridi gr. -jV (0.002), antipyrine gr. ii (0.12), sacchari lactis et aquae destillatae q. s., fiat tales trochiscos no. xx. I^, ammonii hydrochloridi gr. xx ACUTE FOLLICULAR TONSILLITIS. 327 (1.33), pulveris ipecacuanhae gr. i (0.065), pulveris capsici gr J (0.015), extract! glycyrrhizse 5" (8-o); massa fiat et div. in trochiscos no. xx; of any of the foregoing tablets one may be dissolved in the mouth every 2 or 3 hours. The first formula is indicated in moderate pharyngeal inflammations, the second and third when pain and irritating cough are present and the fourth when the pharynx is covered with thick and tenacious secretion. Small pieces of cracked ice held and allowed to dissolve in the mouth are agreeable when the pharynx is dry and painful. Gargles are unsatisfactory as it is very difi&cult to reach with them the site of the inflammation but they may be used by patients to whom the atomizer spray is disagreeable. Various sprays may be prescribed. The following will be found useful; potassium chlorate 5 grains (0.33); alum 5 grains (0.33); tannic acid 5 grains (0.33) or tincture of iron chloride 10 drops (0.66) to the ounce (30.0) of water. Direct applications by means of a camel's hair brush of (a) equal parts of glycerin and tincture of iron chloride, (b) glycerole of tannin or (c) silver nitrate 10 to 15 parts to 480 of water may be employed. In the severe cases quick relief will usually follow the use of astringent sprays of which any of the following is applicable; zinc chloride or zinc sul- phate I part to 24 of liquor antisepticus; iron and ammonium sulphate 6 parts, glycerite of tannic acid 6 parts; or silver nitrate i part to 48 parts of water. These may be sprayed into the throat by means of an ordinary atomizer, first having cleansed the parts of mucus by means of an alkaline solution such as dilute liquor antisepticus, every hour or two during the acute stage of the inflammation, the intervals being lengthened as recovery progresses. Sprays of oily solutions such as oil of sandal wood i part or eucalyptol 2 parts to 100 parts of liquid albolene are often soothing to the dry and irri- table throat. An important adjunct to the management of acute pharyngitis is the proper treatment of accompanying nasal, tonsillar or laryngeal inflammations. ACUTE FOLLICULAR TONSILLITIS. Synonyms. Acute Lacunar Tonsillitis; Angina FoUicularis; Ulcerative Tonsillitis. Definition. An acute exudative inflammation characterized by the appear- ance of whitish-yellow spots upon tonsils. iEtiology. The direct cause of this condition is doubtless a microbic infec- tion probably due to one of the commoner pyogenic bacteria. It is prone to attack the enlarged tonsil, and the exciting cause is usually undue exposure. Some persons seem predisposed to this disease. It is frequently seen in children. 328 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Pathology. The tonsils are red, congested and swollen; their crypts are filled with plugs consisting of mucus, pus, epithelium and bacteria. There is no true ulceration but occasionally one or more of the tonsillar crypts becomes the seat of a small abscess. Symptoms. These resemble so closely those of a severe acute pharyn- gitis that they hardly need separate description. The prostration is apt to be marked and, especially in children unless the throat is carefuUy examined, the condition is likely to be mistaken for some more serious condition. Exam- ination -jof the throat reveals swollen, red and congested tonsils and pharynx and the presence upon the former of the characteristic spots. The differen- tial diagnosis from true diphtheria is often impossible without bacterial exami- nation. General bodily pains and a febrile movement are, as a rule, present. Treatment. When spots are seen upon the tonsils of children it is always wise to give diphtheria antitoxin in therapeutic dosage without waiting for a bacterial examination of the exudate, otherwise valuable time may be lost. The constitutional treatment of the condition otherwise is practically that of an acute pharyngitis. The application to the outside of the throat of the local measures described upon p. 326 is also in order. With regard to local applications the use of an antiseptic spray of Dobell's solution or of liquor antisepticus and water is excellent; in addition the tonsils should be painted with some astringent or antiseptic such as Monsell's solu- tion, tincture of iron chloride, tincture of iodine, or i to 1000 mercury bi- chloride solution. As an adjunct to the above treatment one to two drachms (4.0 to 8.0) each (for an adult) of tincture of iron chloride and glycerin should be slowly swallowed every hour or two so that the mixture may come into contact with the dis- eased surface and the patient may dissolve in his mouth every 3 or 4 hours a pastille containing -gV of a grain (0.002) of thymol, J of a grain (0.02) of sodium benzoate and J of a grain (0.016) of saccharin. One of these is kept in the mouth until it has lost its taste. It is then removed, since by this time the saliva has become so impregnated with the medicaments which it contains that in swallowing, these come in contact with the seat of the inflam- mation. When adenoids and hypertrophy of the tonsils exist the removal of these as a prophylactic measure is strongly to be advised. It is needless to say that the operation should not be done during the acuity of the inflammation. Important also is attention to the general condition of patients disposed to tonsiUar inflammations. Proper hygiene, diet and tonic treatment are indicated. The exhibition especially of codliver oil and the syrup of iron iodide is especially to be commended in this connection. QUINSY SORE THROAT. 329 QUINSY SORE THROAT. Synonyms. Peritonsillar Abscess; Phlegmonous Tonsillitis; Acute Paren- chymatous Tonsillitis. Definition. An acute suppurative inflammation of the tonsillar or peri- tonsillar tissue. .etiology. The causes of this condition are practically identical with those of acute follicular tonsillitis. It is seldom seen in children or persons beyond middle-life. Its actual cause is pyogenic germ infection but attacks are often excited by exposiure, and it is frequent in individuals possessing hyper- trophied tonsils. Pathology. One or both tonsils may be affected; they become swollen, red, painful and tender and if pus formation occurs the induration gradually becomes less marked and an abscess supervenes which unless opened may rupture and discharge its contents. The lymph glands of the neck are often enlarged and tender. Symptoms. The disease is usually ushered in by a chill followed by a marked rise in temperature, general pains and prostration. There is pain in the throat increased by swallowing and by opening the mouth. There is tenderness over the angle of the jaw and in the neck. The voice becomes nasal, the secretion of saliva is increased and the pain caused by swallowing may result in dribbling from the mouth. Bad odor upon the breath and of the saliva is not infrequent. The swelling of the pharynx may cause difficulty in breathing; the pulse is rapid and bounding and the temperature curve is likely to be of septic type. These symptoms last several days until the abscess forms and bursts or is relieved by incision. Under proper treatment the prognosis is good. Frequent palpation of the seat of the inflammation should be made to determine the presence of pus. Treatment. Prophylaxis consists in the removal of hypertrophied tonsils and attention to nasal or pharyngeal conditions. If there is any rheumatic tendency it should be combated by the administration of the salicylates. At the beginning of the attack the patient should be put to bed and his bowels freely opened by means of repeated small doses of calomel followed by a saline. The diet should be of fluids. If seen early an attempt to abort may be made by means of the administration of sodium salicylate 10 grains (0.66) every hour until physiological effect has become apparent, tincture of aconite one minim every hour until 4 doses have been taken and a single dose of 10 grains (0.66) of quinine with one (0.065) of opium. These measures may succeed if instituted within 24 hours of the inception of the inflammation. The pain and discomfort may be mitigated by the local application of 5 to 10 percent, cocaine solution, by frequent application by means of the finger to the tonsil of sodium bicarbonate and by the external use of cata- 330 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. plasma kaolini, hot water bags or hot compresses. Garghng the throat with as hot water as can be borne, the use of alkaline and antiseptic sprays and inhalations of steam may also relieve the patient's discomfort. Local blood- letting by means of punctures (never scarification) with a slender sharp pointed knife will relieve the tension and reduce the inflammation. The tonsils should be frequently felt by the physician and as soon as fluc- tuation is manifest the abscess cavity should be freely incised in the vertical direction over the point of maximum fluctuation and the pus evacuated. After ii?cision the use of antiseptic gargles and sprays should be continued until all inflammation has subsided. In rare cases where the dyspnoea due to the swelling of the pharynx and consequent closure of its opening is extreme, tracheotomy may become necessary. DISEASES OF THE (ESOPHAGUS. ACUTE OESOPHAGITIS. Definition. An acute inflammation of the oesophageal mucosa and sub- mucosa, rarely involving the muscular coats. -Etiology. Acute oesophageal inflammation is usually the result of the swallowing of caustic or very hot liquids or of the presence of foreign bodies. The eruptions of the various exanthemata may involve the oesophageal mucous membrane and inflammations of the throat may spread downward to this structure. Pathology. There is more or less redness of the oesophageal lining and there may be sloughing and destruction of tissue, depending upon the cause of the lesion; hollow casts consisting of the entire lining of the organ have been given off following the ingestion of corrosive acids or alkalies. As healing progresses the newly formed scar tissue may contract and produce stenoses of varying degree. Symptoms. These vary with the degree of the inflammation. They consist of pain under the sternum which is increased upon deglutition, some- times to such an extent as to render this process impossible. There may be profuse secretion of mucus, which may be either raised or swallowed, from the inflamed surface. Should the action of the cause of the lesion be sufficient to erode the vessel walls there will be regurgitation of blood or this will appear in the stools. The resulting stenosis interferes with swallowing. Treatment. This consists in putting the part as much at rest as possible. If the patient is able to swallow hquids only, these shoifld be of the most soothing character, such as milk or arrowroot or other cereal gruels. The various demulcents or the swallowing of cracked ice afford relief to the pain When swallowing is impossible the patient must be fed by the rectum. CHRONIC CATARRHAL CESOPHAGITIS. 33 1 CHRONIC CATARRHAL CESOPHAGITIS. This condition may exist as a complication of chronic endocarditis, cirrhosis of the liver or other affections which result in venous stasis. The oesophageal mucous membrane is the seat of a chronic catarrhal inflammation with hyper- secretion of mucus. The veins of the part may become dilated and tortuous and may rupture with consequent regurgitation of blood. The treatment of this affection consists in the proper management of the causative condition. CESOPHAGEAL SPASM. Synonym. (Esophagismus. .etiology. This affection is usually seen in persons of neurotic or h^-po- chondriacal temperament of either sex. It may also occur in insanity, epilepsy, chorea and other nervous diseases. Symptoms. The spasm is brought on by the attempt to swallow or by the thought of this act. There is no history of any condition which might have caused a stricture yet the patient complains of difi&culty in swallowing and sometimes of painful deglutition. The condition does not get worse as it usually does in true strictiire and there is equal difficulty in swallowing fluids and solids; in cases of long dmration, above the seat of the spasm a dilatation may develop with a consequent catarrhal oesophagitis. There is usually loss of flesh and strength. Treatment. This is usually efficacious and consists, in addition to the proper managing of the neurotic condition of the patient by means of sedatives, tonics, diet and regulation of the mode of life, in the passage of the stomach tube or oesophageal bougie. This should be done slowly and gently. The instrument should be passed into the oesophagus until it reaches the seat of the spasm. Here it should be held and upon it very gentle pressure should be exerted, suddenly the spasm will give way and the bougie or tube will pass through. This should be done once or twice a day. In conjunction with the passage of the tube it is often well to wash the stomach and introduce fluid food. CANCER OF THE CESOPHAGUS. Cancer of the oesophagus is usually of the epithelial type beginning in the waU of the organ and gradually surrounding it; the growth develops in hard masses which may or not ulcerate, and usually causes a stenosis, above which dilatation is likely to form. The cancerous process may involve any portion of the tube but is slightly more frequent in its lower portion. It may extend to the adjoining structures a,nd metastases may be set up in the various viscera; oesophageal cancer is rarely seen before middle life. 332 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Symptoms. The first of these to attract notice is dysphagia; at first it occiirs with sohd food only, later liquids are swallowed with difficulty and finally complete oesophageal obstruction may develop. The difficulty in swallowing is accompanied by the regurgitation of food. There is often pain referred to the oesophageal or sternal region; this is especially marked when the patient swallows and may be present when the oesophagus is at rest. As the disease progresses the typical cancerous cachexia appears and its advancement may be rapid because of the difficulty of getting sufficient food into th^ patient's stomach. Examination by the oesophageal bougie reveals the presence of an obstruction and may cause slight haemorrhage. Treatment consists in the employment of means to prolong the patient's life. He should be fed by the mouth as long as he is able to swallow and afterward rectal feeding must be employed. The obstruction may be retarded in its tendency to cause stenosis by the gentle passage of a stomach tube from time to time. Gastrostomy may be performed and the patient's life prolonged by making a permanent gastric fistula through which he may be fed. Other surgical measures are of little avail. The use of radium has been exploited and is worthy of trial. The metal may be enclosed in a tube attached to a flexible bougie and exposure made by passing the same to thp site of the lesion. BENIGN STRICTURE OF THE (ESOPHAGUS. .etiology. This condition is rarely congenital. More frequently is it acquired. Its most usual cause is cicatricial contraction following ulcers which may have resulted from the ingestion of escharotic substances or from syphilis. The oesophagus may also be narrowed as a result of pressure of tumors extraneous to it, such as enlarged mediastinal glands or new growths, aneurysms, etc., and as a result of tumors having their origin in its wall. Symptoms. The symptoms of non-malignant stricture of the oesophagus are those of stenosis, difficulty in swallowing of greater or less degree, and regurgitation. Pain is sometimes present. Above the stricture there is usually dilatation. Treatment consists in the gradual dilation of the stricture by means of bougies. If cancer is present this must be done with great care. The situa- tion of the lesion should be determined by the passage of one of these instru- ments and then, by using sizes successively smaller, the calibre of the opening is ascertained. When this has been done the stricture is dilated by passing as large an instrument as is possible without causing too much pain. At successive sittings the bougies used may be of larger and larger sizes. Certain strictures may be of such small diameter that no bougie can be passed, in which case rectal feeding must be prescribed and surgical procediures are necessary. These consist of the making of a permanent gastric fistula through DILATATIONS OF THE (ESOPHAGUS. 333 which the patient may be fed, or the performance of various operations upon either the oesophagus itself or upon the extraneous lesions which by their pressure cause the obstruction. DILATATIONS OF THE (ESOPHAGUS. These may be either fusiform, involving the whole circumference of the organ, or sacculated, involving only a portion of its periphery. The former variety is usually secondary to strictvire although rarely it may occur idiopathically. It may involve the whole length of the tube or only a portion. Its diameter is frequently greatest at its lowest part; the wall of the tube is thickened and at times its muscular coat is paralyzed. Sacculated dilatations or diverticula are of two varieties, (i) those due to contraction of some tissue which as a result of inflammation has become adherent to the oesophagus; these are more frequent in children, are usually small and may be miiltiple. (2) The second variety is usually seen in adults, is found in the upper part of the tube where its wall is weakest and is due to pressure, exerted by boluses of food which are over-large or to traumatism, such as the lodgment of a bone. Such diverticula involve the posterior wall. Symptoms. Those of the fusiform dilatations are dysphagia, regurgitation of food and at times vomiting. The patient may complain that, though a considerable quantity of food is eaten, there is a sensation as if very little reached the stomach. The diverticula due to contraction are usually without symptoms but those due to pressure cause difficulty in swallowing and, as the sacs become larger and catch the food swallowed, this is regurgitated. At times there is a foul odor upon the breath due to the decay of food retained in the sac. This form of dilatation tends to increase in size and as the enlargement progresses it may press upon the oesophagus and cause occlusion. As the difficulty in getting food into the patient's stomach increases he loses flesh and strength and may finally die from starvation. The diagnosis of the condition is made by the use of the bougie and it must be carefully differentiated from stricture without dilatation. This may be done by passing one instrument into the sac and another into the stomach. At times it may be difficult to pass a sound into the diverticulum, but this may be more readily accomplished by the use of a specially constructed sound slightly bent at its end. Treatment consists in the dilatation of the stricture if it is present and by feeding through the stomach tube. Rectal feeding may be found useful as an adjunct to other means. Surgical measures, such as the formation of a permanent gastric fistula, the relief of the causative stenosis by various oper- ative procedures or the removal of the diverticula, may be employed as indicated. 334 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. DISEASES OF THE STOMACH. ACUTE CATARRHAL GASTRITIS. Synonyms. Acute Gastric Catarrh; Gastric Fever; Acute Dyspepsia. Definition. An acute catarrhal inflammation of the mucous membrane lining the stomach due to simple irritation or occurring as a result of the presence of the products of decomposing or fermenting food. .Etiology. The disease may follow interference with the hepatic function, it may ^e caused by exposure or it may complicate any of the acute infec- tious diseases. The most usual causes, however, are over-loading the stomach with indigestible or highly seasoned foods or the excessive drinking of alco- holic beverages. Pathology. The gastric mucous membrane becomes first congested and swollen and its secretions are diminished. Later the mucous secretion is increased in quantity and there may be an exudation of serum and emigra- tion of white blood cells. More rarely there may be small hsemorrhagic spots or haemorrhagic erosions upon the gastric lining. Symptoms. The principal symptoms are lack of appetite, nausea, usually followed by vomiting, which may bring relief to the patient, bad taste in the mouth, headache, dizziness and general physical and mental depression. Pain of greater or less degree may be present. The lips and mouth are dry, the tongue is coated and palpation of the stomach may reveal indistinctly localized tenderness and distention of the organ involved. There are eructations of gas and of acid or bitter matter. The vomiting may be frequent and the patient sometimes is unable to keep anything in the stomach. The bowels are usually constipated, though diar- rhoea is at times observed. The skin and conjunctivae may be jaundiced as a result of an accompanying duodenitis. There may be a moderate febrile movement, but elevation of temperature is not a feature of this disease. With the fever the pulse is accelerated. The urine is scanty and highly colored and usually contains urates in excess. Indicanuria is not infrequent. An attack of acute gastritis usually lasts from two to four days. The Stomach Contents as shown by the matter vomited or by the result of a test-meal show an abnormal increase in mucus, a diminution in the total acidity and a lack of free hydrochloric acid. Lactic, butyric, acetic acids and bile are often present. The food is only partially digested and fre- quently appears to have been little changed since it left the mouth. Treatment. In persons susceptible to attacks of acute gastritis much may be done in the way of prevention by the wearing of proper clothing. Con- striction of the region of the stomach by improperly fitting or too tightly laced corsets and especially the suspension of garments from the waist often predisposes to gastric attacks in women and consequently these practices ACUTE CATARRHAL GASTRITIS. 335 should be inveighed against. Chilling of the abdomen is likely to bring on an attack, and to provide against this, snugly fitting garments, sufficiently warm in texture and preferably not open below should be worn. Dietetic prophylaxis consists in the avoidance of indigestible or highly seasoned foods and especially those which may be adulterated with chemical substances. The practice of food-adulteration is becoming all too common; •coloring matters and preservatives are frequentl}' introduced and these sub- stances are prone to disturb the susceptible stomach. Not only must the quality of the ingested food be supervised but care should be exercised against over-loading the stomach, the teeth must be kept in good condition and the patient advised concerning proper mastication and salivation. The treatment of the attack proper consists in insuring as complete rest as possible for the organ involved, consequently it is wise to give as little food and drink as possible until the gastric irritability has disappeared. There is no reason why the patient suffering from acute gastritis should not fast for a day or more, even though there is a sustained prejudice amongst the laity against the practice. When excessive thirst is present the mouth may be rinsed with cool water, which should not be swallowed, or cracked ice may be sucked. A little dry champagne, a weak solution of hydrochloric acid, carbonated waters, or cold tea without sugar may be employed in check- ing thirst, but it is important that very little fluid of any sort should be taken at a time. After the day's fast the first food to be allowed is milk; this may be dilu- ted with a little lime water or Vichy, peptonized or boiled and but a small quantity should be given at a time. Beef or chicken broth containing egg or rice may follow and on the third day zwieback or soda biscuit may be given. By the fourth day the tolerance of the stomach and the patient's hunger will have so increased that a return to a more general diet will be necessary and such foods as calf's brain boiled in bouillon and broiled, broiled chicken or squab, broiled sweet-breads and veal boiled in bouillon may be given; po- tato puree soup, scraped beef, scraped ham, stewed ripe fruit, tapioca, rice and eggs, soft boiled, scrambled or as omelet may be added by the sixth day. On the second day of the attack it is wise to administer calomel either in six quarter grain (0.016) doses, one every half hour, or better in two large doses of 5 grains (0.33) one at night, the other in the morning. By this means any irritating substance which may have gotten beyond the pylorus will be prevented from doing further harm and any accompanying constipation will be relieved. The frequent vomiting of the fu-st day will usually interfere with any medication by mouth, even were it necessary. This vomiting as a rule empties the stomach effectually but should this not be the case and should the emesis persist beyond the endurance of the patient, gastric lavage with 336 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONiEUM. warm water by means of the stomach tube should be employed. In children it is particularly beneficial. Here a soft rubber catheter of appropriate size must be used and, while its eye may be too small to allow the admission of the larger food particles, its introduction will induce vomiting and the wash water poured through it wiU cleanse the stomach. During the lavage the patient should be directed to change his position, standing erect, then lying on the back and each of his sides in succession. Changes of position are easily made in the case of children but in the adxilt unaccustomed to the tube it will be found more difficult. The object of assuming different postures is to permit the lavage to cleanse every portion of the stomach. A drachm (4.0) of sodium bicarbonate added to each quart (litre) of the water used will assist in dissolving the mucus from the gastric lining. When the water returns clear a final washing with a disinfectant solution of thymol 8 grains (0.5), boric acid ^ ounce (15.0) to the quart (litre) of water is advisable. As a substitute for washing the stomach copious draughts of warm water may be taken and emesis induced by applying the finger to the pharynx. The use of emetic drugs is considered inadvisable by most gastrologists because of the depression and increased gastric irritation which they produce. However one may, if necessary, give a drachm (4.0) of syrup of ipecac to a child; in the adult the hypodermatic use of apomorphine hydrochloride yj of a grain (0.005) ^^ to be preferred to ipecac or antimony. A few hours after the stomach has been cleansed the high colonic irrigation consisting of a gallon (4 litres) of warm — 105-110° F. (40.5-43.3° C.) — half saturated boric acid solution should be given in order to remove any irritating substance which may be present; in asthenic patients this procedure acts also as a stimulant of considerable value. Very persistent vomiting is very exhausting to the patient and when not relieved by emptying the stomach by lavage, may be controlled by bismuth and cocaine in combination. In rare cases weakness and tendency to collapse occur and may be com- bated by small doses, ^ to i drachm (2.0 to 4.0) of iced champagne or brandy and cracked ice repeated as indicated. Pain or feeling of oppression in the abdomen may be relieved by hot or cold applications or turpentine stupes. When fever is present the cold are to be preferred; if the patient is chiUy the hot are indicated. The use of morphine hypodermatically for the pain is not to be recom- mended except under exceptional circumstances. In all ordinary cases this symptom may be controlled by codeine by mouth or combined with bella- donna in suppositories containing each a quarter of a grain (0.016) of codeine and an equal quantity of extract of belladonna. One of these may be used every 2 or 3 hours until the pain is eased. Codeine by mouth may be given in tablet form or in solution. Quarter CHRONIC CATARRHAL GASTRITIS. 337 to half grain (0.016 to 0.03) doses may be taken every 3 hours. This drug may also be administered hypodermatically with good effect. Following an attack of acute gastritis the appetite may be poor; in such a contingency the bitter tonics, condurango, rhubarb, etc., may be given either alone or with dilute hydrochloric acid to supply the lack of this substance in the stomach. Ten drops of the dilute acid (0.66) may be given in a glass of water before or during meals. The following prescription is also useful in this connection and when there is need of a general tonic. ^ strychninae sulphatis, gr. ss (0.03), acidi hydrochloric! diluti, gss (15.0), fluidextract of condurango, 3vi (25.0), syrupi aurantii corticis q.s. ad §iv (120.0). Misce et signa, one teaspoonful in a wine glass of water ^ hour before each meal. It should be remembered that mixtures containing hydrochloric acid should be taken through a tube in order to prevent corrosion of the teeth. CHRONIC CATARRHAL GASTRITIS. Synonyms. Chronic Catarrh of the Stomach; Chronic Dyspepsia; Chronic Gastric Catarrh. Definition. A chronic catarrhal inflammation of the mucous membrane of the stomach, usually associated with the hypersecretion of mucus and abnormalities of the digestive elements of the gastric secretions. .Etiology. This condition may result from repeated attacks of acute gastritis or the complicating gastritis of the infectious diseases. It follows the continued ingestion of too much or improper food or the abuse of medi- cines, tobacco and alcohoHc drinks. Conditions which interfere with the proper blood supply of the organ such as chronic endocarditis, cirrhosis of the liver, chronic pulmonary disease and chronic nephritis often produce this affection. Pathology. The mucous lining of the stomach is swollen and congested, it is grayish or brownish in color, may be ridged and usually is covered with a viscid alkaline mucus. The peptic glands are first increased in size, finally degenerate and become atrophic. The supporting connective tissue stroma may be in a state of hyperplasia. In marked cases the glands may be obliterated by this over-growth of tissue. These changes may involve the entire gastric mucosa or a limited portion of this structure. Symptoms. Pain is a frequent symptom and varies from a sense of dis- comfort or fulness referred to the stomach to marked distress. Tenderness may be present; it is, as a rule, diffuse. The appetite is diminished or lost and even the thought of food may disgust the patient. There is an unpleasant taste in the mouth, a coated tongue, nausea and oftentimes vomiting. The 338 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. vomitus consists of mucus and undigested food with, rarely, a little blood. Its reaction may be acid or not; when the former is the case the acidity is not due to the presence of the normal hydrochloric acid of the stomach but to that of lactic, butyric and acetic acids, resulting from the fermentation of the undigested food. The eructation of gas is a frequent symptom. In the alcoholic type of the disease early morning vomiting of mucus — the so-called water brash — is frequent. The bowels are likely to be constipated. The urine is scanty, high colored and contains phosphates or urates in excess, ^ndicanuria and oxaluria may at times be observed. The patient complains of headache, dizziness and loses flesh as a conse- quence of the lack of proper digestion and assimilation, he sleeps poorly and may be melancholic. A febrile movement is not a characteristic of this disease and the pulse rate is variable. Reflex dyspnoea and palpitation may be present. The so-called stomach cough is probably not due to any gastric condition but is much more likely to be due to pulmonary tuberculosis and the clinician should always be on the lookout for beginning apical lesions when indefinite stomach symptoms are described. Many such cases are treated by the gastrologist to the great detriment of the patient. The course of chronic gastric catarrh is long and complete recovery hardly to be expected. The symptoms can, however, be held in abeyance by proper diet and treatment and the patient's usefulness and enjoyment of life may continue with little impairment. The Stomach Contents. The quantity withdrawn after a test-meal is usually considerable and contains much mucus unless there is total atrophy of the glandular coat. The hydrochloric acid and pepsin are deficient and in cases of glandular atrophy there may be total achylia. Bacteria, a few blood cells, sarcinae and epithelial cells are often seen. Usually a number of test-meal examinations must be made before the true state of the case can be determined with certainty. Treatment. Prophylaxis consists in the avoidance of the errors in diet and mode of life that are likely to cause this condition. The food should be of proper quality and quantity, it should be eaten at regular intervals, slowly and thoroughly masticated. Excessively hot or cold fluids should not be drunk and the abuse of alcoholic beverages and tobacco must be avoided. Proper attention should be paid to the care of the teeth and where these are beyond repair artificial ones should be provided. The use of the tooth-brush after every meal should be advised, together with the removal of all food particles from between the teeth by means of a wooden tooth-pick or dental silk. The mouth should also be rinsed after eating with a suitable wash such as equal parts of hydrogen dioxide, liquor antisepticus, lime water and water. CHRONIC CATARRHAL GASTRITIS. 339 Conditions of the heart, Hver or kidneys to which gastric congestion is often secondary should be carefully treated. In cardiac lesions when com- pensation is likely to become disturbed digitahs, either alone or in combina- tion with strychnine, should be prescribed. The digitalis is unlikely to disturb the gastric function and under its use the congestion disappears, the appetite and general condition improve. If the drug disturbs the stomach it may be given per rectum in the form of the infusion or hypodermatically. . Lavage. By this means we are able to remove from the stomach the excessive accumulation of mucus with which it is burdened and to relieve the organ of its retained content of fermenting food. It is the mode of treat- ment par excellence in gastritis with excessive mucus production and muscular atony. In this form of the inflammation frequent washings are necessary, while in atrophic gastritis with little production of mucus the procedure need not be undertaken so often. In mucous gastritis the frequency of the lavage depends upon the state of the gastric inflammation, but usually once a day is sufficient. In marked cases with large quantities of mucus and advanced atony lavage before breakfast and in the evening may be necessary. The most favorable time for stomach-washing is in the evening before supper, since at this time the stomach has been quiet since the noon meal — which in these cases should be the principal one — and the supper to be taken after- ward will as a rule be light. The tube having been passed, the mucus may be removed, allowing the water to run in under considerable pressure, the patient being recumbent and directed to change his position from time to time. No mucus may appear until the stomach has been relieved of whatever food it may contain but after this has been washed out fiulher lavage will usually detach mucus from the wall of the organ in considerable quantity. Certain substances calculated to dissolve the mucus may be added to the wash water; among these may be mentioned sodium bicarbonate (i to 250), lime water (i to 500), and sodium chloride (i to 200). Alkaline mineral waters may also be employed. If the stomach contains decomposing and fermenting food a final washing with a disinfectant solution is indicated. Of these there are a number, such as o.i percent, salicylic acid, i percent, boric acid, 0.6 percent, butyric acid, i percent, resorcinol, 0.6 percent, hydrochloric acid, I percent, chloroform water. This last is prepared by adding the chloro- form, shaking the mixture, allowing the chloroform to settle and using the water poured off. In the atrophic form of chronic gastritis, with little mucus, lavage should be employed to stimulate the stomach-lining directly. Decinormal hydro- chloric acid may be used and if stomach analysis shows enzymes to be still present a solution of sodium chloride not stronger than i percent, is recom- mended. Drug treatment plays a less important part in the management of the 340 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. affection than do lavage and diet regulation. Of the drugs likely to prove beneficial silver nitrate may be mentioned. It may be given by mouth — i.o grain (0.065), ^o peppermint water i ounce (30.0); dose ^ ounce (15.0) three times a day when the stomach is empty — by means of the intra-gastric spray of a i-iooo solution, or the organ may be washed with a 1-2000 solution. Bis- muth salts, especially the subgaUate and the subnitrate given together, often produce a good effect. A powder of i part of the subgallate to 3 parts of the subnitrate may be prescribed, of which the dose is 30 (2.0) grains 3 or 4 times a^ day, or this powder may be applied directly to the lining of the stomach by means of an intra-gastric powder insufflator. The disadvantage of the bismuth treatment is its likelihood to produce constipation, consequently in connection with it laxative mineral waters and diet should be advised. In the management of symptoms drugs are often necessary. Of the symp- toms which are likely to need attention pain is one. Diet and stomach washing may be sufficient treatment, but if the pain is very distressing the patient may be put to bed and hot compresses applied over the stomach. Opium should be used only as a last resort and may be administered hypo- dermatically or -per rectum. Vomiting is seldom distressing where lavage is employed. When neces- sary, this symptom may be controlled by sucking bits of cracked ice, by iced champagne taken in small quantitieSj and by intra-gastric sprays of weak cocaine or menthol solutions. Eructation may be controlled by lavage or by capsules of magnesia ponderosa or sodium bicarbonate with or without the admixture of a little sodium sub- salicylate. Animal charcoal in doses of from ten to twenty grains (0.66 to 1.33) is also useful. Constipation is a frequent accompaniment of chronic gastritis. It should not be treated by laxatives but by dietetic means, mineral waters, abdominal massage and by irrigations, if necessary. Loss of appetite may prove an annoying symptom. It may be managed by various means. Stomach washing with sodium chloride or hydrochloric acid solutions and the administration of the vegetable bitters, especially con- durango, n\ix vomica and gentian, or of basic orexin are recommended. This last is best given in broths in doses of about 3 grains (0.20) before meals. Artificial digestants are of very limited value. The administration of pepsin either alone or with hydrochloric acid does not increase the digestive power but when there is lack of the stomach ferments and of hydrochloric acid, the latter should be supplied. The dilute acid should be administered in doses of about 20 drops (1.33) after meals, weU diluted and taken through a glass tube; if not well borne the dose should be diminished or sodium bicar- bonate and pancreatin in doses of 5 grains (0.33) each shoiild be substituted. These are especially useful in old cases. By means of the pancreatin and CHRONIC CATARRHAL GASTRITIS. 34 1 the alkali, which must be given in sufl&cient quantity to neutralize the acidity of the stomach, if any remains, pancreatic digestion is performed in the stomach. Other artificial digestants, of which there are a number on the market, are of little use. Mineral Wafers. The great benefit that sometimes accrues from courses of spa treatment is probably due rather to the rigid regulation of diet and mode of life than to any special therapeutic effect of the mineral waters drunk. It may be stated, however, that in chronic gastritis the salt and alkaline waters, as well as the alkaline-saline and alkaline-hydrochloric waters are useful. When drtmk in large quantities they tend to cleanse the stomach of its excess of mucus but in this connection they cannot, in more than a very slight manner, take the place of lavage. It would seem that the alkaline, alkaline-hydrochloric and sodium sulphate waters are likely to benefit gastritis with increased or only slightly diminished hydrochloric acid while the alkaline and saline waters are useful in diminished gastric secretion. In decreased stomach motility with dilatation only small quantities at a time should be allowed. General Hygiene. For patients who have become weak and emaciated a rest cure should be prescribed. For those of moderate bodily vigor a morning cold tub or sponge, if there is good reaction afterward, is advisable. Cleansing baths of warm water may be taken twice a week. Exercise in moderation should be systematically taken. Five minutes' work with light wooden dumb-bells or clubs before breakfast, at noon, and at bed time, together with walking, golf, horseback or bicycle riding or a moderate amount of swimming or rowing, is an excellent means of keeping the muscular system in condition. Exercises of the muscles of the abdomen, such as those described in works upon physical culture are important in all gastric abnormalities except those attended by haemorrhage. Electricity, while it probably has little or no effect upon the secretion or motility of the stomach, is an excellent adjuvant to other treatment of chronic gastritis. Both the galvanic and faradic currents may be employed. Fara- dism acts in the same fashion as massage and should be administered by applying one electrode to the spinal region while with the other the limbs, and particularly the abdomen, are stroked. Intra-gastric electricity with Einhorn's electrode by means of which both the faradic and galvanic currents may be applied is useful and makes an excellent impression upon the patient. Massage has a particularly good effect in gastritis with dilatation and atony and in patients too weak to take proper exercise. Both general massage and local massage over the abdomen are indicated. The latter plays an impor- tant part in sustaining the tonus of the abdominal muscles, and when given directly after a meal aids the atonic organ in passing its contents into the intestine. 342 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Diet is perhaps the most important factor in the treatment of chronic gastritis. No fixed list of proper articles of food can be given but each patient must be studied by himself both from a standpoint of his symptoms and with a view to the chemical findings upon stomach-contents analysis. In prescrib- ing a diet the patient himself can materially assist by informing the physician as to what articles of food agree and what do not. At the beginning of treat- ment the diet should be light and easily digestible and, if the gastric muscula- ture is functionating properly, fluids and semifluids should make up the dietary to a great extent. Oftentimes a patient wiU do better on a number of small meals daily than on three large ones. If the analysis shows hydrochloric acid and pepsin to be present in considerable quantity we may give a diet contain- ing considerable proteid, but even when there is lack of secretion of these elements proteid need not be wholly eliminated. Carbohydrates in which there is no admixture of large amounts of cellulose and those which are not likely to ferment are allowable and fat, even in considerable quantity, is not harm- ful. The preparation of the food is important. Meats and fish should be cooked in a steam boiler and if necessary may be minced before being served; in all cases they should be finely divided before they reach the patient's mouth. Milk is an excellent food but often patients bear it ill. In such cases it may be mixed with other articles of diet such as puree soups, cereals, etc. When given thus it is usually well digested, often the addition to it of vichy or lime water will render it less liable to undergo fermentation. Soups and meat jellies are usually well borne as are the white meats, sweetbreads, scraped beef and fish. It should be remembered that only small quantities of meat should be given at a time. Cereals are excellent and the lighter vegetables, potatoes, beans, peas, asparagus, etc., may be given in the form of puree soups, which when properly made are very appetizing. Mashed potatoes are allowable and toast or zwieback is preferable to plain bread. Stewed ripe fruits and puddings of rice, tapioca, sago, etc., may be given. It need hardly be stated that highly seasoned foods are out of place although a little mustard or pepper may be given at intervals to increase the appetite. Such alcoholic drinks as beer, because of the yeast which it contains, and spirits should be avoided and it is better in most cases to forbid the use of fermented beverages entirely, but if they are allowed a pure wine containing no tannic acid is best. Certain cases of gastritis due to over-indulgence in alcohol seem to digest better if wine is allowed; a good port, tokai or malaga is to be preferred. If lactic acid fermentation occurs upon the use of these sweet wines a good dry champagne may be substituted. Naturally the quantities taken should be small. Coffee in moderate amount may be taken, but tea, on account of its consti- pating effect, and tobacco should be stopped. PHLEGMONOUS GASTRITIS. 343 PHLEGMONOUS GASTRITIS. Synonyms. Suppurative Gastritis; Purulent Gastritis. Definition. A rare form of gastric inflammation characterized by a diffuse infiltration of the submucosa, with pus, which may extend to the muscular and peritonseal coats of the organ. Occasionally the pus is localized in an abscess cavity. .Etiology. This condition may occur idiopathically. Primary phleg- monous gastritis, however, is very rare, most cases being secondary to infec- tious processes, pyaemia, puerperal sepsis and typhoid fever, for example. The suppurative process may also result from infection of an ulcer or new growth or from traumatism. Pathology. In the diffuse form the submucosa of the pyloric region is most likely to be the seat of the process. This portion of the wall of the stomach is infiltrated with pus and may necrose; the other coats are thickened. Perforations may take place through the mucosa and the pus may exude into the cavity of the organ. If there is abscess formation, single or multiple collec- tions of pus will be observed. Symptoms. In secondary phlegmonous gastritis the symptoms closely resemble those of peritonitis with sepsis; there are usually abdominal pain, more or less distinctly localized epigastric tenderness, meteorism, vomiting— the vomitus rarely contains pus, however — diarrhoea, a septic temperature, sniall, rapid pulse and great prostration. In cases with abscess formation a tumor may be palpable. If the disappearance of such a manifestation is coincident with the vomiting of pus, there is good ground for making a diag- nosis of suppurative inflammation of the stomach. Simple vomiting of pus, however, may occur in other conditions, such as an oesophageal or other abscess which may have ruptured into the stomach. Rupture may take place through the wall of the stomach into the peritonaeal cavity with the accompanying symptoms of perforation. The disease is quickly fatal, almost without excep- tion. Treatment. If the diagnosis is made in time, surgical treatment offers some hope and is always indicated; otherwise the treatment is purely symp- tomatic. Medication given by mouth is ineffectual. The pain may be less- ened by sucking cracked ice, applications of cold to the epigastrium and by hypodermatic injections of morphine. Stimulants given hypodermatically and per rectum are indicated. TRAUMATIC AND TOXIC GASTRITIS. Definition. An inflammation of the stomach caused by swallowing caustic substances, such as acids, alkalies, arsenic, mercury bichloride, etc. Pathology. The post mortem appearances differ with the degree of the 344 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. corrosion of the gastric lining. Marked cases reveal a dark eschar covered with necrotic mucous membrane bordered by an inflamed margin. In less severe cases the cells of the gastric mucous membrane are swollen, degenerated and eroded. There may be haemorrhages and ulcer formation. The fundus exhibits the most marked degree of irritation for this region is reached first by ingested substances. In cases which recover the healed cicatrices may contract and produce deformities of the organ. Symptoms. These vary in severity with the degree of the irritation, but as a rule theje is marked gastric pain, localized tenderness, vomiting and thirst. The vomitus often contains blood, mucus and pieces of exfoliated mucous membrane. Marked cases are characterized by an expression of anxiety, weak, rapid pulse and symptoms of collapse which may terminate in death within a few hours. The diagnosis is made from the history, but when this is wanting eschars about the lips and in the mouth, together with the odor of the breath may suggest the causative factor. Treatment consists in the administration of antidotes both chemical and physiological; the chemical antidotes in the case of acids being alkalies, sodium bicarbonate for instance, and for alkalies mild acids such as dilute vinegar. The irritation may be soothed by demulcents — milk, albumin water, mucilages, etc. — and free dilution of the toxic substance by drinking water is always indicated. The collapse necessitates free hypodermatic stimulation by means of strychnine, alcohol, etc., and high rectal injections of hot black coffee. The after treatment consists of rest for the stomach, rectal alimentation and the bismuth salts in large doses. DIPHTHERITIC GASTRITIS. This is a rare inflammation and may occur as a complication of true diphtheria of the upper air passages or an extension of throat or laryngeal Klebs-Loffler infection to the gastric mucous membrane. Gastritis with the production of a false membrane may also occur as a complication of the various infectious diseases, smallpox, typhoid and typhus fevers, septicaemia, scarlatina and pneumonia. The lesion cannot be diagnosticated intra vitam, and is therapeutically of no interest. MYCOTIC GASTRITIS. Cases have been reported of gastric infection with certain fungi, notably those of thrush and anthrax. These have followed infections of the mouth; yeast fungi also have been known to set up gastric inflammation. Fortunately the acidity of the gastric secretion is usually able to destroy the swallowed GASTRIC ULCER. 345 micro-organisms and in cases in which lesions of this variety have occurred the gastric fmictions have been at low ebb. The larvae of the common house fly and other insects have been known to produce inflammations of the stomach. GASTRIC ULCER. Synonyms. Ulcer of the Stomach; Peptic Ulcer; Round Ulcer; Embolic Ulcer; Thrombotic Ulcer; Perforating Ulcer, Ulcus Ventriculi. Definition. A loss of continuity of the substance of the mucous lining of the stomach, not tending to heal but rather to increase both in area and depth. The acute form is likely to spread by increasing its depth while the chronic variety tends to spread laterally; its walls usually slope inward toward the base of the lesion while those of the acute type are more vertical and clearer cut. Perforation into a blood-vessel or through the muscular and peritonaeal coats of the organ may occur in either type. The condition is usually characterized by gastric pain, digestive disorders, and at times haema- temesis. .etiology. Gastric iflcer has been attributed to a number of causes. The disease seems to be rare in the United States, but it is probable that many cases are undiagnosticated. It is most common in young adult females. According to Hemmeter there are five chief factors in the production of this lesion, a. An interference with the vitality or resisting power of the mucous membrane, h. Increased acidity of the gastric juice, c. An altered con- dition of the blood, d. Local bacterial infection, e. Local traumatism. The vitality of the wall of the stomach may be impaired by local or general diseased conditions or by interference with the blood supply of a particular area. Thrombosis, usually the result of disease of the blood-vessels, and embolism, infective or non-infective, are the common causes of this inter- ference. Constitutional diseases, such as the blood dyscrasiae, syphilis, tuberculosis, arterial diseases of various character, malaria, etc., are to be considered. Of bacterial infections the most common are those of tuberc\ilosis, t}^hoid fever and various types of dysentery. Other bacteria have been found in cases of gastric ulcer and may exert a causative influence upon the condition. It must be remembered that while HCl is germicidal it does not destroy bacterial spores and there are times when the glands which secrete this acid are at rest and consequently the antiseptic action of the HCl is slight or absent. Hemmeter suggests that the bacteria cause a primary necrosis and encourage ulcer formation through autodigestion. Direct injury and consequent impairment of the power of resistance of the mucosa may be the result of the traumatism from the swallowing of various foreign bodies such as fish bones, oyster or nut shells and the like. Corrosive 346 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. poisons and the ingestion of very hot Hquids or food are factors worthy of consideration and certain observers have exploited the theory that the fre- quency of ulcer in those in whose work pressure upon the stomach is exerted may be due to an anaemia of the organ resulting from such pressure. Pathology. Ulcer of the stomach exists by a large percentage most often upon the posterior wall or lesser curvatiure of the organ and it is rare that a single lesion is found, the condition being usually miiltiple. The typical round punched-out appearance is not so often seen as is the oval non-symmet- rical ufcer with irregular edges. The edges usually slope inward since the mucous coat of the organ is first involved. If there is no tendency toward healing the lesion progresses through the muscular coat and finally perforates the peritonaeum covering the viscus. The typical iilcerous perforation is circular and has as cleanly cut edges as if punched out with a die. but as above stated this form is less often seen than the less symmetrical type. . During the progress of the lesion the blood-vessels in the stomach wall may be eroded, resulting in haemorrhage more or less profuse in type. A healed ulcer leaves behind a distinct and typical scar. Accompanying the ulcer there is, as a rule, a complicating gastritis. Symptoms. The most characteristic symptoms of gastric ulcer are: a. Localized pain. This is due to irritation of the sensory nerves laid bare. It is burning in character, most marked after the ingestion of food and fre- quently increases during the process of digestion. There is local tenderness which is increased on pressure, or by the wearing of a corset. Various other pains due to sympathetic neuralgias of the intercostal nerves, of the left brachial plexus and even of the nerves of the lower limbs may be present. A point of tenderness, "the dorsal point," sometimes exists at the back to the left of the spinal column at the level of the loth to the 12th dorsal vertebra. In many cases there is an unpleasant burning sensation in the region of the stomach which is the result of irritation of the organ from its hyperacid contents. This " heart burn" may also be referred to the region of the oesoph- agus. h. Vomiting. This is the result of excessive peristalsis and reverse peris- talsis caused by the irritation and increased acidity due to the ulcer. The vomiting exercises an influence favorable, rather than otherwise, over the course of the disease since the emptying of the stomach allows it to collapse, thus bringing the edges of the ulcer into approximation. The vomiting is usually followed by a temporary relief from pain. c. Vomiting of blood is a very characteristic symptom of gastric ulcer and is the result of erosion of a blood-vessel. If the haemorrhage is large a considerable quantity of dark pure blood may be vomited, if small, the blood may remain in the organ, undergo partial digestion and be later vomited as "coffee-ground" matter. The blood resulting from gastric haemorrhage is GASTRIC ULCER. 347 frequently not vomited in toto but part may pass through the intestine and appear in the stools as a black, tarry matter. Muscular exertion of any character may induce haemorrhage. Excessive Hydrochloric Acid is present in a large majority of cases of gastric ulcer and by most authorities is considered as a causative factor, rather than a result of the lesion. The appetite is usually normal or increased, the tongue is not coated and there is likely to be excessive thirst. Constipation is the rule but a normal condition of the bowels may exist, although the quantity of faecal matter is likely to be small owing to the lessened quantity of food ingested. The urine is hyperacid except after emesis when it may be alkaline because of the large amount of acid suddenly withdrawn from the body. The chlorides are diminished. The blood, except after haemorrhage, when the number of red cells may be much diminished, usually shows a slight decrease in the number of the eryth- rocytes and a considerable diminution of the haemoglobin. After hsemate- mesis there may also be what is called a "post haemorrhagic leucocytosis." This usually disappears within a few days. A distinctly palpable tumor is rarely felt except in old lesions with thickened cicatrices or adhesions to neighboring parts. If a tumor is felt, as a rule it is small, smooth of surface and not movable. The ulcer may proceed toward healing leaving a cicatrix behind when the process is completed. This latter may contract producing the hour-glass stomach, or a stenosis of the pylorus with consequent dilatation and ptosis, in accordance with the original situation of the lesion, or it may undergo carcinomatous degeneration. In other cases the ulcer may eat its way through the entire stomach wall and bring about a local peritonitis if adhesions sufficient to shut off the site of the perforation have formed, or, failing this a general peritonitis. Perfor- ation upward through the diaphragm resulting in pyopneumothorax is a less frequent complication. The disease is variable as regards the length of its course but under proper treatment 95 percent, of cases should terminate in recovery in from 12 to 14 days. Complete cure, however, should hardly be claimed until the patient has been without gastric pain for a number of months. Frequently the excess of hydrochloric acid remains after recovery has taken place. The diagnosis of gastric ulcer by means of the test-meal and stomach tube is hardly necessary, and the passage of this instrument, except by a skillful hand, is hardly to be advised. The only striking abnormality found upon chemical examination of the stomach contents in ulcer is an abnormal amount of hydrochloric acid. Digestion does not seem to be delayed in ulcer, but is, on the contrary often accelerated. 348 DISEASES OE THE DIGESTIVE SYSTEM AND PERITONEUM. Howard in a series of 54 cases of ulcer of the stomach and duodenum reports the following findings. Total Amount of Residue: 54 percent, above normal, 17 percent, below normal, 29 percent, within normal limits. Total Acidity: Hyperacidity in 27.5 percent., hypoacidity in 42.5 percent.; within normal limits 30 percent. Free hydrochloric acid. Hyperchlorhydria in only 17.6 percent. Normal content of hydrochloric acid in 26.4 percent. Hypochlorhydria in 26.4 percent. Tests for lactic acid were employed in 43 cases with positive result in 14 percent j> doubtful in 7 percent, and negative in 79 percent. The statement so positively made by most authorities with regard to exces- sive free hydrochloric acid in ulcer is hardly borne out by the above figures. Treatment. Prophylaxis: patients with increased acidity and subject to discomfort and pain referred to the stomach, without definite signs of ulcer should be put upon a simple and non-irritating diet, and extremely hot or cold food or drink forbidden. The h^'peracidity should receive drug treatment. In the treatment proper of gastric ulcer the problems confronting us are: 1. To encourage healing on the part of the ulcer by a, enforcing as com- plete rest as possible; h, protecting it from irritation by food and from other mechanical injury, and from irritation from chemical sovirces; c, by counteract- ing the secretory fermentive abnormalities taking place within the organ. 2. To treat the distressing symptoms of the condition as they may arise. 3. To maintain the bodily strength by the administration of nourishment per rectum. A period of complete rest in bed on the part of the patient, to last until the gastric pain and tenderness have disappeared should be enjoined. Unless haematemesis has recently occurred or is anticipated, he may read, write and receive visitors in moderation and a daily sponge bath, with or without alco- hol should be given. Gentle massage of the limbs will add to the patient's comfort and augment his recuperative power. In order to protect the ulcer from irritation and to encourage it toward healing the heaviest of the bismuth salts — the subnitrate — is administered in dosage of 90 to 120 grains (6.0 to 8.0), if given by the mouth, daily. The salt possessing the highest molecular weight is preferable since it will be most likely to sink to the dependent portions of the stomach and consequently come in contact with the ulcerating smrface wherever situated. Fleiner, who has been the special advocate of the use of bismuth, is accustomed to administer the drug as follows: Before food is taken in the morning the stomach is washed until the washings return clear and non-acid in reaction; then through the tube 2^ to 5 ounces (75.0 to 150.0) of bismuth subnitrate, free from arsenic, suspended in 6 to 8 ounces (240.0 to 300.0) of water are given. After the withdrawal of the tube the patient should assume the recumbent position GASTRIC ULCER. 349 and remain quiet, so that the mixture may come into contact with the ulcer if possible. If the patient is receiving food by mouth he may take his break- fast within a half hour. The bismuth acts not only as a non-irritant protec- tive to the ulcerating siirface but favors the healing of the lesion by an anti- septic and astringent action. It is said, also, to decrease the excessive acidity. Being given by the mouth the bismuth is quite as effective as through the tube and passing this instrument may be omitted without influencing the efficacy of the treatment. The insufflation of the drug in powdered form has been practised but presents no advantage over the ordinary method of administration. In the employment of the bismuth treatment Hemmeter uses one drachm of the subgallate (4.0) to three (12.0) of the subnitrate in a pint (J litre) of water. He previously washes out the stomach with a solution of sodium bi- carbonate ^ ounce (15.0) to the pint (^ litre). The problem of neutralizing the excessive acidity present in the stomach is often not met successfully because the attempt is not made according to chemical principles. Sodium bicarbonate, a drug frequently employed, is worse than useless since its presence in the stomach results in an excess of sodium chloride and carbon dioxide. The former wiU split up and give rise to still more hydrochloric acid, while the latter stimulates peristalsis, both of which results are exactly at variance with our purpose. The most effec- tual method of combating the hyperacidity is by the administration of mag- nesia ponderosa in dosage of 10 grains (0.66) every four hours. In addition to the reduction of the existing hyperacidity and the prevention of the forma- tion of additional hydrochloric acid from the chemical combination resulting, magnesium chloride is formed which exercises a favorable influence upon the usually co-existent constipation. Numerous other treatments of gastric ulcer have been from time to time exploited and among them may be mentioned Cohnheim's olive oil treatment which consists in administering this substance in doses of from i to 4 ounces (30.0-120.0) three times a day, passed into the fasting stomach, which has previously been washed; as in the case of the bismuth treatment the oil may be swallowed without the use of the tube. It would seem, however, that a pre- vious lavage would increase the efficacy of this treatment, since its object is to allow the oil to come into direct contact with the ulcer and form a protective coat for it. It is claimed also that the oil relieves the nausea and pain, dimin- ishes the excessive acidity and lastly is a food itself. The originator of this method asserts that the milder cases may be fed by mouth during the treat- ment — the diet, of course, being properly restricted — and strict rest in bed is not necessary. The systematic rest and mineral water treatment advocated by Fox and with certain unimportant modifications by von Leube and von Ziemssen is 350 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. not adapted to the acute cases with hsematemeses but, after the intervention of two weeks succeeding such an occurrence, it may be pursued. The details of the treatment are as follows: The patient is kept in bed, not even being allowed up to evacuate the bowels and bladder, and is given every morning a glass of Saratoga Carlsbad or Hathorn water (either of which has quite as beneficial effect as the imported Miihlbrunnen of the original treatment) to which 75 to 150 grains (5.0 to 10. o) of Carlsbad sprudel salts (natural or artificial) have been added. The mineral water exerts no specific action, but serves only to keep the bowels open and to lessen the gastric acidity. Local applications to the epigastrium of a flannel compress dipped in hot water and covered with oil-silk are prescribed and renewed every three hours night and day. The diet for the first two weeks of the treatment is limited to milk and beaten eggs. During the third week the patient is allowed to move from his bed to a lounge, but is still kept very quiet, the mineral water is continued, and toast or zwieback, oysters, broiled fish, sweetbreads, calf's brain, or minces of very finely chopped meat may be allowed in small amount. During the fourth week vegetable purees of peas, beans, potatoes or other vegetables, and stewed fruits are permitted. From now on the patient may gradually return to ordinary diet but for years all raw fruits, acid, highly seasoned, cold and hot food and drinks must be interdicted. In connection with this treatment Hemmeter employs the following prescrip- tion to assist in reducing the excessive acidity and prevent autodigestion. I^ magnesiae ponderosae, sodii bicarbonatis, potassii carbonatis, aa, grains Ixxv (5.0); sacchari lactis, drachms viss (26.0). Of this half a teaspoonful (2.0) is taken dry on the tongue every 3 hours. Silver nitrate has been recommended by Gerhardt. According to his reports the distressing symptoms will often cease directly upon its adminis- tration, while in other cases it has no influence whatever and in still others it seems to aggravate the symptoms. He believes that this drug is useful in patients who suffer pain when the stomach is empty, on account of its neu- tralizing effect upon the hydrochloric acid. His method is to give this agent in doses of from y^- to ^ a grain (0.006 to 0.03) in solution several times in the 24 hours upon an empty stomach. Boas considers silver nitrate useful especially in the less severe cases of ulcer and in those for whom it is impossible to institute a rest cure. He starts the treatment with ^ an ounce (15.0) of a i grain (0.065) to i ounce (30.0) solu- tion of the nitrate in aqua menth. pip. three times a day on an empty stomach. Later he increases the strength of the solution to 1.2 grains (0.07) to the ounce (30.0) and still later to 1.6 grains (o.i) to the ounce (30.0). In con- nection with this treatment the diet must be carefully regulated and the patient should remain as quiet as possible. Numerous other drugs have their advocates in the treatment of ulcer. GASTRIC ULCER. 35 1 among which may be mentioned chloroform. Stepp considers that this agent given in connection with bismuth — chloroform, i part; bismuth sub- nitrate, 3 parts, distilled water, 150 parts — exerts a favorable influence. Condurango bark, in the opinion of Gerhardt, acts well especially in old vilcers in poorly nourished patients. Fuchs believes that the action of bismuth in ulcer is not alone due to its neutralizing effect upon the hydrochloric acid and to the fact that it is mechan- ically a protective biit that the subnitrate is reduced to an oxyhydrate which, being dissolved, is absorbed by the granulating tissue and here acts specific- ally. It also increases the secretion of mucus which has a considerable protective action. Bismuthose, a combination of bismuth and albumin is more astringent than bismuth, more insoluble, and has a greater acid- combining power. Eisner reports good results from its use. Its great dis- advantage, however, is the influence of its astringency upon the co-existent constipation. It is particularly useful in combating hyperacidity. The treatment of the excessive acidity often present in ulcer has received much attention and various methods have been recommended as applicable to the reduction of this manifestation. Ewald uses the alkalies mixed with powdered rhubarb and sugar. Others advocate the use of sodium bicarbon- ate, which according to chemical principles directly defeats the object with which it is given. Riegel, in uncomplicated cases, advises the following formula: I^ sodium bicarb., magnesias ponderosae, aa, drachms ii (8.0); sac- char, lactis, drachms iii .(12.0). To this a small amount of powdered rhubarb may be added if the constipation is marked. Of this J teaspoonful (2.0) after meals is prescribed. In cases where the increased acidity is continuous the alkali should be given more frequently and in smaller doses. Atropine has a decided influence in diminishing the secretion of the gastric juice and consequently it and belladonna have their places in the treatment of hyperchlorhydria. The treatment of the pain is to a certain extent that of the hyperchorhydria since the former is the result of the latter. Usually the administr?.tion of anal- gesics is unnecessary, for as a rule the pain disappears within a day or two after the institution of the ordinary treatment. In severe cases at the beginning the hypodermatic use of morphine is indicated; however, according to recent investigators, this is likely to cause an increase in the secretion of gastric juice and consequently is to be avoided if possible. Codeine or its phosphate are sanctioned by certain high authorities. Cannabis indica while acting as a hypnotic to a very slight degree is likely to cause disagreeable mental phenom- ena. Strontium bromide is recommended. Orthofqrm (a methyl aether of benzoic acid) is said to have a marked effect upon the pain of ulcer and Murdoch believes that gastric pain which is relieved by this drug augurs the existence of ulcer. 352 DISEASES or THE DIGESTIVE SYSTEM AND PERITONEUM. Local applications such as poultices of flax seed may afford relief but the Priesnitz umschlag — flannel wrung out in hot water and covered with oil-silk — will usually be found to act as weU. Sharply localized pain due to peritonitis may be relieved by the ice bag or coil. Vomiting seldom needs special treatment since it usually ceases upon the institution of the ordinary course of treatment directed toward the cure of the ulcer. If this symptom continues to distress the patient cracked ice may be given and various antiemetics such as cerium oxalate, grains v to x (0.30 to O.J56), chloretone, grains x to xv (0.66 to i.oo), dilute hydrocyanic acid, minims ii to vi (0.13 to 0.4) in water, chloroform, minims i to ii (0.065 to 0.13) in water, etc., may be used. Hmmatemesis should be treated by absolute rest and the application of an ice coil to the epigastrium. Cracked ice is allowed by some authorities, while others insist that nothing should be given by the mouth. If the haemor- rhage has been considerable a tube should be very carefully introduced. For this a skilled hand is necessary for the tube must be passed only a very short distance beyond the cardia. A pint (500.0) of water at 120° F. (48.9° C.) is now introduced and allowed to remain. Later the clots should be siphoned out so as to allow the organ to contract and a small amount of water containing about ten grains (0.66) of heavy magnesia is put into the stomach and allowed to remain. Lavage of the stomach with ice water has given good results in a few cases, according to Ewald. The hypodermatic use of morphine sulphate in dosage of J of a grain (0.016) will quiet the patient, relieve the air hunger and stimulate the heart action. Ergotal, 20 to 30 minims (1.66 to 2.00), hypo- dermatically is recommended by Hemmeter as an excellent haemostatic. Sub- cutaneous injections of ergotine, 5 to 10 grains (0.33 to 0.66) in equal parts of glycerin and water may be found effective. Certain authorities mention hydrastis, hamamelis (witchhazel), lead acetate, iron chloride and other haemos- tatic drugs in this connection but it is probable that the irritation caused by their entrance into the stomach more than counteracts their power over the haemorrhage. Adrenalin chloride in doses of from 10 to 30 drops (0.66 to 2.00) of the I to 1000 solution given in a drachm (4.00) of water has seemed to act well in certain cases of gastric haemorrhage and it will be interesting to observe the results of its administration under the skin. Excessive gastric haemorrhage with its accompanying symptoms of heart weakness, pallor, and general collapse calls for immediate and energetic treat- ment. The usual means employed in haemorrhage from any source m.ust be instituted at once. Hypodermatic stimulation by means of camphor and aether or camphor and oil, strychnine sulphate, etc., is indicated. The so- called bleeding of the patient into his own tissues which consists in applying snug bandages to the limbs and thus forcing the blood into, the trunk, is an excellent resource as is the administration of copious high rectal enemata GASTRIC ULCER. 353 of normal (0.9 percent.) solution of sodium chloride, at a temperature of io5°-ii2° F. (40.4° to 44.5° C). Intravenous infusion of saline, or, what may be much more rapidly performed, the giving of the solution under the skin of the fleshy parts of the back, chest or thighs may be advised. For this procedure the only necessary apparatus is a fair sized aspirating needle, a few feet of rubber tube and a funnel. The funnel is filled, the solution al- lowed to flow through the tube and the needle, and the last is plunged into the subcutaneous tissue of the part selected. If the part is massaged as the fluid is flowing in a pint (500.0) or more of the solution may be given. A necessary precaution in connection with this as with other methods of stimulation is to take care lest the vascular tension be raised to such an extent as to excite further haemorrhage and thus defeat our object. The tension shoifld be aUowed to remain low lest this accident take place. Feeding in Gastric Ulcer. During the progress of the treatment most approved by the author — i.e., that of bismuth subnitrate combined with heavy magnesia — the patient is fed entirely by rectum. A nutrient enema, preceded by a high rectal irrigation of about a quart (litre) of normal saline so- lution at about 105° F. (40.5° C.) to cleanse the intestinal mucous membrane and facilitate absorption, is administered every 4 hours. The enema preferred by the author consists of one-half to one ounce (15.0 to 30.0) of starch paste with 2 to 3 ounces (60.0 to 90.0) of beef e:!ttract, liquid peptonoids or pano- pepton. Rectal feeding should usually be continued for about two weeks. Other enemata useful in this disease may be chosen from the following formulas : 1. Milk, 4 ounces (120.0); the yolks of two eggs; salt, i drachm (4.0); claret, i ounce (30.0); aleuronat flour, one-half ounce (15.0). (Boas.) 2. Two or three eggs beaten with a little water; i ounce (30.0) of dextrinized flour boiled with 4 ounces (120.0) of 20 percent, solution of lactose; one wine- glass (30.0) of claret, a little salt. The eggs shoifld not be mixed with the other ingredients until the latter have cooled so that their temperature will not coagulate the albumin of the former. 3. Bouillon, 8 ounces (240.0); wine, 2 ounces (60.0); the yolks of two eggs; dry peptone i to 5 drachms (4.0 to 20.0). (Jaccoud.) 4. Milk, 8 ounces (240.0); two to three eggs; a little salt. (Riegel.) 5. Milk, 8 ounces (240.0); liquid peptone, i ounce (30.0); yolk of one egg; laudanum, 5 drops (0.33); a small quantity of sodium bicarbonate for chem- ical neutralization if the peptone is acid. (Dujardin-Beaumetz.) 6. Two eggs; whiskey, one-half ounce (15.0); starch paste, one-half ounce (15.0); milk up to 8 ounces (240.0). Other formulae may be made up as occasion requires. In quantity nutrient enemata, according to most authorities, should not exceed 3 or 4 ounces 23 354 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. (90.0 to 120.0), and the proper interval for their administration is about every four hours. Four enemata during the 24 hours will be found to be sufl&cient. When enemata larger in quantity than the above are weU borne it may be wise to give as a routine three daily injections of a pint (500.0) of food each. This procedure relieves the patient of too frequent disturbance and allows his sleep to be unbroken. The enema may consist of the whites of two eggs, a teaspoonful (4.0) of salt, i^ ounces (45.0) of a saturated solution of glucose, and milk up to a pint (500.0). Such a mixture contains carbohyhrates, fat, prc^eid and salts in approximately proper proportions. Nutrient enemata, particularly those of considerable size, are better given from a fountain s}Tinge than by means of the piston variety, since the force and tendency of the latter to sudden spurts may cause irritability of the bowel. Food given per rectum will be more readily absorbed and assimilated if peptonized and not only the milk but the other constituents of nutritive enemata should undergo this process. Preparations for the convenient peptonizing of food substances are obtainable at any apothecary's. In certain cases nutrient enemata may not be well borne or may be difficult of retention on account of irritability of the bowel. Such a complication may be obviated by preliminary cleansing of the bowel by a saline enema and, if this procedure fails, by the addition of a small dose of the tincture of opium to each enema. Nutrient enemata should be thoroughly mixed and administered warm. 100° F. (37.8° C), under moderate pressure and very slowly through a soft rubber rectal tube passed as high into the bowel as possible. Care should be taken lest the tube turn on itself and its extremity, instead of being in the sigmoid flexure, be just inside the anus. The best position for the patient to assume while receiving the enema is upon the left side. After about 30 minutes he should turn to the right side and a pillow shoiild be placed under his hips. These positions facilitate the flow of the enema through the colon. At intervals it may be necessary to give a high enema of clear water for the relief of the thirst. After the cessation of rectal feeding the return to ordinary diet must be very gradual. The first foods allowed by mouth may be equal parts of milk and Hme water, beef bouillon to which such substances as plasmon, nutrose or somatose may be added, and albumin water. These fluids must be given at a neutral temperature — neither hot nor cold. Sugar solution (20 percent.) may also be allowed. Dextrose is the preferable form of sugar, but cane sugar is allowable. Lactose is least desirable. After about ten days a more liberal diet may be instituted consisting — according to v. Leube — of boiled sweet- breads, calf's brain, white meat of chicken, various gruels and vegetable puree soups, tapioca with milk, oatmeal and finely scraped raw beef. After a week scraped raw ham, finely chopped rare broiled beef steak, toast or GASTRIC ULCER. 355 zwieback and mashed potatoes are allowable, as also are stewed fresh non- acid fruits. Further extension of the diet shotdd be postponed as long as possible, but when this becomes necessary the patient may eat broiled chicken and veal, rare roast beef, fish, plain meat soups, etc. All irritating foods, such as vegetables containing an excess of ceUulose, breads with hard crusts, fruits with tough skins, together with alcoholic bever- ages should be refrained from until all the symptoms have disappeared and have remained absent for a long period of time. Cold and hot, sour or highly- spiced foods and drinks should be avoided for many months after the cure is apparent. The anaemia so frequently accompanying gastric ulcer should never be neglected. To combat this important factor in the disease iron and arsenic are our chief rehance. It is needless to say that their administration should not be begun until all the symptoms of gastric irritation have disappeared. Ewald is accustomed to give a 2 or 3 percent, solution of iron sesquichloride three times a day in teaspoonful (4.0) doses in an ounce (30.0) of albumin water. This should be taken through a tube. The various forms of organic iron which have lately been put upon the market should be useful in this connection particularly iron viteUin in half ounce (15.0) doses given three times daily after meals. Arsenic may be given in the form of Fowler's solution or arsenic tri oxide. The various mineral waters containing and arsenic will be found useful. The Surgical Treatment of Gastric Ulcer may be divided into: a. The treatment of the ulcer by excision. b. The treatment of haemorrhage. c. The treatment of perforation. d. The treatment of gastro-peritonaeal adhesions. e. The treatment of the various resulting gastric deformities such as stenosis of the pylorus, hour-glass contraction, etc. It is conceded by most surgeons that acute gastric ulcer is a medical condi- tion but chronic ulcer with obstinate and persistent emesis and pain may be treated surgically by excision or cauterization. In multiple ulcer excision of all the ulcerating points is, however, impossible. Ulcers situated near the pylorus and associated with pylorospasm may be relieved and even cured by the operation of gastroenterostomy. In ulcers of other regions of the stomach this operation may also afford relief. Repeated haemorrhage, unless the patient is too anaemic to withstand the shock of operation, probably constitutes an indication for surgical treatment. If possible the bleeding point should be cauterized or excised. If these are multiple, gastroenterostomy should be performed. Perforation should be treated surgically as soon as the diagnosis is made, unless it is an absolute certainty that adhesions shutting off the site of the 356 DISEASES OP THE DIGESTIVE SYSTEM AND PEEITONiEUM. perforation from the general peritonaeal cavity, have been formed. The longer operation is postponed after the contents of the stomach have been emptied into the peritonaeal cavity the less the likelihood of the recovery of the patient. Adhesions about the stomach which cause pain and other unpleasant symptoms may necessitate surgical interference. Hour-glass contraction and other post-ulcerous deformities of the organ are also amenable to oper- ative treatment. -» CANCER OF THE STOMACH. Synonyms. Gastric Cancer; Carcinoma of the Stomach; Carcinoma Ventriculi. .Etiology. The direct setiology of cancer is unknown. Heredity plays ' some part in its causation and gastric ulcer is undoubtedly a predisposing cause. Cancer of the stomach is rarely seen before middle age and is more common in males than in females. It not infrequently occurs in individuals who have had apparently healthy stomachs during their earlier years. Pathology. Cancer of the stomach is usually primary. AU varieties of carcinoma may occur in the stomach but the most frequently seen are: a. The scirrhus which is an infiltrating growth, hard and dense in struc- ture; it usually involves a considerable portion of the submucosa and may spread through its whole extent. b. The meduUary type develops rapidly, is likely to ulcerate and is prone to extend directly or by metastasis to other structures. c. The coUoid variety grows to a larger size than do the other types and frequently spreads by direct contiguity to neighboring tissues, making with them a mass of considerable size. The majority of gastric carcinomata begin near the pylorus and from this point tend to extend along the curvatures, involving chiefly the submucous coat. The growth, as a rule, originates in the tubules, it progresses, infiltrating and causing induration of the remaining tissues of the organ, and results in a nodular tumor which may ulcerate. The neighboring lymphatic glands become hardened and enlarged and may themselves become the seat of car- cinomatous growth. When the tumor is at the pylorus stenosis results which causes dilatation of the organ, otherwise the stomach tends to diminish in size. Ulcerations infrequently perforate the stomach waU but often erode a blood-vessel and cause haemorrhage. Symptoms. Before gastric cancer is suspected the patient is prone to in- definite symptoms referred to the stomach, such as loss of appetite, distress, eructations of gas and constipation, but it must be remembered that the growth may exist for considerable time without giving rise to any symptoms which call attention to the stomach. The cancerous cachexia, with its characteristic CANCER OF THE STOMACH. 357 color of the skin, anaemia, and loss of flesh and strength becomes sooner or later apparent and palpation of the stomach may or may not reveal the pres- ence of a tumor which is rarely observed in the normal region of the pylorus. It is more likely to be near the umbilicus but may be found much lower. The reason for this displacement is that the weight of the tumor drags the stomach downward. The tumor varies in size and in consistency and may not be nodular, it may be either fixed or movable; a pyloric growth is not likely to change its position on respiration but the contrary is true of tumors upon the curvatures. At times when situated over the aorta the tumor may seem to pulsate, but this pulsation is non-expansile. It is not very imusual for no tumor to be palpable even in the latest stages of the disease. As the disease progresses the vomiting usually becomes more distressing. The vomitus consists of food particles and at times contains blood or " coffee- ground" material — the result of the admixture of the gastric secretion and blood; it may be of foul odor and if particles of food are detected which have been eaten a number of hours previously, we may, in the presence of other suggestive symptoms, diagnose a malignant pyloric stenosis. Vomiting is less frequent when the growth is situated in portions of the organ other than the pyloric region. In the later stages there may be lymphatic enlargements in the clavicular and inguinal regions, enlargement of the liver, jaundice, oedema of the lower limbs and an irregular febrile movement. Albumin may be present in the urine, and the presence of metastatic growths, partic- vdarly in the liver, may be detected. Blood examination shows a diminution in the red ceUs, seldom, however, below 2,000,000, and a corresponding decrease in haemoglobin; the haemoglobin index is low, a point which is of assistance in the differential diagnosis from pernicious anaemia. The white blood cells are, as a rule, increased to a moderate degree — 20,000 or there- abouts — the increase being confined primarily to the polymorphonuclear neutrophils. In advanced stages of the disease nucleated red cells and myelocytes have been observed. The Stomach Contents. Chemical examination of the gastric contents withdrawn after a test-meal typically reveals an almost total or an entire absence of free hydrochloric acid and an excessive amount of lactic acid. While absence of free hydrochloric acid and an excess of lactic acid may occur in other lesions, if repeated gastric analyses after test-meals show these condi- tions to be constantly present and the clinical symptoms point toward malignant neoplasm, the probability is strongly in favor of the existence of gastric cancer. The microscope should always be employed in the examination of the result of the test-meal and significant findings are blood, the Boas-Oppler bacillus and fragments of the growth. The Boas-Oppler bacillus is said to be present in gastric cancer almost without exception and if a piece of the tumor can 358 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. be demonstrated to be carcinomatous tissue the diagnosis is established beyond doubt. Rontgen ray examination may reveal the presence of a tumor in certain cases but this means of diagnosis is as yet hardly trustworthy. The prognosis is distinctly unfavorable, medical treatment offering no hope. Radical surgical intervention, early in the course of the disease, may be attended with good results, but the diagnosis is seldom made before sur- rounding structures are involved, rendering entire removal of the malignant neoplasm impossible. The disease is usually fatal within a year but under siirgical treatment this period may be slightly lengthened. Treatment. Medical treatment is merely palliative and consists in reliev- ing the pain, improving the digestion and keeping up the patient's nutrition. By attention to these factors life may be prolonged and made more comfor- table. The pain may be controlled by means of hot or cold applications to the epigastrium. When it is apparently due to retained and fermenting food it may be effectually relieved by gastric lavage and removal of the exciting cause. Sodium chloride in 30 grain (2.0) doses well diluted thrice daily will often relieve pain. The narcotics should be used with care; belladonna extract, gr. ^ (o.oi), may prove effectual and codeine may be employed; hydrated chloral should rarely be used because of its liability to cause heart weakness; morphine may be given hypodermatically when all else fails. The appetite may be improved by the administration of various stomachics. Of these condurango has been exploited as a specific in gastric cancer. While exerting no effect upon the course of the disease it does increase the appetite and aid digestion. It may be given with hydrochloric acid which also acts as a tonic upon the organ, in the following formula: ^fluidextract condur- ango, 5ii (60.0); strychninse sulphatis,gr. ^(0.02); acidi hydrochlorici diluti 3iv (15.0); fluidextracti gentiani q.s. ad §iv (120.0); misce et signa, one teaspoonful in a wine-glass (60.0) of water through a tube, after meals. Lavage with plain water or with infusions of the vegetable bitters cleanses the stomach and acts favorably upon the appetite. Vomiting may be controlled by lavage since it is frequently due to the stag- nation and decomposition of food in the stomach. When the vomitus is of foul odor washing the organ with various antiseptic solutions such as those suggested under the lavage treatment of chronic gastritis (p. 339) is indi- cated. Other means of relieving nausea and vomiting are bits of cracked ice in the mouth, sips of iced champagne, carbonic water, tincture of iodine, cold applications to the epigastrium, and hypodermatic injections of mor- phine. If the vomiting persists the patient should be fed exclusively per rectum for a few days. (For the treatment of hsematemesis see treatment of gastric ulcer, p. 352.) CANCER OF THE STOMACH. 359 Constipation is not infrequent and is better treated dietetically and by means of enemata of water or oil, or suppositories, than by means of purgatives. In persistent cases, we may, however, employ the milder laxatives, such as rhamnus purshiana, rhubarb or aloes, singly or in combination. Their depleting effect should contraindicate the salines and the purgative waters. Diarrhoea may be combated by means of phenyl salicylate (salol), bismuth subsalicylate or subgallate, beta naphthol bismuth (qrphol) and other intes- tinal antiseptics. Stomach lavage is often effectual in preventing diarrhoea, since it removes the cause, the fermented and decomposed contents of the dilated stomach. The anaemia and cachexia necessitate the administration of the preparations of iron and arsenic and the exhibition of heart stimulants, particularly strych- nine. In cases of carcinoma with obstruction at the oesophageal entrance the passage of a bougie from time to time will keep the passage clear but great care must be exercised. Potassium iodide and arsenic are said to delay closure in such cases. When swallowing becomes impossible the patient must be fed through the tube or a gastric fistula must be made. Diet is the most important factor in the management of gastric cancer and unfortunately no suitable diet list can be laid down as applicable to all cases. Each case must be studied by itself. The food allowed should be easily digestible, finely divided and as concentrated as possible. The patient should be consulted as to what foods attract him and what disagree with him and, while carbohydrates, fats and proteids may be allowed when there is no obstruction or fermentation, when these are present the diet should be chiefly of proteid. It is usually best to prescribe small meals at frequent intervals especially if there is motor insufiiciency. Milk in small amount at a time may be given if it is well borne; peptonized milk, the fermented milks, koumyss, matzoon and kefir, often are preferred by the patient; all meats and fish should be eaten minced and in small amounts only, at a time. The green vegetables, cereals, puree soups, stewed fruits, toast and zwieback are allowable as are also cocoa, chocolate, especially von Mehring's " Kraft- chocolade," tea and coftee. Alcoholic drinks, such as beer, which are likely to ferment in the stomach should not be taken but the light wines may be permitted. The artificial substitutes for meat may be given but they are merely makeshifts; of these the best are probably nutrose and somatose. Surgical treatment affords the only hope of complete recovery from gastric cancer and this may be brought about only when operative interference is undertaken in the early stages. The operation consists in complete re- moval of the tumor and is most likely to prove successful when this is situated at the pylorus. When the disease has progressed so far that removal of the neoplasm in 360 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. its entirety is impossible, a gastroenterostomy permits free egress of the stom- ach contents into the intestine and prolongs the patient's life. He may even gain flesh for a time following this procedure. Certain authors believe that in all cases, in which the diagnosis of gastric cancer cannot be ruled out, an exploratory laparotomy is indicated and that even benign pyloric strictures should be excised. HYPERTROPHIC STENOSIS OF THE PYLORUS. Definition. A condition characterized by hypertrophy of the muscular coat of the stomach at the pyloric oriflce and usually accompanied by spasm and interference with the passage of stomach contents into the duodenum. .Etiology. The aetiology of the congenital form is unknown; the acquired variety is rarely seen before middle age and our knowledge of the causation of it is limited. It may occur as a result of a congenital abnormality but more frequently appears to be due to a chronic inflammatory condition of the stomach. The disease is a rare one. Pathology. In the congenital type the muscularis of the entire stomach is the seat of some degree of hyperplasia, but especially is this the case at the pylorus; here the gastric waU is firm to the feel and dense in texture. The chief seat of the hypertrophy is the coat of circular fibres, the longitudinal coat seldom being much involved. The stomach itseK may be contracted and the pyloric hypertrophy may extend to some extent throughout the remain- der of the muscularis. Dilatation of the organ is unusual. In the acquired variety of this condition when the hypertrophied tissue is limited in extent to the pyloric region there is likely to be dilatation, when there is general thickening of the muscular coat contraction of the organ is more common. Symptoms. Congenital pyloric stenosis is evidenced by frequent and per- sistent vomiting without assignable cause. The vomiting may occur directly after the ingestion of food or an hour or more later and the fact that no bile is found in the vomitus is significant. Rarely is a tumor palpable. The patient rapidly becomes emaciated and death usually takes place within 3 or 4 months. In adults the principal symptom is gastric pain with a sense of fullness and pressure. If there is co-existent dilatation and muscular atony, emesis may occur. A palpable tumor may or may not be present but the thickened pylorus is usually distinguishable by the skilled observer, especially in thin subjects and fortunately, for the sake of diagnosis, these patients usually are ill-nour- ished although true cachexia is not a feature of the condition. This fact, together with the rarity of the disease and its freedom from haematemesis, is a useful point in the differentiation from malignant disease. The prognosis as to recovery without operation is, in both types of this disease, bad. Treatment. The palliative treatment of the congenital form consists of GASTRIC DILATATION. 36 1 lavage to remove retained food and to prevent vomiting. Feeding through the tube may relieve that form of reflex vomiting which sometimes results from the mere act of deglutition. Surgical intervention in pyloric stenosis offers the only hope of recovery. The operations applicable are gastroenter- ostomy, pyloroplasty and excision of the pylorus. Loreta's operation (manual dilatation of the pyloric orifice) is not advised. In adults the treatment aside from surgical interference is that of the causative chronic gastritis (see p. 338 and ff.). GASTRIC DILATATION. Synonyms. Dilatation of the Stomach; Gastrectasis. Definition. A condition of the stomach in which its capacity is increased. .Etiology. In the causation of gastric dilatation two factors must be taken into account, i. Atony of the musculature of the organ due to frequent dis- tention by excessive quantities of food or drink, to inflammatory interference with the nourishment of the stomach, as in chronic gastritis, and to various constitutional diseases which lower the tone of the muscular system in general, such as the acute infectious diseases, pulmonary tuberculosis, various nervous diseases, the anaemias, diseases of the heart, liver or kidneys, etc. 2. Dilatation due to pyloric obstruction caused by malignant growths, h3rpertrophy or thick- ening of the gastric wall at this situation, contraction of cicatrices following vilcers, traumatism, etc., and pressure from without of adhesions, abdominal tumors or misplaced viscera, or the habitual wearing of over-tight corsets. The disease is one of adult life, though it has been met in children. Pathology. The capacity of the organ may be increased to three or four times the normal, which is a little over a quart (litre). Its lower border is, in consequence, markedly displaced downward. There is atrophy of all the coats and the wall is often thinned as a result of the stretching which it has undergone, while at times there may be thickening due to the replacement of the normal structure with connective tissue. Symptoms. These are a sense of weight in the epigastrium, especially after a full meal, eructations of gas often mixed with liquid or food particles, and nausea, which at times is followed by emesis. The vomitus is frequently of large amount and may be seen to contain bits of food which have been ingested a number of days previously. The appetite may be good or poor and there is often thirst. The bowels are usually constipated and the urine is often scanty, highly colored and loaded with urates. As the disease progresses the patient becomes anaemic, weak and emaciated. A condition known as gastric tetany may develop as a result of absorption of the toxins generated by the decomposition of the stagnant food retained in the stomach. The tetanic convulsions follow premonitory sensations of drowsiness, tingling of the extremities and sometimes vomiting. The move- 362 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. merits affect both sides of the body, one, usually, less than the other, involve chiefly the muscles of the limbs and face and are accompanied by pain. Death from exhaustion and preceded by loss of consciousness is a frequent conse- quence (75 percent, of cases). Physical Signs. Inspection in thin patients, particularly if the stomach is distended with food or gas, may reveal the greater curvature even several inches below its normal level (i^ to 2 inches above the umbilicus) and in marked cases the line of the lesser curvature may be demonstrable. Peris- taltic movements from right to left may be observed to stop at the pyloric region where a prominence due to a tumor may be visible. If the organ is artificially distended by gas, resulting from the administration of ^ drachm (2.0) of tartaric acid in a little water and a couple of drachms (8.0) of sodium bicarbonate, also in water, given separately, or by inflating with a bicycle pump through an ordinary stomach tube, the examination will be greatly facilitated. One must be careful however to rtde out the possibility of ulcer before employ- ing these procedures. Palpation enables us to feel what we have hitherto seen and even when not visible, the border of the stomach may be demonstrated by this means. A pal- pable tumor may be made out and peristalsis also may be felt. Light pressure quickly made and as quickly released may bring out splashing sounds which may be distinctly audible to the lower limit of the organ. These sounds are more easily obtained and more plainly heard than over the normal stomach. Percussion plainly evidences the borders of the enlarged organ, the note over it being tympanitic in character when the patient is recumbent; when he is upright it is flat in its lower part owing to the fluid or food in its most dependent portion; distention of the stomach by water and of the colon by air or vice versa may aid the observer in mapping out the borders of the organ. The use of the stiff sound may show the greater curvatiure to be at a lower level than normal, and its extremity may be palpable through a thin abdom- inal wall. The gastrodiaphane, an instrument constructed to illuminate the stomach by electric light, may be employed. This, in a word, consists of a small incandescent lamp at the extremity of a stomach tube and when passed into the organ aids in determining its size and position. The examination must take place in a dark room. When the stomach is filled with a fluorescent medium the value of this method of examination is much enhanced. Also bismuth subnitrate in dose of 2 drachms (8.0) may be administered and the patient subjected to a fluoroscopic examination ten minutes later. Skia- graphs, likewise, taken after the ingestion of bismuth may demonstrate the gastric enlargement. The administration of certain drugs which are not absorbed from the stom- ach and which after passing the pylorus are excreted in the urine is another GASTRIC DILATATION. ' 363 means of testing the gastric tonicity and the patency of the pylorus. In this connection phenyl salicylate (salol) may be employed. Normally salicy- luric acid should be present in the urine within 5 or 6 hours after its admin- istration. Urine containing this acid takes a port wine color upon the addi- tion of a small quantity of the tincture of iron chloride. Stomach Contents. The organ should be washed on the evening before the test-meal is given in order to remove its decomposing and stagnant contents. The examination of a test-meal withdrawn an hour after its ingestion gives evidence of delayed and imperfect digestion and if cancer is present there will usually be absence of free hydrochloric acid and presence of lactic acid and the Boas-Oppler bacillus, otherwise the content of free hydrochloric acid is variable. Numerous organisms, yeast, sarcinse and other bacteria are usually present in large numbers and butyric and acetic acids may be found. Treatment. The medicinal treatment of this condition consists in admin- istering drugs calciilated to improve the muscular tone of the stomach and to lessen the tendency to decomposition of the retained food. As a muscle tonic strychnine is most valuable. It may be given alone or in combination with physostigma — strychnine sulphate, gr. -2V (0.003) ^^^ extract of physos- tigma, gr. \ (o.oi) three times a day. If the hydrochloric acid is diminished in quantity the dilute acid should be prescribed; this substance is also useful in neutralizing the gastric fermentation. Hyperacidity may be neutralized by heavy magnesia, gr x (0.66), bismuth subcarbonate and sodium bicarbonate, of each, gr. v (0.33) given about an hour after meals, and fermentation may be retarded by the following formulae I^ resorcinolis, gr. Ixxv (5.0); bismuthi sub- salicylatis, pulveris rhei, sodii sulphatis aa 5ii ss (lo.o); sacchari lactis 5iii ss (14.0); misce et signa, J teaspoonful (2.0) twice a day (Ewald). Pancreatin may be used in cases which do not bear hydrochloric acid well, and creosote and guaiacol are recommended — 'f\ v (0.33) in capsules — as antifermentatives. Lavage usually will relieve the vomiting and at the same time is an impor- tant adjunct to the treatment, since by this means we may remove the decom- posing contents of the stomach. The addition to the wash water of antisep- tics (see p. 339) is often advisable. Constipation is frequent, the intestine being often atonic as well as the stomach. Purgatives should never be given but a movement of the bowels should be secured daily by diet regulation. A glass or two of cold water on rising and the ingestion of stewed fruits, green vegetables, graham or whole wheat bread, together with proper abdominal massage and electricity usually suffice in this regard. Intestinal irrigations may be given from time to time. If laxatives are absolutely necessary rhamnus purshiana is the least objectionable. Massage and electricity are necessary, the former being employed only when the stagnant contents of the stomach has been removed and the latter, the intra-gastric faradic current especially, is to be given as described on p. 341. 364 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. The tonic effect of hydrotherapeutic procedures, especially the cold morning sponge, is not to be overlooked and the fact that properly fitting abdominal binders can do much toward supporting the prolapsed and enlarged organ must not be ignored. Diet. The patient must be warned not to eat or drink large quantities at a time, but should be advised that four to five small meals per day are prefer- able to three large ones and that he must avoid all foods likely to cause fer- mentation — especially fats and sweets. Liquids shoiild be restricted to a quantity not greater than 3 pints (i^ litres) during the 24 hours. If thirst is troublesome further fluids may be given per rectum. The conditions revealed by repeated gastric analysis will demonstrate the diet applicable to each particular case. With plenty of free hydrochloric acid the red meats may be allowed, also cereals, gruels, eggs, and vegetables which last must be mashed or better given in puree form; the carbohydrates aside from those above mentioned must be restricted. When the free hydro- chloric acid is abnormally smaU in amount more carbohydrates may be taken but the animal proteid element of the diet should be restricted to the white meats, fish, calves' thymus, etc. Alcoholic drinks are best omitted, but when a light sweet or sour wine seems to benefit the patient it may be allowed in small quantity — two sherry glasses at each meal, for instance. Surgical Treatment. In cases which continue unrelieved despite medical treatment the question of surgical intervention must be considered. Where the dilatation and atony are due to pyloric obstruction pyloroplasty, pylorec- tomy or gastroenterostomy is applicable, depending upon the conditions which confront us. A dilatation depending merely upon atony of the gastric musculature may be relieved by a gastroenterostomy or by gastroplication. Both physician and patient, however, must not lose sight of the fact that none of these oper- ative procedures is by any means certain to bring about complete relief and that the adhesions and other factors that are likely to follow a laparotomy may render the patient's discomfort little less than before he entered the surgeon's hands. ACUTE GASTRIC DILATATION. Synonym. Acute Gastrectasis. Dej&nition. An acute, rapid dilatation of the stomach. -Etiology. Various causes are said to bring about this rare condition; certain cases appear to be idiopathic, others take place as a result of some influence on the nervous system producing a paralysis of the nerves of the organ in question. Acute dilatation may occur during the infectious diseases, pneumonia, meningitis or peritonitis; as a result of acute obstruction of the HOUR-GLASS OR BILOCULAR STOMACH. 365 pylorus, as from a foreign body; after parturition, abdominal operations, or anaesthesia, where it has been thought to be due to the swallowing of anaes- thetic-impregnated mucus from the throat. Constriction of the duodenum by the superior mesenteric vessels has been considered a factor in its causation, and it may follow the rapid consumption of very large amounts of food and drink. Pathology. After death the wall of the stomach is thin, its cavity is large and its greater curvature may extend far below the umbilicus. The viscus contains gas, fluid which is usually watery and of a greenish tinge, rarely it is thick and brownish, and perhaps undigested food. There may be drops of blood upon the lining of the organ and the blood- vessels are dilated. Symptoms. The onset of the condition is usually sudden, although after operations it may not appear for a day or two. There is usually little pain and the thirst is marked. The abdomen is greatly distended and vomiting is present as a rule, the vomitus being thin and tinged with green or brown. The outline of the stomach is often plainly apparent but peristalsis is seldom visible. There is no rigidity of the abdominal wall. The constitutional symptoms are those of great depression, with subnormal temperature, rapid, weak pulse and rapid and shallow respiration. Death may take place in collapse. The prognosis is bad but all cases do not terminate fatally. Treatment. Prophylaxis consists in washing the stomach if there is marked vomiting after anaesthesia. Since the condition may be the result of the absorption of toxic substances from the stomach this organ should be subjected to frequent lavage, and the intestine cleared by means of high irrigations. Rest from the work of digestion is advisable, consequently rectal alimentation should be undertaken, and as relapses may occur even after several days, food and drink by mouth should be given with the utmost caution. As soon as the condition of the stomach will allow, small doses of calomel or of a saline should be given and frequently repeated. The constitutional depression should be combated by means of hypoder- matic stimulation — especially strychnine and atropine — hot applications to the extremities, hypodermatoclysis, etc. HOUR-GLASS OR BILOCULAR STOMACH, Definition. A condition in which the stomach is divided by a constriction into two parts, more or less equal in size. It is a rare state and still more rarely is the organ separated into three or more sacs. .Etiology. The bilocular stomach may be congenital — though this state- ment is refuted by some authorities — or acquired. The latter form is usually the result of the cicatricial contraction of ulcers or erosions from the ingestion 366 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. of corrosive substances, more seldom is it due to outside adhesions or malignant growths. The theory has been advanced that it may follow tight lacing. There is said to be at times a contraction of the gastric musculatiire at the seat of the constriction. Pathology. The organ presents a sacculated appearance and at the con- striction the muscle fibres may be thickened. This is by no means always the case for the narrowest part of the organ may be devoid of muscular tissue and consist of a fibrous cicatrix. Symptoms. Moderate degrees of hour-glass stomach often cause no char- acteristic symptoms. There is usually more or less discomfort referred to the organ, which at times may be increased, due to spasm of the hypertrophied muscle fibres about the constriction. The fact that the gastric muscle must force the ingesta over and through the contraction finally gives rise to an atonic condition which is likely to resiilt in dilatation. Diagnosis without physical examination is impossible and fortunately the condition is accompan- ied by a number of unmistakable signs. When the stomach seems empty and the tube has been passed with no result palpation may elicit a splashing sound, due to the fact that the pyloric sac of the organ contains fluid while the cardiac sac is truly jejune. At times during lavage the reflux will be found to exceed the influx in quantity. Distention of the organ by air may, in thin subjects, reveal the constriction with a dilatation upon either side. When this sign cannot be seen the borders of the stomach may be palpable and the condition thus made out. The two portions of a Seidlitz powder given separately by their evolution of gas will distend the cardiac sac at once while the pyloric sac may not be distended at aU or may be seen to slowly enlarge as the gas enters it through the constriction. The gastrodiaphane may simplify the diagnosis and Hemmeter's rubber bag when inflated in the stomach reveals a distention of the cardiac pouch only. A skiUed manipula- tor may succeed in passing a tube through the constriction and obtaining contents from the pyloric pouch which differs materially on chemical analysis from that previously obtained from the cardiac sac. Long standing cases of this condition lose flesh and strength, lack proper nutrition and may terminate fatally. Treatment aside from relieving the symptoms is ptirely surgical and consists in the performance of a plastic operation at the site of the constriction or of a gastroenterostomy to bring about a communication between both sacs and the intestine. VISCEROPTOSIS. Synonyms. Glenard's Disease; Splanchnoptosis; Enteroptosis; Gastrop- tosis. Definition. A condition characterized by a falling of the abdominal viscera VISCEROPTOSIS. 367 to a level lower than the normal and due to a relaxed state or stretching of the mesenteries and peritonaeal ligaments combined with relaxation of the muscular wall of the abdomen. The ptosis may involve the liver, spleen, stomach, intestines and kidneys. Etiology. This condition is more common in women in the proportion of about 3 to I, this fact probably being due to the wearing of over-tight corsets and the extraordinary stretching of the abdominal wall attendant upon preg- nancy. The loss of muscular tone and of fat resulting from prolonged inflammations of the alimentary tract, from the wasting diseases, excessive loss of blood, etc., and over-exertion predispose to downward displacements of the abdominal viscera. Glenard's original hypothesis that a dislocation of the hepatic flexure of the colon caused by a stagnation of faecal matter is the beginning of a general ptosis is probably less correct than the theory that the condition is due to factors such as those mentioned above. Of late the idea has been advanced that there may be a congenital predisposition to visceroptosis since in the foetus and even in the newly-born child the viscera may occupy an analogous position in the abdominal cavity. The fact that the displacement may not involve all the abdominal organs must not be overlooked, for it is not unusual to find a kidney, the stomach, the liver or the spleen in abnormal locations. Symptoms. These are indefinite and indeed the condition may exist without causing any symptoms whatever. In general, however, the patient complains of various dyspeptic symptoms, such as poor appetite, sensations of distention and weight and eructations and rumblings in the digestive tract. Rarely the appetite may be increased; the bowels are usually constipated, though the opposite condition may be present. The breath may be foul, the tongue coated and the mouth dry. Nervous manifestations, such as dizziness, depression of spirits, headache, sleeplessness, palpitation, and tin- gling and sensations of cold in hands and feet are frequent. Considerable bodily emaciation is not rare. A chlorotic condition of the blood often accompanies this condition. Physical examination reveals an abdomen prominent and baggy in its lower part, relaxed and thin of wall. On palpation the abdomen has a characteristic doughy feeling and splashing sounds may be easily elicited. The edge of the liver, when this organ is displaced, may be felt lower than normal, the kidneys and spleen may be palpated. Percussion of the liver shows its upper limit to be displaced downward. The displacement of the stomach may be demonstrated by any of the means described under gastric dilatation (p. 362 and ff.) and it may be shown to be in a position more vertical than normal, its cardiac end usually being in the normal situation and the pylorus far from its proper site. Treatment. Drugs have no great part in the management of this condition 368 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. the principal object being to replace the abnormally situated viscera and to maintain them in their normal position. This may best be done by putting the patient in bed, keeping him there and fattening him. He should be over- fed and as adjuvants to this treatment faradic electricity and the high fre- quency current may be employed. Physostigmine salicylate in doses of gr. y^o" (0.0006) three times a day is usefiil to restore the tonus of the intestinal musculature. This may be given alone or in combination with strychnine sulphate gr. ^o" to -j^ (0.003-0.0025) and capsicum, gr. i (0.065). The bowels should be kept open by means of vegetable laxatives such as aloes or rhamnus purshiana if necessary, but the diet should be depended upon to regulate this function in so far as possible, fruits and foods leaving an undigested residue being particularly indicated. When diarrhoea is present it may be controlled by intestinal antiseptics such as bismuth subsalicylate, resorcinol or benzo-naphthol, and when gastric analysis shows hydrochloric acid to be diminished in quantity this substance may be supplied. When the cure by means of rest in bed is inconvenient or impossible the patient may receive much relief from wearing a properly fitting abdominal binder such as can be furnished by any reliable truss maker. The patient should be taught by his physician how to replace the viscera and this should be done in bed each morning and the belt applied before the erect position is assumed. As a substitute for the abdominal band strapping with zinc oxide adhesive plaster (preferably spread on moleskin) strips has been suggested and often achieves excellent results (Rose). It should hardly be necessary to state that tight lacing is contraindicated in ptosis of the viscera and that women should be advised to wear skirts suspended from the shoulders rather than from the hips. Physical methods such as massage either by the physician or the patient himself, moderate exercise, such as bicycling, golf, etc., and hydriatic pro- cedures have a place in the management of this condition after the rest cure- has succeeded in restoring the organs to their normal situations. The dietetic treatment of visceroptosis offers difficulties. The problem in hand is to fatten an individual whose powers of digestion and assimilation are impaired and to over-feed such a patient without disturbing his already poor digestive ability is not an easy task. And again the difficulty is enhanced by the fact that the regimen for each patient must be chosen with reference to his particular capabilities. During the early part of the rest cure a milk diet should be instituted if the patient can digest and is satisfied with it, later more latitude may be allowed and, if the digestive powers permit, a general diet should be prescribed. If the patient is not undergoing the rest cure and is up and about he should not eat large quantities at a time lest the stomach become over-loaded and the NEUROSES OF THE STOMACH. 369. ptosis accentuated; here four or five small meals per day of concentrated food stufis are preferable to three of large or ordinary size. Fats may be eaten if they can be digested. Gastric analysis and observation of the case in hand will indicate far better the proper diet than can any list of food articles arbi- trarily set down. Surgical measures, such as taking reefs in the lengthened mesenteries, suturing the lesser curvature of the stomach or its anterior wall to the anterior parietes of the abdomen and suturing the edges of the recti abdominis muscles together after having removed the intervening tissues, have been employed with varying results. NEUROSES OF THE STOMACH. HYPERCHLORHYDRIA. Synonyms. Gastric Hyperacidity; Gastrosuccorrhoea; Gastroxynsis; Nerv- ous Hypersecretion of Hydrochloric Acid. Definition. Excessive secretion of hydrochloric acid by the gastric tubules occurs in various gastric disorders but there is a class of cases in which there is a hypersecretion of gastric juice which takes place in the absence of food or of any inflammatory condition. It is usually considered a neurosis and exists in two chief forms. a. Paroxysmal hyperchlorhydria. h. Continuous hyperchlorhydria. This is a chronic state and was first described by Reichmann whose name has since that time been associated with the condition. .etiology. Hvperchlorhydria has no distinct causative factor. It is most frequently observed in persons of neurotic temperament. It is more common in the young and middle-aged and is often seen in chlorotic subjects; it is predisposed to by various mental influences such as grief, worry, etc. Some subjects are afflicted with it directly after eating or drinking certain substances. Symptoms. These are practically identical in the two forms except that in the paroxysmal variety they appear intermittently while in the continuous type they are always present. The most prominent symptoms are pain refer- red to the stomach, "heart burn," the eructation of gas, thirst and nausea. Vomiting is infrequent and when present the very acid taste of the vomitus is noticed. Headache is common. The appetite is usually good and the bowels are, as a rule, constipated. The acidity of the urine may be reduced owing to the excess of gastric acidity. In the paroxysmal form of the disease the symptoms may last only a few hours or may be prolonged for a number of days to be terminated by treat- 24 370 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. ment or in an attack of vomiting. In the continuous type the pain is more marked and if untreated the patient may lose flesh and strength. In long standing cases anaemia is not rare. The prognosis as regards improvement is very favorable and cures are not infrequent. The diagnosis can be made certainly only by means of chemical analysis of the gastric contents. A test-meal removed two or three hours after ingestion will consist of a small amount of thoroughly digested food containing an excess — jsometimes very large — of combined, and especially, free, hydro- chloric acid. If the stomach is washed and several hours later — nothing having been ingested in the meantime — the contents of the organ is expressed this will be found to consist chiefly of gastric juice, where normally none should be present. Treatment. The neutraHzation of the excessive acidity present in the stomach by means of the alkaline carbonates — sodium bicarbonate in par- ticular — has its disadvantages, the resulting sodium chloride from the com- bination of sodium bicarbonate and hydrochloric acid being ready for forma- tion into still more of the offending substance; however, certain observers claim that benefit results from the administration of considerable doses of sodium bicarbonate — lo to 30 grains (0.66-2.0) — after meals; a far preferable antacid, however, is heavy magnesia which results in the formation of mag- nesium chloride which acts as a laxative and is carried off from the body. Some clinicians prefer to give it with sodium bicarbonate, but it is better administered in a combination such as the following : I^ magnesiae ponderosae, gr. X (0.66); pulveris rhei, gr. v (0.33); extracti belladonnae, gr. j-q (0.018); to be taken J to i hour after each meal. Sodium bicarbonate in amount equal to that of the magnesia may be added with benefit in some cases. Other useful formulae are: I^ potassii carbonatis, magnesiae ponderosae aa gr. xii (0.75); extracti belladonnae gr. yt(o-oi8); sacchari lactis gr. xv (i.o). Misce et signa, to be taken about an hour after meals. Sodium bicarbonate may be added to this formula also. I^ sodii bicarbonatis, cretae praeparatae, mag- nesii carbonatis aa gr. iii (0.2). Misce et signa, to be taken after meals. Belladonna is said to lessen the secretion of the gastric juice and it and atropine are also useful in combating the severe pain. This symptom may be rendered less distressing by various narcotic drugs as weU, codeine and strontium, ammonium or sodium bromide being most frequently prescribed. Morphine should not be administered. Pain which resists drug treatment may be relieved by gastric lavage, which removes the hyperacid contents of the stomach. To the last of the water used it is well to add sodium bicarbonate. Washing with a mixture contain- ing bismuth subgallate and bismuth subcarbonate of each i drachm (4.0) to the quart (litre) of water is an excellent measure. HYPERCHLORHYDRIA. 37 1 Intra-gastric sprays of silver nitrate solution (i-iooo) are said to have the double effect of lessening the secretion and relieving the discomfort. Follow- ing this procedure the stomach should be washed with warm water. The drinking of considerable quantities of Carlsbad water, natural or artificial, tends to lessen the production of hydrochloric acid by the stomach and in hypochlorhydria in lithaemic subjects the use of artificial effervescent solutions made according to the following formulae is beneficial. a. b. Sodium bicarbonate 5^^ (8.0). gr. Ixxv (5.0). Sodium borate 5^5 (2.0). gr. xv (i.o). Sodium salicylate gr. xxxvii (2.5). 5ss (2.0). Each of these mixtures is to be added to a quart (litre) of ordinary carbonic water and before breakfast a half tumbler of solution a is to be taken. After meals a half tumbler of solution b should be drunk. Constipation usually yields to the treatment directed at the neutralization of the acidity. If obstinate, the saline waters, abdominal massage, intestinal lavage and the preparations of rhubarb will prove effectual. Electricity in the form of intragastric galvanism may be employed, the anode to be applied inside the stomach, which should be partially filled with lukewarm water, while the cathode is placed upon the epigastrium or back. Diet. Certain clinicians advocate a diet consisting chiefly of proteid substances, since the albuminous foods combine with the excessive hydro- chloric acid, while others consider much carbohydrate and little proteid to be better adapted to the gastric condition because the latter class of foods tends to cause increased hydrochloric acid secretion, but the proper method of deciding upon a suitable diet in these cases is to study each patient. It is probably true, however, that more patients will do well upon a diet principally of proteid. Of the meats, beef, mutton, veal, pork, raw or cooked ham and fowl are allowable, as are eggs, Roquefort and Swiss cheese, cocoa and milk. Fats are not contraindicated but it is generally considered that vegetables containing large amounts of starch are better omitted. Since the period of starch digestion is shortened, owing to the abnormally early secretion of hydrochloric acid after the ingestion of food in this condition, starchy foods should be eaten, when possible, dextrinized, toast, zwieback and the like being preferable to plain bread. Coffee, beer or other alcoholics should be forbidden but the drinking of considerable quantities of alkaline waters with meals is permissible since by this means the excessive gastric juice is diluted. All substances likely to increase the secretion of gastric juice, such as condiments, spices, fruits containing seeds or enveloped in skins, etc., should not be eaten and the food should be taken finely divided and neither very hot 372 DISEASES OF THE DIGESTIVE SYSTEM AKD PERITONEUM. nor very cold. The patient should be advised to masticate thoroughly so that mouth-digestion may be as fully accomplished as possible. The chewing between meals of substances calculated to excite the secretion of saliva has been advocated with the idea that the swallowing of this secretion in large amounts tends to neutralize the gastric acidity, but is of slight value. An attack of pain after the evening meal may be relieved by a glass of warm milk, a cup of broth containing an egg, a soft boiled egg or some raw ham finely scraped. Any of these substances takes up a large quantity of hydro- chloric 'acid. The treatment of paroxysmal hyperchlorhydria consists in the employment during the attack of the means suggested for chronic hyperacidity on p. 370, together with gastric lavage and the application of a mustard paste or hot water bag to the epigastrium. Strontium bromide or ammonium bromide, ^ drachm (2.0) three times a day is said to shorten and to lessen the fre- quency of the paroxysms. The general management of the condition consists in abstention from mental over-activity and in regulation of diet and exercise. Alcohol, tobacco, coffee and aU other stimulants should be interdicted and a life of recreation and free from care and worry should be ordered, and exercise out of doors — the bicycle, golf, tennis, riding, swimming, etc. — should be advised. Dietetically and otherwise the treatment may be carried out along the lines laid down for continuous hyperchlorhydria. HYPOCHLORHYDRIA. Hypochlorhydria, subacidity or hypochylia, is a condition of the stomach in which the gastric juice contains an abnormally small amount of hydro- chloric acid and also of the digestive ferments. It exists in various abnor- malities of the organ, such as gastritis and cancer, in anaemic conditions, during the infectious diseases and in neurotic states; the subacidity of these last conditions, the true nervous hypochylia, occurs in hysteria, locomotor ataxia, etc. Entire absence of hydrochloric acid which is denominated achylia gastrica occurs in hysteria and neurasthenia, in carcinoma, and as a result of the atrophy of the gastric glands due to chronic inflammations. The symptoms of diminution or entire absence of hydrochloric acid and gastric ferments are not typical and the condition may exist for long periods without causing complaint on the part of the patient; when, however, in addi- tion to the secretory disturbance, the motor power of the organ is impaired, the consequent fermentation of stagnant food results in distention, eructations, sensations of weight and fidlness and at times marked gastralgia. Diarrhoea may be present. The diagnosis can be made only on chemical examination of the stomach CARDIOSPASM. 373 contents withdrawn after a test-meal. This shows diminution or entire absence of both free and combined hydrochloric acid and of the gastric fer- ments. Lactic acid is rarely found in nervous hypoacidity. The treatment of both hypochylia and achylia consists in the administration of dilute hydrochloric acid to supply the lack of this substance in the stomach. The dose should be regulated with regard to the amount present in the gastric secretion. When the acid is wholly absent as much as 15 to 20 drops (i.o- 1.33) may be given half hourly after meals until 3 doses have been taken. It must be plentifully diluted and taken through a tube. The administration of pepsin, pancreatin, and especially of fresh pineapple juice, which contains a digestive ferment, may supply the loss of the normal digestive ferments. Loss of appetite may be relieved by basic orexin and by gastric lavage with solutions of the vegetable bitters such as gentian or quassia. In atony of the gastric musculature strychnine nitrate in large doses — gr. 3^ to -2V (0.002-0.003) is indicated and this drug also exerts a favorable action upon any co-existent neurotic condition. Stagnated and decomposed food should be washed out and the stomach irrigated with a disinfectant solution (see p. 339); electricity and hydrotherapeutic procedures are useful adjuncts to the treatment. The diet should be adapted to the digestive capabilities of each patient. Meat need not be interdicted, in fact it is better that the patient eat some meat, this should, however, be taken in a finely divided condition. Green vegetables and puree soups may be taken; fats in the form of cream and butter are allowable unless they cause fermentation. Salty substances such as anchovy paste, caviar, etc., taken before meals in small quantities, increase both the appetite and the gastric secretion. CARDIOSPASM. Synonym. Cramp of the Cardia. This is a spasmodic contraction of the gastric musculature at the cardiac end of the stomach and is usually the result of some irritation such as h)^er- acidity, or distention of the stomach by air or gas. It also occurs as a symptom of neurasthenic and hysterical conditions and very rarely as a true neurosis of the motor system of the organ. It exists in an acute and in a chronic form; the former appears paroxysmally and lasts but a short time, the latter is a serious condition and one difficult of management. The acute variety, when occurring in an empty stomach, gives no symptoms; on a full stomach it produces a spasmodic and cramp-like pain which soon passes; if food or drink is taken during the cramp there may be obstruction to deglutition. In the chronic form the patient may also have difficulty in swallowing and feel that the food stops before entering the stomach. If he continues to eat the 374 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. oesophagus gradually fills and finally the food is regiu-gitated little changed and containing no gastric juice. The inability of food to reach the stomach brings on a progressive emaciation which is likely to cause suspicion of carci- noma, and the accumulation of ingesta in the oesophagus may result in dilata- tion or diverticulum formation. There is likely to be obstruction to the passage of the stomach tube. Treatment. This consists in the appropriate treatment of any co-existent inflammation or secretory disorder of the stomach. The food should be non-irrhant, easily digestible and taken in finely divided form. In the severer grades of this condition milk diet or feeding through the stomach tube may be necessary although it is stated that at times solids are more easily swallowed than liquids. Any constitutional neurotic condition should receive proper treatment. The insertion of a firm tube of good size through the cardiac orifice and allowing it to remain in place for a half hour at a time is an approved method of treatment. Before eating, the gastric mucosa at the cardia may be cocainized by a small sponge fixed at the extremity of a stomach tube by means of a thread passed through the tube. The sponge should be saturated with 2-4 percent, cocaine hydrochloride solution, the tube passed as far as the cardia and the cocaine solution expressed by puUing the thread. An intragastric spray of cocaine, or cocaine and menthol solution may also be employed to produce anaesthesia. The use of the galvanic current is an excellent measure in spasm of the chronic type; the anode is introduced into the cardia, the location of which has previously been ascertained by measurement, the cathode is applied to the back of the neck and a current of about 25 milliamperes is employed for 10 minutes; the anode is then placed over the stomach and the cathode within the cardia and the process repeated. PYLOROSPASM. This condition is analogous to cardiospasm, but takes place at the pyloric extremity of the stomach. It occurs in excessively acid states of the organ, accompanying gastric dilatation, as a result of the action of caustics, and as a concomitant of pyloric ulcer or cancer. The interference with the passage of stomach contents through the pylorus results in stagnation and fermentation and finally in dilatation with the accom- panying symptoms of these conditions. In thin subjects the gastric peris- talsis may be visible and in some cases reversed peristalsis with vomiting takes place. Treatment consists in the exhibition of sedatives, such as the bromides, strontium bromide, 15 to 20 grains (i. 0-1.33), codeine phosphate, ^ to ^ a grain (0.016-0.03) or extract of belladonna, ^ to ^ a grain (0.016-0.03) three times a day. Hydrated chloral may be used but is dangerous because of the GASTRIC HYPERPESISTALSIS. 375 possibility of establishing the habit. The spasm may be controlled by the intragastric cocaine spray, and intubation of the pylorus, allowing the tube to remain in place for about 10 minutes is recommended. The galvanic current may be used as described under the treatment of cardiospasm. All food which may irritate the stomach, and over-burdening the organ with large amounts of food should be avoided. GASTRIC HYPERPERISTALSIS. Synonym. Peristaltic Unrest. This is a condition characterized by rapid and continuous contractions of the stomach. The movements are most marked after meals, but sometimes occur when the stomach is empty and may persist through the night. Little or no pain is present but the patient complains of uncomfortable sensations referred to the stomach. Gastric hyperperistalsis is the result of an increased irritability of the sensory or motor nerves of the organ due to a reflex result- ing from gastric hyperaesthesia or to irritation from excessive acidity, fermenta- tion or distention; it may occur with pyloric stenosis. The contractions may be felt by the examiner's hand and at times when very active, may be seen as well. The symptoms are loss of appetite, eruc- tations, nausea and vomiting. In severe cases the patient may lose flesh and strength and the continuous discomfort brings on a neurotic condition. At times the small intestine may take part in the excessive peristalsis and cause the regurgitation into the stomach and even the vomiting of intestinal contents. Treatment. The drug treatment is identical with that of pyloric spasm and the patient should be advised to lead a regular and quiet life, avoiding mental and physical exertion. Intragastric galvanism and hydrotherapeutic procedures are useful adjuvants. Only easily digestible foods shoifld be aUowed in order to avoid all irritation of the stomach and possibility of dis- tention by means of fermentation products. A rest cure with rectal alimenta- tion continued for a fortnight may bring about good results in severe cases. MERYCISM OR RUMINATION. Definition. This is a condition in which the patient voluntarily causes his food to return to the mouth where it undergoes further mastication and is swallowed again or expectorated. It occurs in individuals of neurotic habit as a rule and in marked cases the food is regurgitated after every meal, the patient often asserting that the act causes pleasant sensations. The condition of the gastric secretions is not uniform but a subacidity seems to exist in most cases. 376 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Treatment consists in the correction of secretory disorders by the use of hydrochloric acid or alkalies as the case may be. The patient's nervous and general condition should receive attention and he should be enjoined to masticate slowly and thoroughly. He should be encouraged to resist the impulse to raise his food and to combat the habit with the utmost strength of his wiU. Bits of cracked ice taken after meals are said to be useful and intra-gastric electricity may be employed. The administration of lo grains (0.66) of quinine sulphate after each meal may break the habit by rendering the food unpleasantly bitter. The diet of these patients should consist chiefly of easily-digested fluids and semi-solids. NERVOUS ERUCTATION OF GAS. This symptom is often seen in hysterical and neurasthenic patients. The gas raised is usually tasteless and consists chiefly of swallowed air, and various gastric symptoms may or not be co-existent. The belching frequently occurs in paroxysms but at times is almost continuous. Treatment consists in teaching the patient to guard against swallowing air. This is a habit which a little thought and attention on his part can stop; keeping the mouth continuously open for a half hour or so at a time may be tried for air cannot be swallowed when the mouth is open. The neuras- thenic or hysterical condition should receive general treatment to which massage and hydrotherapeutic measures are useful adjuncts. The bromides, arsenic and belladonna may be employed, and the following pill may be found effectual: I^ extract! physostigmatis, gr. yV (0.006); extract! belladonnas, gr. -g- (0.012); strychninse sulphatis, gr. yg- (0.0015). Signa; one pill three times a day. Purinaemic conditions may result in neurasthenia and when such are accom- panied by nervous eructation the treatment is plainly that of the causative factor. GASTRIC HYPERESTHESIA. This is a sensory disturbance of the stomach in which the ingestion of food results in pain referred to the organ, at times so great as to cause reluctance on the part of the patient to eat. Hysterical individuals may assert that only certain articles of food cause the distress while others may be eaten with impunity This neurosis often occurs in anaemic and chlorotic conditions, after periods of over-eating or indulgence in indigestible foods and as a result of sexual or alcoholic excesses. Another cause is hyperacidity and the condition may also exist in organic nervous diseases such as locomotor ataxia. GASTRALGIA. 377 Symptoms. These are distress after eating and nausea, often followed by vomiting. When the stomach is empty they are absent. Often pulsation of the aorta is complained of and constipation is usually present. Diffuse tenderness over the region of the stomach is frequently observed and other nervous manifestations such as headache and various neuralgias are common. Examination of the stomach contents reveals nothing characteristic. Treatment. Attention should be given to the constitutional condition, if this is the causative factor, and a rest cure is frequently effectual. The pain itself may be controlled by hot applications and the use of an intra-gastric spray of cocaine and menthol, care being taken to control the amount of the former drug. Intra-gastric galvanism is appropriate, and when the intra- gastric electrode cannot be used external galvanism with the electrodes applied to the abdomen may be employed. Silver nitrate gr. I (0.016) in 2 drachms (8.0) of peppermint water taken in water a half hour before each meal has been suggested, and the bromides and codeine may produce good results. The diet should at first be of milk taken a small quantity at a time. Later, as the condition becomes ameliorated, eggs and semi-solids may be allowed, and finally a return to solid food may be permitted. Later massage, hydro- therapeutic measures, moderate exercise, and a change of climate are to be recommended. Alcohol, tobacco and the abuse of tea and coffee should be forbidden. GASTRALGIA. Synonyms. Gastrodynia; Gastric Neuralgia. This is an affection characterized by severe paroxysmal pain referred to the stomach. The pain may be localized in the epigastrium or may radiate to any part of the abdomen or to the back. It occurs in motor and secretory neuroses, and in various other gastric lesions such as ulcer and cancer, in certain nervous diseasel, such as tabes dorsalis, during infectious diseases, especially malaria, in nervous and hysterical conditions and as a reflex pain the result of diseases of the genito-urinary organs, particularly in women. Idiopathic gastralgia occurs in chlorotic and anaemic states, in convalescent conditions, nephritis and various toxaemias, and especially in incipient pul- monar}^ tuberculosis. The fact that it often manifests itself in early phthisis is responsible for much mistaken diagnosis and treatment, many of these patients putting themselves in the hands of the gastrologist who is apt to miss the true causative factor of the condition. The attacks of pain usually begin suddenly and are at times so severe as to be almost unendurable, perspiration appears upon the forehead, the pulse is weak and may be faster or slower than normal. There may be suppression of urine; the bowels are usually constipated. The patient is much prostrated. 378 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. As the severity of the paroxysm wanes the patient begins to yawn, belches gas and may vomit. Treatment consists in the proper management of the underlying cause when this can be ascertained. If no cause can be found symptomatic treat- ment must be instituted. Various analgesic drugs such as codeine sulphate, ^ grain (0.03) every 3 or 4 hours, chloroform water, i to 2 drachms (4.0- 8.0), hydrated chloral, 10 to 15 grains (0.66-1.0), hyoscyamus, belladonna, etc., may be employed. In cases with cardiac depression compound spirit of aether may be given and stimulation by means of aromatic spirit of ammonia or alcohol may be necessary. Acetanilide, methyl acetanilide (exalgin), pyramidon (a derivation of antipyrine) and other antineuralgics are recom- mended. In cases characterized by very severe pain opium may be em- ployed but only with the greatest caution lest the habit become formed. It is best given in the form of opium and belladonna suppositories or hypo- dermatically as morphine sulphate in connection with atropine. These drugs are useful only in lessening the patient's pain and have no curative effect; the routine employment of electricity is an excellent method of treatment. The faradic current may be employed but the galvanic is likely to accomplish better results, a current of 25 milliamperes at least, being necessary. Large flat electrodes are used, they are moistened in water as hot as can be borne and applied, the anode to the epigastrium and the cathode to the interscapular region. Gastric lavage with a mixture of a pint (500.0) of camphor water, and bismuth subgallate 5i (4.0), and bismuth subnitrate 5ii (8.0) is said to be efficacious. The camphor water should be measured as it returns and not more than an ounce (30.0) allowed to remain in the stomach. The diet shoidd consist of easily digestible foods. Spices, condiments alcohol and excessive amounts of tea and coffee are to be avoided. BULIMIA. , Synonym. Hyperorexia. Bulimia is a condition characterized by an excessively large appetite. It occurs chiefly in persons affected with functional or organic nervous disease such as hysteria, epilepsy, brain tumors, etc., with intestinal parasites, uterine diseases and various gastric conditions. The hunger comes on suddenly, at times even directly after a full meal. The symptom is almost irresistible and if it is not appeased palpitation of the heart, paleness, faintness, noises in the eg-rs and gastric pain ensue. In some cases even small amounts of food suffice to cause a disappearance of the symptoms. Treatment must be instituted with a view to improvement in the cause of the neurosis. The nervous system, the genito-urinary system, the stomach or whatever part may be at fault must receive appropriate treatment. The ANOREXIA NERVOSA. 379 bromides are useful, Fowler's solution in doses increased to the limit of tolerance is recormnended and the administration three times a day of one drachm (4.0) of camphorated tincture of opium or of 2 drops (0.13) of the tincture of bella- donna in 2 or 3 drachms (8.0-12.0) of simple elixir may prove effectual. Gastric atony, if present, may be treated by massage and strychnine and intra-gastric faradism should achieve good results. Lavage with warm and cold water alternately may be employed. ANOREXIA NERVOSA. Nervous anorexia is a state in which the appetite is wholly lost and the sense of hunger unknown. This manifestation may last for months, even while the digestive apparatus is perfectly normal in condition. The neurosis is more commonly seen in female subjects and is predisposed to by hysteric and neurasthenic conditions. It also occurs in chlorosis and in individuals addicted to the abuse of drugs, especially alcohol, tobacco and opium. The degree of the distaste for food determines the prognosis of the affection. Those subject to this manifestation become progressively anaemic and lose flesh and strength, the pulse is weak, the extremities are cold. Insomnia is common. The diagnosis of the affection is simple but that of its cause is more difficult. Treatment consists in combating the anaemia and the nervous condition by appropriate medication and in properly managing any co-existent organic dis- ease. The rest cure — putting the patient away from outside influences and in the hands of a trained attendant, and over-feeding him — is an excellent method; in this connection electrical and balneo-therapeutic measures and mas- sage are to be employed, as well as any means in the line of suggestion that the physician may be able to use. If the refusal to eat is carried to extremes there should be no hesitancy in employing forced feeding by gavage. If the repug- nance to taking food is due to discomfort attendant upon this act the admin- istration of sodium bromide — 10 to 15 grains (0.66-1.0) — before meals may overcome this disinclination. Orexin — 5 to 10 grains (0.33-0.66) — before such meals in a little warm bouillon may cause a distinct increase in appetite and the following formulae may be found useful: I^ tincturae cinchonae, 5ss (2.0); acidi sulphurici diluti, Tixvii (0.5); syrupi zingiberis, Siiiss (14.0). Misce et signa, take before meals through a tube in a claret glass of water. ^ fluidex- tracti condurango, ir^xlv (3.0); strychninas sulphatis, gr. ^^^q- (0.0015); acidi hydrochlorici diluti, tt^x (0.66); elixiris gentianae, q.s. ad Sss (15.00). Misce et signa, take in wine glass of water before each meal through a tube. CYCLIC VOMITING. Definition. Cyclic, paroxysmal, periodic or recurrent vomiting is a con- dition seen in children and characterized by the sudden appearance of violent 380 DISEASES OF THE DIGESTIVE SYSTEM AND PERITON^UM- and persistent emesis which may persist long after the stomach has been entirely emptied. The attacks usually appear when the child is about two years old and recur with a lessening degree of frequency as puberty approaches when they cease. The intervals vary in different cases, being from a few weeks to a few months, and at times the vomiting is so severe and continuous as to bring about a condition of collapse which has been known to result fatally. The aetiology of this condition is not definitely known but it is probable that it is a disorder of metabolism. Both acetone and diacetic acid have been foun^ in the urine preceding or diiring the attack. Treatment at times will be found to have little effect but the administration of large doses of sodium bicarbonate — 100 to 125 grains (6.66-8.33) P^^ ^^.y — is the most approved method and may succeed in aborting or cutting short the paroxysm. It has been suggested that fats — except fresh butter — are. not well borne by patients subject to this manifestation and that too large a carbohydrate content in the diet may produce digestive changes which favor the occurrence of the vomiting. During the attack it is better not to attempt to feed the patient but if the paroxysm is protracted rectal feeding may be instituted and at aU times it is well to administer water by this route to allay the thirst — 6 to 8 ounces (300.0-500.0) 4 or 5 times a day being sufl&cient quantity. When the attack has ceased the first foods allowed may be broths, smaU amounts of cold milk and lime water, equal parts, and barley water. Attention should be given to the patient's general hygiene during the intervals of the paroxysms. H^MATEMESIS. The vomiting of blood is a symptom of various morbid conditions of the stomach and has been discussed at length in the sections devoted to the dif- ferent affections in which it occurs. It results from the rupture into the viscus of blood-vessels in its walls, from the regurgitation of blood from the intestine or from the swallowing of blood — later to be vomited — which has been extravasated from vessels of the nose, pharynx, or oesophagus. That blood may be raised from the respiratory tract, swallowed and finally vomited must not be forgotten. Haematemesis occurs in injuries of the stomach, either from outside trauma- tism or as a result of the ingestion of caustic substances, in neoplasms of the organ, in diseases of the organ, such as gastritis of any kind, ulcer, etc., in diseases of other organs, notably hepatic cirrhosis, in malignant forms of the infectious diseases, yellow fever, smallpox, etc., and in constitutional diseases such as purpura, haemophilia and pernicious anaemia. Vomiting of blood has been observed after the rupture of aneurysms into the oesophagus. The condition of the blood vomited depends upon the length of time which DISEASES OF THE INTESTINE. 38 1 it has lain in the stomach. If fresh it may be bright in color and otherwise little changed. If it has been subjected to the action of the gastric juice it is likely to be dark and may be of "coffee -ground" appearance. The differ- entiation of haematemesis from haemoptysis may usually be made on the following points: Vomited blood is usually dark in color, not frothy, and often is acid in reaction, while blood from the respiratory tract is light red or pinkish, is likely to contain an admixture of air and is consequently frothy, and is alkaline in reaction. In haemoptysis the stools are not "tarry," while in gastric haemorrhage the blood which has passed through the pylorus appears in the stools, imparting to them a black color. The symptoms of gastric haemorrhage are those of loss of blood from any other part, viz., paleness, prostration, rapid, feeble pulse, subnormal temper- ature, air hunger, depression, faintness, and cold clammy skin. Fortunately death, from this cause primarily, seldom occurs. The treatment of haematemesis has been fully dealt with in the section relating to the management of gastric ulcer (p. 352). DISEASES OF THE INTESTINE. SIMPLE ACUTE CATARRHAL ENTERITIS. Synonyms. Acute Diarrhoea; Acute Intestinal Catarrh; Acute Ileo-colitis. Definition. An acute inflammation involving the small intestine and at times the upper portion of the colon. .Etiology. This disease is more common during the hot months and espe- cially in children. The heat is not so much a direct cause as it is a predis- posing one, since it diminishes the bodily resistance and increases the suscep- tibility of the intestinal tract to the influences of over-eating or improper food. Acute intestinal catarrh often follows excessive indulgence in food or drink, particularly if the substances taken are impure, such as unripe or decayed fruit, decomposed food, contaminated drinking water or the like. The ingestion of irritant drugs such as mercury bichloride or arsenic may cause intestinal inflammations and the condition is also predisposed to by any sudden chilling of the body. Excessive or diminished secretion of bile may be mentioned as causes, the latter since it may favor fermentation by depriving the intestine of the supposed antiseptic effect of this fluid. Enteritis often accompanies certain of the infectious diseases and is pre- disposed to by conditions of congestion of the intestine such as occur in cardiac and hepatic lesions and by inflammations of adjoining structures such as the peritonaeum. Chronic wasting disease, tuberculosis, cancerous states, anaemia, etc., may be complicated by acute diarrhoea. Pathology. The mucous membrane lining the intestine is first congested, 382 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. red and swollen; the secretion is at first diminished but later there is an exces- sive production of mucus, with exfoliation of the epithelial cells; the solitary- follicles are hypersemic and swollen and may become filled with pus; such tiny abscesses may rupture leaving an ulcerating surface. In severe forms of the inflammation the agminated follicles also may be involved in like manner. Chronic inflammation may resiilt in rare instances. Symptoms. Diarrhoea is the most characteristic of these. The evacua- tions at first consist of ordinary faecal matter, but as they continue they contain bile, mucus, and finally become watery. In severe cases blood may be present. They vary in number from 5 or 6 to 15 or 20 per day, and may be accompanied by colicky pain and tenesmus. They are likely to be foul at first and accompanied by gas, later they may lose their odor. Loss of appetite is the rule and nausea and vomiting may be present. A rise of tem- perature of 2 or 3 degrees F. may accompany the diarrhoea, and thirst and diminished urine are noted as a result of the loss of water through the intes- tinal tract. Physical examination reveals little more than slight diffuse abdominal tenderness, meteorism and gurglings in the intestine. When the inflammation is localized various symptoms may call attention to probable involvement of particular portions of the intestinal tract. If the skin, conjunctivae and urine are colored with bile pigment it is probable that the inflammation particularly affects the duodenum. If the jejunum and ileum are involved to the exclusion of the large intestine diarrhoea is absent, but the pain, distention and other symptoms are present; the diagnosis of inflammations affecting this portion of the alimentary tract alone is difficult and of little practical value. When the morbid condition involves both the small and large intestine mucus is present and may be observed distinct and separate from. the faeces which may contain bits of undigested food. The diagnosis of acute intestinal catarrh should present no great difficulties; it may be differentiated from enteric fever by its short duration, lack of charac- teristic temperature curve, absence of exanthem and of Widal reaction. The condition is not a serious one, recovery under proper treatment taking place within a few days. Treatment. In mild cases the patient need not be confined to his bed but should refrain from exertion of any sort. Certain cases need no treatment further than a strict milk diet, for as soon as the intestine has by its own action rid itself of the cause of the inflammation, spontaneous recovery takes place. In most cases, however, it is better to aid nature by administering a laxative which shall hasten the passage of the offending substance. The laxatives most frequently employed are calomel and castor oil. The former is best given in doses of i to ^ a grain (0.016-0.03) every half hour until 6 doses are taken, it exercises, in addition to its purgative action, an antiseptic effect upon the CHRONIC CATARRHAL ENTERITIS. 383 intestine, while castor oil, which should be given in single dose of 2 to 4 drachms (8.0-16.0), has the advantage of a slightly constipating after-effect. The emptying of the bowel may be facilitated, especially in children, by irrigation of this viscus vAih warm normal saline solution by means of a rectal tube or soft rubber catheter and a fountain s}Tinge. W^en intestinal astringents or antiseptics are necessar}' on account of the prolongation of the diarrhoea, any of the salts of bismuth may be given, the subsalicylate — gr. x to xx (0.66-1.33) every 4 hours — being especiaUy eft'ectual. Bismuth naphtholate (orphol) 5 to 15 grains (0.33-1.0), resorcinol — gr. ii to %dii (0.13-0.5) — or phenyl salicylate (salol) — gr. ii to v (0.13-0.33) — may also be employed. If the diarrhoea still persists, opium in sufficient doses of the powder, the tincture or of Dover's powder, as suppositories or in the form of an opium and starch enema — one or two teaspoonsful of starch, I to 2 grains (0.065-0.13) of powdered opium, 8 ounces (240.0) of warm water, should be given. For the constipation resulting from the use of opium laxatives need not be given since the bowels will, as a rule, move normally after a few days. The h\^odermatic administration of morphine may be necessary in severe cases when frequent vomiting and purging preclude the exhibition of opium by mouth or rectum. The abdominal pain may be controlled by hot or cold compresses. Diet. During the first day or two of the attack as little food as possible should be allowed and that preferably in the form of milk. As the condition becomes ameliorated other non-irritating foods such as bouillon, soft boUed eggs, milk toast, etc., may be eaten to be followed as the diarrhoea ceases by sweetbreads, calf's brain, scraped beef, meat jeUies, the white meat of chicken and mashed potatoes. Green vegetables, fruit and all irritating and indigesti- ble articles of diet should be omitted from the diet for some time. CHRONIC CATARRHAL ENTERITIS. Synonyms. Chronic Diarrhoea; Mucous Colitis; Chronic Entero-colitis; Ulcerative Colitis. Definition. A chronic catarrhal inflammation of the small and large intes- tine, characterized by the excessive production of mucus, and at times, the development of ulcers. ^Etiology. This disease may follow attacks of acute entero-colitis or of dysentery. The disease may occur primarily, and it is predisposed to by cardiac lesions, hepatic cirrhosis or any other condition attended by chronic h}'per£emia of the digestive tract, by conditions of feeble nutrition, purin- aemic states, and chronic wasting diseases such as anaemia, nephritis or phthisis. It may foUow the infectious diseases, notably malaria and cholera. 384 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Pathology. At first the pathological state is that of acute catarrhal enteritis; these lesions become permanent and in marked cases ulcerations of the lymph foUicles take place with consequent haemorrhage, and, when the ulcers heal, cicatricial contractions which may result in stenosis. Pigmented spots in the diseased mucous membrane are sometimes observed and the destruction of the intestinal glands by the inflammation may result in atrophy of the mucous membrane and at times of the muscular and peritonaeal coats of the bowel. Syj^ptoms. While diarrhoea is the rule in acute entero-colitis, in the chronic form of this inflammation this is not the case. The bowels may be consti- pated, there may be diarrhoea or there may be an alternation of these condi- tions. A fairly constant symptom is the presence of mucus in the movements from the bowels. This mucus is variable in quantity, from a small amount mixed with the fsecal matter to large masses discharged in the form of casts of the intestine. If ulceration exists there may blood in the stools. The type of the disease characterized by the passage of casts of the bowel is seen usually in neurotic women. Constipation is usually present and at intervals stools of the type described above are passed, accompanied by tenes- mus and abdominal pain and tenderness. Subjective symptoms may be wholly absent in chronic entero-colitis, the appetite and gastric digestion are often good but there are at times abdominal discomfort and flatulence. Physical examination may reveal nothing characteristic, although at times tympanites may be detected. When the intestinal contents is fluid, palpation may elicit gurglings and in the type of the disease of which constipation is a feature the hard faecal masses may be made out. The course of the disease is often long drawn out and the patient may be apparently well save for his intestinal symptoms. Other cases become gradu- ally emaciated and may die from exhaustion rather than from the disease itself. The prognosis as regards life is good but as to recovery, especially in cases of long standing, it is distinctly bad. Treatment of this disease is unsatisfactory, consequently many drugs have been recommended as useful. Of these silver nitrate may be mentioned first. Its dosage is J grain (0.016) three times a day, or it may be given in I to 1000 aqueous solution in doses of 2 or 3 drachms (8.0-12.0) three times a day. Other metallic astringents such as copper sulphate, J grain (0.016), lead acetate, 2 grains (0.132), or zinc sulphate, 2 to 4 grains (0.132 to 0.25) may be employed. Other drugs, given with the idea of lessening the diarrhoea by means of inhibiting the fermentive and putrefactive processes going on in the intestine may be mentioned almost without number. The best of these are the bismuth salts, especially bismuth naphtholate (orphol), 5 to 15 grains (0.33-1), bismuth tribromophenolate, 8 grains (0.5) and bismuth tetraiodo- CHRONIC CATARRHAL ENTERITIS. 385 phenolphthaleinate, 5 to 8 grains (0.33-0.5). The subsalicylate, the sub- gallate and the subnitrate may also be employed in doses of 10 grains (0.66) or more, frequently repeated. The vegetable astringents are less effective than the bismuth salts but in view of their former popularity may be mentioned. What action they exert, for we now know that they do not act as astringents when introduced into the alimentary tract, is due to their tannic acid content. Of these calumba, catechu, rhatany, campeachy wood, and tannic acid may be mentioned. Tannalbin, tannocol and tannigen in doses of 8 to 15 grains (0.5-1.0), as well as the calcium salts — the phosphate, carbonate and salicylate — given in solution in carbonated water, may be employed. Goto — the powder in dosage of 10 grains (0.66), or as cotoin, ^ to i grain (0.032-0.065) — is used empirically. Neurotic diarrhoeas due to hysteria, the symptom complex of neurasthenia, migraine, and the climacteric require not only careful management based, on the underlying cause but call for a further word of comment. The best results are obtained from the persistent use of the bromides, preferably stron- tium bromide (free from the barium salts), 60 to 90 grains (4.0-6.0) daily. After 3 days this may be diminished in quantity and the solution of potassium arsenite commenced, 3 drops (0.2) thrice daily and increased i drop (0.065) per day until slight untoward symptoms supervene. Nephritic or ursemic diarrhoea should be recognized as a salutary effort of the organism to rid itself of the poisons whose effects we characterize as "iiraemia." The proper method of dealing with this condition is the admin- istration of a high intestinal irrigation of normal sodium chloride solution, in quantity a gallon (4 litres) of a temperature of 112° F. to 116° F. (44.5° to 46.5° C.) through a rectal tube, inserted at least 12 inches, the reservoir be- ing elevated about 3 feet. If the chronic nephritis is predominatingly paren- chymatous, the sodium chloride should be replaced by sodium bicarbonate. Intestinal irrigation will free the bowel from irritating contents, will enable the kidneys to functionate normally and will stimulate the heart. Purinaemic diarrhoeas are best combated by 60 grains (4.0) daily of saligenin tannate, regulation of the diet and inhibition of intestinal fermentation by intestinal antiseptics until the proteid metabolism is re-established upon a satisfactory basis. Malarial diarrhoea is best treated by arsenic, methylthionine hydrochloride (methylene blue) or a combination of extract of ergot, 2 grains (0.13), berberine sulphate i grain (0.065) with piperine ^ grain (0.032) 4 times daily. In patients who have survived the acute onset of cholera, a diarrhoea fre- quently persists. This is best treated by bismuth tribromophenolate, 90 to 120 grains (6.0-8.0) daily. In addition dried suprarenal extract, 5 grains. (0.33) 3 times a day will assist in restoring the vascular tone. 25 386 DISEASES OP THE DIGESTIVE SYSTEM AND PERITONEUM. If bile pigment is present in the stools the disturbance is presumably high in the intestine and a combination of salicylic acid, 6 grains (0.40) with the same amount of acid sodium oleate, with 4 grains (0.25) of phenolphthalein and ^ grain (0.032) of menthol given once daily for several days will disinfect the bile and remove this cause of intestinal indigestion. The constipation occurring in chronic entero-colitis must never be allowed to persist and should be combated by mild rather than drastic measures. Enemata of warm water, castor oil, calomel or laxative waters such as Hunyadi, Apenta, etc., are the best means of controlling this symptom. Faecal impac- tions are best relieved by softening them by quart (litre) injections of warm olive oU, the patient being in the knee-chest position, or drachm (4.0) doses of arsenic-free sodium phosphate twice daily by mouth; y^o^ of a grain (0.0006) of physostigmine salicylate 3 times a day will enable the intestinal muscularis to recover its tone. Opium is admissible in the treatment of chronic diarrhoea only, when the alimentary cana,l has been thoroughly emptied, to check excessive peristalsis. It should be given hypodermatically, as morphine, in substantial doses, and not repeated. A prescription for opium, or any of its preparations or alkaloids, should never be entrusted to patients of the nervous type. There is too great danger of habit formation. The extract of denarcotized opium and extract of belladonna have been recommended as useful in the relief of the abdominal pain from which some patients sviffer but both these drugs should be employed with utmost caution, the former on account of the danger of causing the habit, the latter lest toxic symptoms be induced. Treatment by means of colonic irrigation is effectual when the chief seat of the inflammation is the large intestine. A soft rubber rectal tube passed high into the bowel and attached to a fountain syringe or a large funnel should be used. Various solutions have been employed in this connection, those preferable being silver nitrate 1-2 to 1000, boric acid i to 100, sali- cylic acid 2 to 100, tannin 2-4 to 1000, zinc sulphate 3 to 1000 and mercury bichloride i to 15,000. The last is irritating and if absorbed is likely to pro- duce mercurial intoxication, consequently it should be administered with great caution. Diet. By far the best diet for chronic entero-colitis is milk, but it cannot be continued indefinitely. The author reserves its use for between meals and at bed time. The first choice is a properly peptonized milk, not taken too cold. For the meals clear meat soups, gruels, eggs, poached on toast, soft- boiled or raw, fresh butter, sweetbreads, calf's brain, rare, grilled or broiled steak or lamb chops, fresh chopped beef, with ^ drachm (2.0) of dilute hydro- chloric acid to each 2 ounces (60.0), oysters and fish, toast, hard rolls, mashed potatoes and macaroni, will carry the patient well toward the time when a 1 CHOLERA MORBUS. 387 regular mixed diet may be resumed. To be avoided are fruits, raw or soiir, cooked or sweetened, succulent vegetables, fat meats, all highly seasoned and indigestible foods, foods leaving much residue, and sugar. All dishes should be properly cooked and prepared as simply as possible in every way. Mineral waters seem to have a certain influence upon chronic intestinal catarrhs. The waters of Carlsbad and Vichy have a considerable vogue among European clinicians and the waters of Saratoga and of the Virginia hot springs of our own country may prove quite as beneficial. Water cures at home are seldom as beneficial as when taken at the springs for the mode of life, regular diet and exercise at these resorts has an additional favorable action upon the lesion. Aside from sojourns at spas, other changes of climate and scene may benefit the patient. Hydrotherapeutic procedures have a place in the management of chronic diarrhoeas and a course of cold water treatment at an institution frequently acts favorably. Diarrhoeas from cold almost invariably may be relieved by the daily use of a morning cold bath. The bath should commence with a tem- perature of 88° F. (31.1° C), and be taken cooler by a degree or so each morn- ing until 68° F. (20° C.) or even 58° F. (14.5° C.) is reached. A 5 minute bath followed by a brisk rubbing with a rough towel results in a vigorous reaction, and the morning bath not only soon becomes a therapeutic necessity but a luxury as well. In addition an abdominal bandage of flannel shoiild be constantly worn. Wet abdominal binders and hot or cold compresses are often useful adjuncts to treatment. CHOLERA MORBUS. Synonyms. Cholera Nostras; Sporadic Cholera. Definition. An acute inflammation of the stomach and intestines charac- terized by profuse emesis, diarrhoea and severe abdominal cramps. .Etiology. No micro-organism has yet been proven to be the specific cause of this disease although it is possible that it may be of bacterial origin. Until its specific cause is isolated we must consider it to be the result of the ingestion of impiire, decomposing or indigestible articles of food, such as decayed or unripe fruit, fish, salads, etc. Attacks of cholera morbus are most frequent during the hot months and seem to be predisposed to by exposure to draughts while the body is over-heated. Pathology. The morbid conditions found in fatal cases of cholera morbus resemble too closely those of acute enteritis to need separate description. Symptoms. The onset of cholera morbus frequently takes place in the night. The patient is seized without warning with nausea, followed by 388 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. vomiting, profuse diarrhoea and severe abdominal cramps. The vomitus consists at first of the stomach contents followed by bile and later by watery fluid. The stools are often so frequent as to be almost without interval, at first they are of the faecal matter contained in the bowel but soon become very loose and watery. A rise of temperature is infrequent. Thirst due to the rapid loss of water is marked. The pain is abdominal, paroxysmal and colicky; the muscles of the limbs later become painful; in severe cases the patient may fall into a state of collapse, with marked bodily weakness, cold, clammy skin and weak and rapid heart action. Death may supervene in rare instances but recovery from the acuity of the attack within half a day is the rule. The depression, weakness and irritability of the digestive tract may last for a few days longer. Treatment. Since the train of symptoms known as cholera morbus is the result of some irritating substance in the gastro-intestinal tract the first indi- cation in treatment is to get rid of the cause of the offence. This may be done by administering calomel in doses of J grain (0.016) every J hour until 6 doses have been taken, or castor oil ^ ounce (15.0). In cases with marked and frequent vomiting it may be impossible for medication given by mouth to be retained; here the most approved method of cleansing the intestine is by high rectal irrigations of warm water. The severe pain may be controlled by the application of counter-irritation by means of the mustard or flax-seed poultice or a capsicum plaster to the abdomen. These should be carefully watched lest they cause blisters. When relief is not brought about by these means the hypodermatic injection of morphine may become necessan^ but this remedy shoifld be used with the greatest caution. In the later stages of an attack the use of a prescription such as the following may be indicated: I^ acidi sulphurici aromatici, rr^vi (0.4); extract! haema- tox}don, rr^vi (0.4); spiritus chloroform! TTLxii (0.8); fluidextracti ipecacuanhas, nxiii (0.2); s}T:upi zingiberis, q. s. ad 5i (4-o)- Misce et signa, one dose every 2 hours. The marked thirst must be relieved by supplying water to the tissues either by high rectal enemata of normal saline or by hypodermatoclysis of the same solution. The latter process consists in allowing a pint (J litre) or more of saline to run into the tissues through a needle attached to an irrigation appa- ratus and plunged into the thigh or buttock, the skin of which has been previ- ously sterilized and, if advisable, anaesthetized by means of an ethyl chloride or aether spray. This quantity of the solution wiU be quickly absorbed and the procedure may be repeated if necessary. For the vomiting the patient should be given cracked ice to hold in the mouth, sips of iced champagne or carbonated waters. The tendency to collapse necessitates the exhibition of hypodermatic stimulation, strychnine, DIARRHCEAS OF CHILDREN. 389 camphor and aether, etc., the application of heat to the extremities or wrapping the body in a hot sheet. Diet. During the acuity of the attack and for a day or more after, the less eaten the better. As the vomiting ceases the patient may begin to take small quantities of milk and lime water or milk mixed with a carbonated mineral water and as progress toward recovery is made soups, toast, soft eggs, etc., may be allowed, to be gradually followed by a return to ordinary diet. DIARRHCEAS OF CHILDREN. Acute Gastro-enteritis. Synonyms. Summer Diarrhoea; Gastro-intestinal Catarrh. Definition. An acute catarrhal inflammation of the gastro-intestinal tract characterized by vomiting, diarrhoea and a febrile movement. etiology. The specific cause of this disease is probably bacterial. Various micro-organisms have been considered to have a part in the production of this condition, namely the colon baciUus, the streptococcus, the staphylococcus, the baciUus pyocyaneus, the bacillus proteus and Shiga's bacillus. The disease is predisposed to by teething, hot weather, unhygienic surroundings and poor bodily condition. The exciting cause seems usually to be improper feeding, either in quantity or quality. Not only bottle-fed babies are subject to the infection but those fed on mother's milk are often attacked, since im- proper diet, mental excitement, etc., are capable of materially changing the lacteal secretion and thus causing the digestive disturbance. Pathology. The gross appearance except for the presence of excessive mucus is little changed. The mucous lining of the gastro-intestinal tract may either be pale or hyperaemic and the solitary and agminated follicles of the smaU intestine may be swollen. Patches of congestion may be observed in the large intestine. The intestinal waUs are not thickened. Symptoms. The disease occurs in two chief types, the mild and the severe. In the former the onset is gradual with symptoms of indigestion, little or no rise of temperature, restlessness and fretfulness; the stools become more fre- quent, are diarrhoeal in character, greenish, yellowish or brownish in color, of bad odor and contain undigested food; later mucus appears. In the second type the onset may be gradual, with symptoms of digestive disturbance, or sudden, with a rapid rise of temperature — 102° to 105° F. (38.9° to 40.5° C.) — hot dry skin, restlessness, and vomiting. There may be convulsions or stupor. The thirst is often extreme. The vomitus consists first of undigested food, and if emesis continues after the stomach has become empty, mucus or bile may be vomited. In certain cases the vomiting may be 390 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. wholly absent. The diarrhcea may not appear for a number of hours after the onset of the attack. The stools are at first of faecal matter and are accom- panied by colicky pains and gas; later they become thin, watery and foul; in color they are grayish, greenish or brownish. They contain mucus after a few days and may be as many as 15 or 20 during the 24 hours. The child rapidly becomes weak and emaciated; the disease may prove rapidly fatal or the symptoms may abate and the condition become subacute. Relapses are not uncommon and the disease may go on to an entero-colitis. Treatment. Prophylaxis, in view of the probable infectious character of the disease, consists in careful attention to the surroundings and hygiene of infants, especially during the summer, the immediate washing or disinfection of all soiled napkins, and above all proper feeding, the use of boiled water for drinking purposes and the boiling of bottles and nipples — in the case of artificially fed infants — previous to their use on every occasion. Breast feeding should be encouraged and mothers advised against weaning during the summer. The treatment of the attack proper consists in measures calculated to reheve the digestive tract of its irritating and toxic contents. If the vomiting is per- sistent the stomach should be washed by means of a soft rubber catheter of appropriate size attached to a rubber tube of larger calibre, and a funnel. The lavage should be continued until the water returns clear and it is wise to leave a little water in the stomach. If the vomitus has been very acid a little sodium bicarbonate may be added to the water left behind. In children who struggle against the stomach tube full draughts of boiled water may be substituted. The small intestine should be relieved of its contents by cathartics. When vomiting is not a feature, castor oil, 2 drachms (8.0), may be given to a child of I year while older children may take up to J ounce (15.0). Calomel in divided doses of ^ to ^ a grain (0.016-0.032) should be given every half hour up to 6 doses. The tablets may be dissolved in a teaspoonful of boiled water and are wiUingly taken. The colon should be irrigated with warm normal saline solution. Two quarts (litre?) should be used and given through a soft catheter passed high into the bowel. This procedure shotild be carried out twice or thrice during the first day of the attack and once a day thereafter. Drugs are often unnec- essary but should they be indicated bismuth subgallate in doses of 3 or 4 grains (0.2-0.25) may be given to a year old child every 3 hoiirs or phenyl salicylate (salol) in doses of i to 2 grains (0.065-0.13) may be administered. Antacids, such as lime water, milk of magnesia or chalk mixture are often useful when h}^eracidity of the stomach with fermentation is present. In cases with marked prostration stimulation is necessary in the form of whiskey or brandy given frequently in small amounts fuUy diluted. A half ounce (15.0) in divided doses during the 24 hours is not too much for a child CHOLERA INFANTUM. 39 1 of I year. Hot mustard baths and applications of heat are useful and if the diarrhoea has been profuse enough to deprive the system of a large amount of water this should be supplied by rectal irrigations or by hypodermatoclysis of warm normal saline solution. Diet. Too great emphasis cannot be laid on the statement that no food should be given for at least 24 hours, or for even longer periods, should the vomiting continue; cold water should be supplied, however, and thin barley water or albumin water (the white of one egg in 8 ounces (250.0) of boiled water) to which a little brandy has been added are allowable. If these are refused the stomach should be allowed to rest. Usually after 24 hours the child may be allowed to nurse, but for not longer than 2 to 3 minutes, at intervals of at least 4 hours. In the intervals barley or albumin water may be given. Gradually the intervals between breast feeding may be lessened and the length of the nursing prolonged so that in 4 or 5 days the child is fed as usual. Bottle-fed infants should be deprived of all milk for several days and barley or rice water, artificial malted foods, beef or chicken bouillon substituted. When milk is allowed again it should be boiled, the quantity should be small and the dilution very weak. During convalescence the child should be carefully watched and if possible a change of climate is advantageous. The climate does not seem to matter particularly, so long as excessively hot neighborhoods are avoided; babies taken from the city to the country do well and vice versa. All errors in diet should be studiously guarded against. Cholera Infantum. Definition. An acute catarrhal inflammation of the intestinal tract of very severe t}^e characterized by high temperature, profuse diarrhoea and great prostration. Etiology. No specific cause for this disease has been isolated but it seems to be closely associated with the decomposition of the intestinal contents, especially if this is impure milk. The predisposing causes are poor general condition, unhealthy surroundings, etc.; they are similar to those of acute gastro-enteritis. Pathology. Post mortem examination reveals no marked abnormality in the affected intestine. Symptoms. Cholera infantum usually occurs in children in whom there has been previous intestinal disturbance. Prostration and fever are often present before the appearance of the vomiting and diarrhoea. The former may appear first or both it and the purging may occur simultaneously. The emesis is frequent, the vomitus at first consisting of the contents of the 392 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Stomach, then of mucus, serous fluid and later bile. It is brought on by the ingestion of any food or drink. The patient is very thirsty and eagerly drinks water only to vomit it almost immediately. The movements from the bowels are copious, greenish, yellowish or brownish and may be as many as 20 or 30 in 24 hours. Their odor is, as a rule, not foul but at times is very offensive, and as the disease progresses they become serous in character. Nervous symptoms are frequent; at first they are those of excitation of the nervous system, later they may merge into convulsions, stupor or coma. The pros^ation is marked and emaciation is rapid. The temperature varies with the severity of the attack from 102° to 105° F. (38.9° to 40.5° C), the pulse and respiration are rapid and weak and at times irregular. In the fatal cases the skin is cold and clammy and the facies typical, the eyes being sunken, the skin pale and the expression anxious to a marked degree. The cerebral symptoms may lead to a mistaken diagnosis of brain lesion, but they are probably the result of the action upon the nervous system of toxins absorbed from the intestine. In cases in which recovery takes place the emesis and purging become less frequent, the constitutional symptoms become ameliorated, the temperature falls and the nervous symptoms subside. Convalescence is slow and relapses are very likely to occur. The prognosis is serious, the outcome in the majority of cases being fatal. Treatment can hardly be considered satisfactory. The first indication is to relieve the digestive tract of its toxic contents. This is to be done by means of gastric lavage and colonic irrigation as described in the section on chronic catarrhal enteritis (p. 390); the action of piirgatives is too delayed. Drugs by mouth are vomited, consequently hypodermatic medication must be under- taken. For the nervous manifestations morphine, gr. J^ to -f^o (0.0012- 0.0006) with atropine, gr. g-g-g- (0.00013) ^^7 be given to a child of i year of age and may be repeated in an hour if improvement is not noted. For the pyrexia baths are indicated. They should be begun at 80° F. (26.1° C.) and reduced to 70° F. (21.1° C), may last from 10 to 30 minutes and may, if necessary, be repeated every hour or two. When baths, for any reason, are impossible, wrapping the patient in a wet sheet, or cold water injections may be substituted, and as an adjunct to the hydrotherapeutic measures, ice com- presses or an ice cap should be applied to the head. To supply the fluid lost by emesis and diarrhoea hypodermatoclysis, given as described under the treatment of acute gastro-enteritis, (p. 388) is indicated. Eight ounces (250.0) or more of normal saline should be administered in this fashion every 12 hours. There should be no attempt to give food or medication, except stimulants, by the mouth. The patient may suck bits of ice and stimulation by means of brandy or iced champagne — small amounts frequently repeated — may ACUTE ENTERO-COLITIS. 393 be administered by this route. If these are not retained hypodermatic stimulation — brandy or whiskey, camphor, aether, etc. — is indicated. The feeding and convalescence of patients suffering from cholera infantum are to be managed according to the principles laid down under the treatment of acute gastro-enteritis (p. 391). Much can be done with regard to the prophylaxis of this disease by means of attention to the suggestions on p. 390. Acute Entero-colitis. Synonyms. Acute Ileo-colitis; Follicular Enteritis; Dysentery. Definition. An acute inflammation of the mucous membrane of the ileum and colon chiefly involving the lymph follicles of these structures. .etiology. This disease is most frequently seen diu-ing the summer. The predisposing causes are the same as those of acute gastro-enteritis. The children affected are usually under 2 years, although the condition may occur up to the 5th year. Recent research seems to have established a definite connection between Shiga's bacillus and this affection, this organism being demonstrable in the stools, and characteristic agglutinative blood reactions being obtainable in a large majority of cases. Pathology. The colon is the chief seat of the lesions and when the ileum is involved these extend to a distance of but 2 or 3 feet above the ileo-coecal valve. The mucous membrane is congested and swollen and the solitary and agminated follicles are enlarged. The follicles of the large intestine may go on to iflceration but the agminated follicles of the ileum rarely are subject to this process. The ulcers may penetrate to the musciflaris, the wall of the intestine may become infiltrated with- small cells and its thickness may be increased to two or three times the normal. There may , be small haemorrhagic spots and the formation of a false membrane may occur. The mesenteric lymph nodes are frequently enlarged. Symptoms. Ileo-colitis may have its origin in an attack of cholera infantum or acute gastro-enteritis or it may occur as a primary infection. At the onset the symptoms often resemble those of acute indigestion, viz., vomiting, abdom- inal pain and distention, a rise in temperature and diarrhoea; the stools at first are loose and vellowish or greenish, later they contain mucus and blood, are very frequent and may be accompanied by pain. The mucus may be clear or mixed with faecal matter. After a week or thereabouts the symptoms may disappear and the patient slowly recover, or they may become more severe, with persistent fever, frequent stools of mucus and blood, pain and tenesmus, loss of appetite and increasing prostration and loss of weight. Nervous symptoms, dry, brown and ulcerated tongue and diminished urine, at times containing albumin and casts, are features of the severe cases. 394 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Such patients may go on in this manner for 4 or 5 weeks and die, or convales- cence, which is always very slow and likely to be interrupted by relapses,, may become established. Few of these cases recover completely, their powers of resistance being so deteriorated that they are subject to any intercurrent disease and they, as a rule, finally succumb. Treatment. Prophylaxis consists in early and careful treatment of all intestinal disorders and the employment of the measiures suggested under acute gastro-enteritis (p. 390). The treatment of the attack consists in emptying the gastro-intestinal tract by means of systematic gastric and colonic lavage and the exhibition of cath- artics as laid down on p. 390; the pain and restlessness should be controlled by paregoric or the deodorized tincture of opium. Local treatment of the diseased areas in the intestine by means of intestinal irrigations of normal saline solution is important. A quart or two (1000.0-2000.0) of the solution at a temperature of about 102° F. (38.9° C.) being allowed to flow into the bowel and out again through a soft catheter passed as high as possible, two or three times a day. If there is much blood in the stools small injections of hot water — io8°-ii2° F. (42.3°-44.4° C.) — or of ice water are useful and injec- tions of astringents — a drachm (4.0) of tannic acid to the pint (500.0) of warm water — may be employed. If the injections cause the child to struggle they must be omitted. In such cases, and others which do not respond to the injection treatment, bismuth subnitrate in considerable doses — 20 grains (1.33) or more every 3 or 4 hours to a child of i year — or castor oil in emulsion — ID minims (0.66) — at the same intervals may be administered. In the later stages good results may attend the use of gelatin which may be employed as follows: 2 J drachms (lo.o) of a 10 percent, aqueous sterilized gelatin solution should be warmed and added to the child's bottle. This dosage should be given three times on the first day of its employment — the amount of gelatin taken by the child being 45 grains (3.0) per day — and increased 15 grains (i.o) daily. It is said that this treatment quickly lessens the number of the stools, supposedly by mechanical action. Attempts at serum treatment have been made but decision as to the benefit to be derived must be reserved at present. Stimulation is usually necessary. Well diluted brandy is to be preferred with iced champagne as a second choice; of either half a drachm (2.0), or more if necessary, may be given a child of i year every 2 or 3 hours. In cases of profound shock atropine sulphate hypodermatically, beginning in doses of g-^Q- of a grain (0.00013), pushed to the limit and followed by brucine has been recommended. It must be remembered that too much medication is usually much worse than too little, in fact, when the acute symptoms have disappeared, the tem- perature but little above normal and the movements less than 6 a day, patients PSEUDO-MEMBRANOUS ENTERO-COLITIS. 395 frequently do better when all drugs are stopped — save stimulants — and the bowel irrigated only every second or third day. In such cases a change of air will often effect wonders. The diet during the acuity of the attack is identical with that described for cases of acute gastro-enteritis. After the acute stage is over, great difficulties are often experienced and the most judicious feeding is necessary. Each case must be studied by itself and no fixed rules can be laid down. To infants, foods which may be given are peptonized skim milk, broths, beef peptonoids, barley or rice water and the various artificial malted foods. Feeding by gavage may be necessary in cases of disinclination to eat. Food should not be given oftener than every 2 or 3 hours, but drinking water may be allowed in the intervals. In older children during convalescence, scraped beef, kumyss, gruels, and soft boiled eggs are allowable. The greatest attention should be given the diet for a long period after an attack since the slightest indiscretion may result in a recurrence of the disease. Hygienic treatment should be carried out as described under the treatment of acute gastro-enteritis (p. 390). PSEUDO-MEMBRANOUS ENTERO-COLITIS. Synonyms. Croupous Entero-colitis; Diphtheritic Entero-colitis. Definition. An acute inflammation of the lining of the intestine accom- panied by the formation of a false membrane. .Etiology. This disease is probably the result of the irritant action of chemical substances resulting from intestinal fermentation or of infection by bacteria. The former setiological factor may act in poisoning by mineral substances, such as arsenic, mercury or lead. The condition may also be secondary to various of the infectious diseases such as pyaemia, scarlatina, smallpox, etc. Whether here the intestinal lesion arises directly from infection by the specific organism causing the disease or not is uncertain. Diphtheritic enteritis also occurs as a complication in cachectic states, nephritis, hepatic cirrhosis, etc. Pathology. Usually only the large intestine is affected but in the cases due to mineral poisons the small intestine may also be involved. Early in the disease the lesions are usually those of simple intestinal catarrh, but more infrequently the membrane is present from the inception of the inflammation. The membrane varies in size and thickness and is grayish white in color. Ulceration may be present with necrosis and perforation or increase in thick- ness of the intestinal waU, Symptoms. These are not characteristic and in mild cases they may be unnoticed. Severe cases resemble dysentery (q.v.); the stools are frequent. 396 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. thin and accompanied by tenesmus; they may contain blood, pus and bits of the membrane. The course of the disease is greatly influenced by its causation, but it is usually slow. The prognosis is not good, death occurring from exhaustion, peritonitis or haemorrhage. Patients who recover are often left with permanent intestinal stenoses due to the contraction of the intestinal cicatrices. Treatment consists in the proper management of the co-existent and causative affection and in the relief of the symptoms as they arise. For details the reader is referred to the sections on the treatment of intestinal ulceration and colitis. PHLEGMONOUS ENTERITIS. This is a rare affection. It is probably of infective origin and consists in an infiltration by pus of the intestinal waU. It may follow other intestinal inflammations such as iilceration and has occurred in strangulated hernia and intussusception. Little is definitely known about the disease and diag- nosis ante mortem is considered impossible. HEMORRHAGIC INFARCT OF THE BOWEL. Definition. An extravasation of blood into the intestinal wall resulting from thrombosis or embolism of one of the mesenteric arteries or one of their branches. .Etiology. The causes of intestinal embolism are identical with those of embolism of any other part, namely valvular heart disease, aneurysm, etc. Pathology. The walls of the jejunum and ileum are congested and swollen and a clot obstructing either the superior or inferior (usually the former) mes- enteric artery or one of its branches is demonstrable. Congestion and infiltration may also be observed in the mesentery. Symptoms. Of these the most important is haemorrhage from the bowel. The onset of the affection is usually marked by sudden nausea followed by vomiting, colicky pain and abdominal distention. The bowels are loose and the movements may contain blood from the beginning or not until later. Cases in which the symptoms closely resemble those of obstruction are more rare. The prognosis is bad although recovery is possible through the estab- lishment of a collateral circulation. Treatment is unsatisfactory it being limited to the relief of the symptoms and the diminution of the excessive blood pressure in the portal circulation by means of cardiac stimulation and venesection. Surgical interference — resection followed by enterostomy — has been suc- cessful in a few cases. ULCERATION OF THE BOWEL. 397 ULCERATION OF THE BOWEL. Ulcer of the Duodenum. etiology. Duodenal ulcer probably occurs more often than is generally supposed and is produced by the same causes as those which result in gastric ulcer, with which it may be associated. Its chief aetiological factors are trau- matism resiilting from foreign bodies, excessive gastric acidity, local infection, embolism or thrombosis in the duodenal wall, with consequent tissue necrosis, and severe skin affections such as burns, erysipelas, etc. Ulcer of the duod- enum, however, is much less frequent than gastric ulcer. Pathology. The morbid anatomy is similar to that of gastric ulcer (q.v.) in every way both in gross appearance and under the microscope. The lesion may be single or multiple and is usually in the first portion of the duod- enum. Perforation takes place more frequently than in gastric ulcer and general or localized peritonitis walled off by adhesions, results. When the adhesions involve the neighboring organs perforation into these may occur. Symptoms. These are so little characteristic as to render diagnosis very difficidt and often when they are sufficiently marked to raise suspicion they are so analogous to those of ulcer of the stomach that differentiation from the latter lesion may be well-nigh out of the question. The most important symptoms are pain and haemorrhage. The former, however, may be absent or so insig- nificant as to attract little notice from the patient; it is usually less severe than that of gastric ulcer and is likely to appear at a longer interval after eating, though this latter statement is doubted by some authorities. Haemorrhage is not rare, and varies from a quantity so slight as to be hardly noticed to a considerable amount which is either vomited, leaves the body through the intestine or is carried off by both these routes. The vomited blood is similar to that of gastric ulcer, while that passed in the stools is black and tarry. Jaundice may occur, but is so infrequent as to cause doubt on the part of some observers as to whether it is a part of the clinical picture or merely a coincidence. Vomiting is not a common symptom; it may appear as a result of a co-exis- tent gastric inflammation or be due to duodenal obstruction resulting from the cicatricial contraction of an old ulcer. The vomitus and the stomach contents in duodenal ulcer are not typical in any way. The appetite is often excellent; the bowels are usually constipated but may be entirely normal in their action. Perforation induces the usual symptoms of intestinal rupture, either those of general or localized peritonitis. The prognosis is not good as regards recovery. In non-perforative cases the symptoms may continue for years despite treatment and in perforative cases, 398 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. without adhesions to wall off the general abdominal cavity, death is certain, unless immediate operation is undertaken. Treatment is practically that of gastric ulcer (p. 348) as regards both medical and surgical measures. Primary Tuberculous Ulceration of the Intestine. This is a rare condition and one seldom seen in the absence of tuberculous lesioi^ in other parts of the body, still it may occur under these circumstances. The condition is seen, as a rule, in children. The ulcers are situated in the small intestine and the rectum, seldom in the colon. They begin in the agminated follicles as tubercles which undergo caseation and finally ulcer formation. The ulcers are irregularly oval, their longer diameter is parallel to the transverse axis of the intestine, their edges are undermined and there is thickening of the peritonaeal coat. Unless in the rectum where they may be seen by means of the proctoscope their existence cannot be certainly diagnosed intra vitam. Rarely they may be found in the appendix vermiformis. Symptoms which lead one to suspect the existence of such lesions are diar- rhoeal discharges with pus and with or without blood, loss of flesh and strength, hectic temperature, abdominal tenderness, and enlarged peritonaeal glands. The faecal discharges should be examined for the tubercle bacillus, which if found, when it is certain that it has not been swallowed, establishes the diagnosis. Inability to demonstrate the bacillus is no proof that the lesion is not tuberculous. Perforation of a tuberciilous ulcer rarely takes place; when, however, this event happens general or localized peritonitis with its attendant symptoms results. Healed ulcers cicatrize and may, by their contraction, cause stenosis. Treatment consists in the employment of the means calculated to relieve the diarrhoea, the pain (see p. 351) and the haemorrhage (see p. 352). Local treatment of the ulcers is possible when they exist in the rectum, and the lower colon; here irrigations, after the bowel has been cleansed by an enema of warm water, with solutions of copper or zinc sulphate (3 to 1000), silver nitrate (1-2 to 1000), silver vitellin (5 percent.), tannic (2-4 to 1000), or boric acid (1-2 to 100) are useful. Ulcers which can be reached by means of the speculum and applicator should be touched with stick silver nitrate or with strong solutions of the same salt. Internally the bismuth salts may be given as suggested under the treatment of chronic intestinal catarrh (p. 384). The administration of a combination of sulphur sublimatum, gr. xx (1.33) and pulvis ipecacuanhas et opii, gr. v (0.33) every 4 hours has been recom- mended in tuberculous intestinal ulceration in adults. The diet should be carefully regulated, consist entirely of non-irritating EMBOLIC ULCER OF THE INTESTINE. 399 foods and should contain as much nourishment as possible. For more specific directions for the feeding of these cases the reader is referred to the section on the diet of chronic catarrhal enteritis (p. 386). Embolic Ulcer of the Intestine. This affection is imcommon and, like other forms of intestinal ulceration, very difficult of diagnosis. The ulcers occur in valvular endocarditis, arterio- sclerosis, multiple neuritis, pysemic conditions, and any other state in which lodgment of an embolus in an artery of the intestine is possible. Following the lodgment of the embolus necrosis of tissue and ulceration take place. Syphilitic Ulcer of the Intestine. This is a rare condition especially in the small intestine; syphilitic ulcers of the rectum are more frequently seen and are usually situated within a short distance of the anus. They are shallow, of smooth base and may occur as primary, secondary or tertiary lesions; in the last case they result from the breaking down of gummata. In healing they tend to produce stric- tures though certain recent observers incline to the belief that this latter is a very rare occurrence. The treatment consists in the administration of mercury and the iodides as described under the section devoted to luetic disease (p. 139), and when the lesions are in proper situation, local applications such as those suggested in the treatment of tuberculous ulceration may be employed. APPENDICITIS. Definition. An acute or subacute catarrhal or suppurative inflammation affecting the appendix vermiformis, usually involving the surrounding tissues (typhlitis and peri-typhlitis) and frequently going on to gangrene or perforation of the organ with consequent abscess formation. -Etiology. While it is probable that this affection occurred as frequently before 1886, the date of the classical paper of Fitz of Boston, as it has done since that time, previous to that year the importance of the disease was not generally recognized. Appendicitis is a disease of young adult life occiuring most frequently between the ages of 15 and 30 years; it is rare in children and after the age of 50. Males are more often affected than females, perhaps because they are more prone to muscular exertion or more probably because in the weaker sex the organ receives an additional blood supply from a branch of the right ovarian artery. 400 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. The anatomical formation of the appendix greatly favors its liability to inflammation. It is a blind sac narrower at its orifice than elsewhere, conse- quently any inflammation of its cavity increases the narrowness of the outlet, thus preventing free drainage and exit of the offending cause of the process and favoring its further development. The shortness of its mesentery is another anatomical factor in the liability of the appendix to infection. This shortness of mesentery is likely to cause a torsion of the organ, which may shut off its blood supply and interfere with its nutrition, since the artery supplying the part is carried in the meso-appendix. Long appendices are particularly subject to torsion because of their proneness to adhere to other tissues. The presence of foreign bodies — the traditional grape seed, etc. — is much less a factor in the causation of appendicitis than the laity are accustomed to suppose. It is true that foreign substances, especially faecal concretions, are not infrequently found in diseased appendices, but these must be con- sidered as predisposing causes only. Various intestinal parasites have also been found in this situation. Errors in diet, exposure to cold, excessive muscular exertion and trauma- tism are also factors in the production of this inflammation. The exciting cause of appendicitis is a bacterial infection. Of the micro- organisms to be considered in this connection the most important and the one most frequently responsible is the bacillus coli communis. This bacterium is a normal inhabitant of the intestinal tract and as such is harmless — even beneficial — but, confined in an appendix, in some manner it becomes malig- nant. Not only is this bacillus capable of exciting appendiceal inflammation but others, such as the streptococcus and staphylococcus pyogenes, the pneu- mococcus, the bacilli of influenza and enteric fever, the bacillus proteus and the infective cause of acute rheumatism, having found ingress to the appendix, are potent in this regard. Pathology. For purposes of ease in description appendicitis may be separated from a pathological standpoint into four types, a. Catarrhal, h. Obliterative. c. Ulcerative, d. Gangrenous. In the catarrhal type the mucous lining of the organ is congested and swollen, there is excessive production of mucus, with which are mixed leucocytes and desquamated epithelial cells, which distends the cavity of the appendix and the free exit of which is prevented by the swelling of the normally narrow opening of the organ. Such an inflammation predisposes to other like attacks and also lessens the resistance of the appendiceal tissues so that they become susceptible to infection by pathogenic micro-organisms. Obliterative appendicitis is really but a later stage of the preceding type, especially of its severer forms, where the submucosa, as well as the mucosa, is involved. Here there is thickening of the wall of the organ by means of cell infiltration, and a consequent decrease in and at times an obliteration of APPENDICITIS. 401 the lumen of the tube. Ulcers also may occur which by contraction or by adherence of their surfaces further tend to contract the calibre of the organ. Of this form of the inflammation three courses may be described: First, the organ may be entirely obliterated and converted into fibrous tissue, therewith precluding all possibility of further attacks of appendicitis; secondly, when mucus or piirulent fluid is retained in the cavity of the organ behind a stenosis the patient is subject to appendiceal crises; and thirdly, when the inflammation has been marked enough in character to involve the peritonasal coat, adhesions to other structures with consequent inflammation of the same by extension of the infection may be formed. In the ulcerative type of the affection the mucosa and submucosa are necrosed in varying degrees. The presence of foreign bodies or faecal concretions is especially likely to produce lesions of this form, it is also seen as a result of the two types described above, and it may occur in enteric fever and tubercu- losis. The ulceration may result in perforation and general or localized peritonaeal inflammation. In the gangrenous type rapid sloughing takes place of either the entire organ or portions of its wall; in either case the condition is a very grave one on account of its liability to occur with little or no warning and even without history of previous attacks of the milder forms of appendiceal inflammation. The process may result in general peritonitis of the severest type or the resist- ing power of the patient may be such as to permit of the walling off of the sloughing part and the limitation by adhesions of the process to a localized abscess cavity. The localized peritonaeal inflammations occurring with the appendiceal lesions described above vary in degree from a simple peri-appendicular plastic exudate forming adhesions to the adjacent tissues which limit the spread of the infection, to severer forms with a cavity containing purulent exudate and waUed off by adhesions from the general peritonaeal cavity. Such an abscess cavity usually occupies the right iliac fossa although it may be found in any part of the abdominal cavity — in the pelvis, the lumbar region, under the liver, etc. — owing to unusual situations of the appendix. These abscesses contain from a few drachms to a pint or more of thick or thin, odorless or foul pus. The suppurative process may break its adhesions and discharge into the peritonaeal cavity, resulting in general peritonaeal infection, or into the intes- tine, the bladder or vagina. Rupture may also take place outward through the abdominal wall. Metastatic abscesses in the liver may be set up through portal embolism or pylephlebitis. Symptoms. Mild catarrhal inflammations of the appendix are likely to cause but slight, often hardly noticeable, symptoms; of these pain in the right iliac fossa and slight tenderness are the only ones worthy of mention; indeed the process may proceed to the ulcerative stage without exciting any appre- 26 402 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. hension on the part of the patient. When the inflammation has involved the peritoneeum locally the symptoms usually become marked. There is pain, at first general, but after a few hours localized over the seat of the lesion in the right iliac fossa when the appendix is normally situated, but the tendency of this organ to be in anomalous situations may result in localized pain in any part of the abdominal cavity — under the liver, in the left iliac fossa, etc . Change of position increases the pain, as does deep inspiration or coughing. The tongue is likely to be dry and coated. Vomiting is often present but the yomitus is not characteristic in any way. The bowels are usually con- stipated this being due to paralysis of the intestinal musculature. At times this symptom is so marked as to suggest obstruction and it may be accom- panied by fsecal vomiting. More rarely the bowels are loose. The temperature is usually elevated, ioi°-io3° F. (38.5°-39.4° C), at first, gradually falling as the process goes on to resolution, or assuming the charac- teristic irregularity if pus is present, although rarely such cases may occur without pyrexia. The pulse is full and rapid — loo to 120. Abdominal dis- tention may be present and is most marked in perforative cases. A leuco- cytosis of 20,000 to 30,000 is not unusual. Physical Examination. The patient usually lies on his back with the right thigh flexed on the pelvis, this position offering some relief to the pain. Upon palpation a point of more or less localized tenderness will be found. The classical situation for the point of maximum tenderness is at the middle point of a line drawn from the right anterior superior iliac spine to the umbil- icus, although in anomalously situated appendices it will be found over the site of the inflammation. An important diagnostic sign is rigidity of the abdominal muscles of the right side, these structures going on guard imme- diately when any attempt at palpation is made. After the tissues have been matted together by plastic adhesions or when abscess formation has taken place a tumor of varying size and consistency may be palpable. Observers with a highly specialized sense of touch may at times be able to feel the enlarged and inflamed appendix. Over the tumor, when such exists, the percussion note is dull and in the presence of a considerable quantity of pus may be flat. Excessive distention of the intestine by gas gives a note more tympanitic than normal. The prognosis for recovery in attacks of the simple catarrhal type is good but recurrences are frequent. In the cases with perforation and abscess formation the outlook is much less favorable, especially where surgical inter- vention is postponed. Treatment. Probably there is no point in medicine or surgery upon which authorities are so prone to disagreement as upon the proper management of this disease. While early surgical intervention in every case has its advocates and these of such character as to demand consideration, it is the part of con- APPENDICITIS. 403 servatism to treat an attack of catarrhal appendicitis by medical means and to consider the advisability after recovery, of the so-called interval operation. Every patient suffering from catarrhal appendicitis should be kept at absolute rest in bed. For the relief of the pain the question of the advisability of the administration of opium is a debatable one. While this drug puts the intestine at rest, thus favoring resolution, as no other drug will, it is insisted by some that its exhibition masks the symptoms indicating the necessity for operative interference. The point against this assertion is that the careful observer will receive sufficient information as to the time for operation from the pulse, temperature, general condition of the patient and the state of the appendiceal tumor. Opium itself, given by mouth or in suppositories, is to be preferred to morphine — the latter, however, may be given hypodermatically when the opium itself for any reason cannot be administered by the other channels men- tioned. The tincture of opium may be administered in doses of 10 or 12 minims (0.66-0.8) every hour until 2 or 3 doses have been taken, then 5 minims (0,33) may be given every 3 hours until the pain is relieved. If the pain recurs another such a course of medication may be instituted. The resulting constipation need cause no alarm but should not be allowed to persist longer than a week. Local applications to the painful area, of the ice coil, ice bag or ice compress are indicated and will be found to greatly relieve the pain and perhaps retard the progress of the inflammation. Warm compresses may be used after the temperature has fallen to normal and the inflammatory process is quiescent. The use of blisters and leeches is unadvisable since if operation becomes necessary the resistance to infection of the skin at their points of application is impaired. Whether or not to administer laxatives is a debatable question. Active purgatives should never be given. There is no doubt that oftentimes attacks of iliac pain, emesis and constipation with what seems to be a tumor in the appen- diceal region quickly recover after a free movement of the bowels, but there is reasonable doubt as to whether such are cases of true appendicitis. Early in appendicitis the object is to keep the intestine as nearly in a state of complete rest as possible, consequently here as well as when perforation is imminent or after suppuration has set in purgation is contraindicated. Con- stipation may be allowed to last 5 or 7 days and when the chances of perforation are past the bowels may be moved by carefully given rectal irrigation and kept regularly open thereafter. The elaboration of an antitoxin from the colon bacillus — since this organ- ism is so often concerned in the causation of this disease — has been suggested with the idea in view that patients may be immunized against relapses and against the danger of secondary infection by pus during operation. The diet during the acuity of the attack should be entirely liquid, milk, 404 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. soups, the artificial infant foods, etc., and in quantity should be smaU; certain clinicians even advocate feeding per rectum in preference to that by mouth. SmaU amounts of water may be taken. When the acuity of the symptoms has subsided semi-solids may be allowed and later, sweetbreads, scraped beef, cereals, etc., may be added. The indication for surgical intervention is, in the minds of many competent authorities, the establishment of the diagnosis of the disease, but it is certain that many cases recover under careful medical treatment. Concerning such, the t[uestion of an interval operation is one to be decided among the patient, his physician and his siu-geon. The most conservative clinicians concur that operation is indicated in all cases in which the symptoms do not ameliorate within from 24 to 48 hours, in cases in which an abscess has formed and in early cases of general perforative peritonitis. Advanced cases of diffuse peri- tonitis which are in a state of practical collapse with rapid and feeble pulse, clammy and cold skin are hardly fit subjects for operation. Here stimulation, heat to the extremities, high rectal irrigations of normal saline solution and the other means usually employed in such conditions are indicated. Very rarely does recovery take place. INTESTINAL OBSTRUCTION. Definition. A condition in which the normal passage of faecal matter through the bowel is impeded. This may result from mechanical obstruction or paralysis of the intestinal musculature and may be due to a number of different causes. Intestinal obstruction occurs in two forms: a. The acute, which may be caused by congenital anomalies, internal strangulation, volvulus, intussusception, foreign bodies or abnormal intestinal contents and intestinal paralysis. h. The chronic, which is the result of narrowing of the calibre of the bowel from new growths within this structiure, cicatricial contraction, from the outside pressure of tumors of neighboring organs or structures or of the accumulation of impacted faeces. I. Congenital Anomalies. These are the result of insufi&cient or improper foetal development and may be situated at any part of the digestive tract. The most frequent sites are at the pylorus (see p. 360), in the duodenum, in the ileum and at the anus. Oftentimes there may be stenoses at two or more of these situations. Symptoms. In cases of imperforate anus there is no passage of meconium and the examining finger will at once perceive the defect. When the obstruc- EXTERNAL STEANGULATION. 405 tion is at other parts of the digestive tract the symptoms usually do not appear until food has been taken. Here the symptoms are vomiting, at times ster- coraceous in character, abdominal pain and ineffectual efforts to pass faeces. At times visible peristaltic action may be detected upon inspection of the abdomen. The prognosis is not good. Treatment is whoUy surgical. An imperforate anus may easily be relieved by means of the knife. A stricture at a higher level offers difficulties since the diagnosis of its situation is weU-nigh impossible. Death, however, being certain without operation, this latter should be undertaken, and the stenosis being found, either a resection should be done or an artificial anus formed. Either operation is unsatisfactory for death from inanition is practically sure to supervene. 2. External Strangulation. This is the most frequent variety of intestinal obstruction and is caused by compression of the bowel by inflammatory adhesions or bands, foetal remains, such as the omphalo-mesenteric duct, the slipping of a knuckle of the intes- tine into one of the peritonseal fossse, through the foramen of Winslow, through the diaphragm, etc. The small intestine is involved in the great ma- jority of cases and the affection is most common in males in early adult life. S5miptoms. Of these the most prominent is sudden, very severe pain which is, as a rule, constant, but may be accentuated at intervals. Persistent vomit- ing occurs and after 2 or 3 days becomes stercoraceous. The bowels are constipated, but absolute constipation does not come on until the bowel below the obstruction has emptied itself. The intestine above the obstruction is distended with flatus and may be demonstrated upon physioal examination. The temperature is at first unaffected, later it may rise to ioi°-io2° F. (38.5°-38.9° C); the pulse is rapid and weak. In the various forms of acute obstruction a useful diagnostic symptom is the gradual increase in abdominal girth which is due to the augmenting meteorism. This symptom may be demonstrated by taking measurements at intervals. Treatment. This consists in operation as soon as the diagnosis is made. In cases in which consent to operate is withheld, means for relieving the patient's symptoms should be instituted as described under the treatment of intestinal obstruction in general (p. 409). 3. Volvulus. This form of intestinal obstruction is due to a twisting of a loop of the intestine about the mesentery as an axis. It occurs most often in men of middle age and is rather infrequent. The small intestine is usually involved 406 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. although cases of volvulus of the stomach and of the colon have been recorded. The torsion of the gut causing interference with its blood supply, peritonitis and at times necrosis vidth rupture may result. This type of obstruction is not an infrequent sequela of abdominal operations. Symptoms. The pain of this form of obstruction is less severe than in any other variety. The constipation, however, is absolute and abdominal dis- tention is a marked feature. The vomiting and other symptoms are similar to those of obstruction due to strangiilation. Treatment other than by operation will be dealt with under the general management of intestinal obstruction (p. 409). 4. Intussusception. Intestinal intussusception consists in the telescoping of one section of the bowel into another. The invagination consists of the intussuscipiens, the outer layer, and the intussusceptum, the two inner layers. The condition may be simulated for purposes of illustration by slipping one part of a glove finger into another. The condition is named in accordance with the part or parts of the intestine involved, e.g., enteric when the small intestine alone is affected, ileo-coecal when the ileum and coecum are invaginated into the colon, etc. Usually the upper part of the gut makes up the intussusceptum but in rare instances reverse intussusception occurs, in which case the oppo- site condition obtains. .etiology. Intussusception is seen most frequently in children under a year old but is not unknown in adult life. As a cause of obstruction it is nearly as common as strangulation. It is predisposed to by diarrhoea and consti- pation, and while its actual cause is not well understood, it probably results when one portion of the bowel, due to some nervous distiu-bance, suddenly contracts while a neighboring segment remains relaxed. Intussusception just ante mortem frequently takes place and the condition is found on autopsy without having caused symptoms during life. Pathology. Inflammatory processes arising in the serous siu-faces of the bowel brought into contact by the invagination may set up adhesions and permanent attachment between intussusceptum and intussuscipiens. Also the invaginated portion may necrose and, the adhesion being of such character as to prevent exit of the intestinal contents into the abdominal cavity, being passed, spontaneous recovery may take place. In other cases the adhesions being insufl&cient the sloughing may result in rupture with general peritonitis. Symptoms. The first of these are sudden pain and vomiting. The pain is usually paroxysmal and very severe in character; as a rule it is not distinctly locahzed although in some cases it may be referred to the umbilical region. It is most severe during the first 2 or 3 days of the attack, later it becomes INTUSSUSCEPTION. 407 less marked. The vomiting is usually persistent and difl&cult of control, it may be projectile in character but is rarely faecal in infants, though in older children it may become so. Bloody stools with mucus are a frequent symptom in children and when the intussusception involves the rectum tenesmus is a common manifestation. The constitutional symptoms are those of marked prostration, with muscular relaxation, pallor, cold extremities and subnormal temperatvire, which late in the disease may rise as high as 104° F. (40° C.) Examination shows the presence of a " sausage-shaped " abdominal tumor in the majority of cases, and when the lower colon is involved it may be possible to feel or even to see the intussusceptum. To the finger it resembles the cervix uteri and it may even protrude for an inch or two. Measuring the circumference of the abdomen from hour to hour is very important and in the diagnosis of obstruction, if the abdomen is gradually becoming larger it is a strong point in favor of the probability of this condition. The affection may terminate by spontaneous reduction or by sloughing of the invaginated gut, rupture of the intestine being guarded against by adhesions. Death from shock may take place — in the more acute cases — from peritonitis, or from exhaustion. Treatment consists in attempts at reduction by means of inflation of the intestine or the injection of fluids. When these measures are ineffectual immediate laparotomy is necessary. Inflation is practiced by means of a soft rubber catheter to which an ordinary bellows is attached. The air should be forced in very gently and may be prevented from escaping by compressing the nates. The hand should be kept upon the abdomen to determine the degree of tension of the intestine. If reduction follows, rumbling sounds may be detected and the tumor may disappear, but often there is no proof of the success of the treatment ; here the air should be permitted to flow out and a thorough manual examination of the abdomen undertaken. Even then the continuance or the remission of the symptoms is the only index of the efl&cacy of the procedure. Anaesthesia is necessary for the proper carrying out of this mode of treatment unless the abdomen is greatly relaxed. The injection of fluids is a legitimate method of treatment and is preferred by some to inflation. Either normal saline solution or milk and water at a temperature of from 100° to 105° F. (37.4°-4o.5° C.) may be employed. The injection is given from a fountain syringe placed about 5 feet above the patient and through a soft catheter, the exit of the fluid being prevented by com- pression of the buttocks. Inversion of the patient, if a child, should be practiced at intervals. The fluid should be allowed to flow for about a quarter of an hour, then it may be permitted to escape. Whether reduction has been accomplished may then be determined as after inflation. 4o8 DISEASES OF THE DIGESTIVE SYSTEM AND PERITON>S:UM. The after treatment consists in absolute rest in bed and the administration of moderate doses of opium for several days. No laxatives should be admin- istered during this period and the diet should consist entirely of fluids. Unfortunately a recurrence of the intussusception not infrequently takes place. 5. Obstruction by Foreign Bodies or Abnormal Intestinal Contents. Tfeie most common cause of this form of obstruction is a biliary calculus; other foreign bodies such as coins, fruit pits, buttons, intestinal parasites, enteroliths, etc., may be mentioned but are much more infrequently causes of intestinal occlusion. This variety of obstruction takes place in most cases in the small intestine, not infrequently at the ileo-coecal valve. The symptoms so closely resemble those described under the sections devoted to other types of occlusion as to need no separate discussion. 6. Strictures and New Growths. Obstructions due to these causes are rare and occur chiefly in adults beyond middle life. They seem to be more common in females than in males and are met usually in the large intestine. Cicatricial strictures foUow healed ulcers especially those due to tuberculosis. Syphilitic stricttire of the rectum also has been observed. Annular stricture of the intestine, and particularly of the rectum occiirs in intestinal cancer of the coUoid type and also in cylindrical-celled epithelioma (see the section on intestinal cancer, p. 419). Various benign neoplasms of the bowel may cause occlusion, and tumors external to the intestine and inflam- matory processes of the neighboring structures, by pressing upon the gut, may cause obstruction. 7. Obstruction Due to Faecal Impaction. Faecal obstruction as a result of chronic constipation or paralysis of the intestinal musculature is not infrequent. Its most common site is low in the large intestine and it is seen more often in old persons and in women rather than in men. Etiology. This condition is predisposed to by chronic constipation and by chronic intestinal and peritonaeal inflammations. It is particularly frequent in the insane and in hysterical and neurasthenic individuals. Its usual site is the large intestine, particularly the coecum and sigmoid flexure. The mass of faeces gradually accumulating in atonic conditions of the intestine becomes THE TREATMENT OF INTESTINAL OBSTRUCTION IN GENERAL. 409 dry and firm and sets up irritation of the intestinal lining. The intestinal musculature above the impaction may undergo hypertrophy and the internal irritation may spread to the peritonaeal coat of the gut, resulting in a local peritonitis. S5miptoms. Of these the most important is an increasing constipation. The abdomen is distended and tympanitic. The breath is foul, the tongue coated and the patient feels weak and languid. Physical examination reveals a faecal tumor situated in the coecal region or other part of the colon. The mass is more or less firm in consistency but may be indented by pressure. If it is in the sigmoid flexure it may consist of a number of separate masses; in the colon proper it is likely to be sausage-shaped and of varying length. Cases of this type with partial occlusion are subject at any time to com- plete obstruction with its attendant symptoms. The Treatment of Intestinal Obstruction in General. The difl&culty in the treatment of this condition is to determine when oper- ative interference may be postponed and internal treatment relied upon. In general it may be stated that when there is reason to suspect strangulation, operation should be done at once and that internal measures may be employed only in such cases as give no evidence of abnormal circulatory conditions. Increased pulse frequency and vascular tension are contraindications to con- servative methods of treatment. In other words cases of obstruction due to foreign bodies and fascal impaction, when the constitutional condition is unaffected, may receive internal treatment, and cases in which the obstruction is manifestly due to strangulation or volvulus should be put into the hands of the surgeon at once. The question as to how long unsuccessful medical treatment may be contin- ued is also important. The answer to this naturally depends upon the same factors as does the decision as to whether or not medical means are justifiable, namely, upon the patient's condition. It may be definitely stated that sur- gical interference should be delayed not longer than three days at most, and may become indicated after a much shorter period should the heart and cir- culatory apparatus give symptoms of weakening. Having decided that internal treatment may be employed remains the decision as to of what this may consist. The means suggested for the medical management of intestinal obstruction have been many and of these the most approved will be discussed. Drugs. Opium is opposed by many, and especially by surgical authorities, on the ground that it induces an apparent improvement and obscures symp- toms which if unaffected by the drug would indicate operation; consequently opium should be given only in the earliest stages, when the pain is unendurable 4IO DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. and when a probable diagnosis is impossible. Here a hypodermatic injection of ^ to |- of a grain (0.016-0.022) of morphine sulphate is admissible. Follow- ing this a second dose may be given if no relief is experienced. Atropine recently has been advocated in the treatment of ileus but statistics are insufficient to justify any positive statement as to its efficacy. The prin- ciple on which is has been administered is based upon its supposed anti- spasmodic effect upon the intestinal musciilature. It may be given in moder- ate doses, YYir to -^-^ of a grain (0.0005-0.001) and hypodermatically three or four times in 24 hours. Purgatives are distinctly contraindicated in intestinal obstruction unless an absolutely certain diagnosis of faecal impaction can be made. In the latter case laxatives may be given; of these perhaps calomel in repeated doses of J to ^ a grain (0.016-0,032) is to be preferred. Treatment by high rectal injections of warm water in considerable quantity, retained as long as possible and repeated, frequently if necessary, is also indicated. Low rectal impac- tions may be removed by the finger or a blunt instrument. Metallic mercury in large amounts is an old form of treatment but one which is dangerous and consequently should be employed with the utmost caution if at aU. Gastric lavage should be employed in aU cases, even in those to be imme- diately operated upon. In these latter by this means the possibility of vomiting during anaesthesia is greatly lessened. The lavage relieves the distressing vomiting and has been known to relieve the obstruction. One should not be content with one washing but the process should be frequently repeated to disembarrass the stomach of the often rapidly regiurgitated intestinal contents. The good effect of this procedure is more marked in obstruction of the small intestine. Rectal enemata are of value in obstruction due to faecal impaction and intussusception. They may also be employed in other forms of acute occlusion in the hope that the resulting stimulation of peristalsis may cause a reduction of the ileus. Enemata if ice water are a more active peristaltic stimulant than those of warm water but must be given with care especially if there is any tendency to collapse. Irritating solutions have been recom- mended in invagination, especially solutions of salt (5 to 8 percent.) and good results are reported from their use. Inflation with air (see p. 407) may also be found advantageous. Massage should be employed only in intussusception and faecal impac- tion and here only with the greatest care. It is distinctly contraindicated when peritonitis is suspected and in cases in which the obstruction is of long standing, since here there is a possibility of gangrenous conditions which may easily be ruptured. Electricity — chiefly the faradic current with both poles applied to the abdomen — may prove effectual in stimulating peristalsis in cases of faecal ENTEROPTOSIS. 4II accumulation, and is said, at times, to exert a beneficial influence in volvulus. It is, however, a method of treatment of little importance. The application of cold and warm compresses or poultices to the abdomen may relieve the patient's pain to some extent but is absolutely useless as a method of treatment of the lesion itself. Diet. In acute intestinal obstruction no food whatever should be allowed. The thirst may be relieved by sucking bits of ice or better by frequently inject- ing small quantities of brandy and water into the rectum or by enemata of water at body temperature, since when ice is allowed to dissolve in the mouth the patient is continually swallowing water in unknown amount. There is no contraindication to frequent rinsing of the mouth. The collapse, if present, may be combated by hypodermatic stimulation. A description of the technique of the surgical operations adapted to the radical treatment of intestinal obstruction is beyond the scope of a work of this character. ENTEROPTOSIS. See section on visceroptosis (p. 367). CONSTIPATION. Synonyms. Costiveness; Coprostasis. Definition. Infrequent or difficult evacuation of the f^ces. The normal human being should have as a rule, one intestinal evacuation every 24 hours. There are, however, individuals, apparently in perfect health, who habitually have a movement of the bowels only every other day, while certain others regularly go to stool twice each day. Pathology. Post mortem examination of the bodies of persons who during life have suffered from habitual constipation reveals no characteristic lesion. .Etiology. Constipation has manifold causes. Among the factors that are potent in producing the condition are: a. Insufficient peristaltic action of the intestinal wall. This is a result of atony of the large intestine, which condition is often brought about by suppressing the inclination to go to stool, by chronic intestinal inflammations, the wasting diseases and lack of muscular exercise. b. Dryness of the intestinal contents resulting from deficiency in the secre- tion of the intestinal fluids, especially the bile. c. Weakness of the muscles of the abdomen due to over-stretching of these structures as in conditions of obesity, after pregnancy, etc. d. Errors in diet. Foods leaving little undigested residue behind, such as milk, concentrated meat soups and jellies, tea and claret, because of their 412 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. content of tannin, are prone to cause constipation, especially when little water, which taken in proper quantity moistens the intestinal contents and increases secretion, is drunk. Indigestible foods, irregular meals, and insufficient mastication also increase any tendency to costiveness. e. Partial stenoses of the bowel caused from within or from without by the pressure of displaced organs, abdominal effusions, peritonaeal bands or adhesions interfere with the normal passage of faecal matter. Symptoms. These may be indefinite or unrecognizable but in a consider- able number of cases the condition results in a variety of manifestations such as a coated tongue, bad breath, lack of appetite, headache, torpor and poor digestion. Uterine and ovarian troubles are accentuated by constipation, and pressure on the veins of the rectum by the masses of hardened faeces often results in haemorrhoids. Diarrhoea, especially in the aged, may co-exist, since loose stools caused by irritation from the faecal masses, may make for themselves a passage through or alongside the impaction. Treatment. Each case should be separately studied and the cause of the constipation, if possible, ascertained. This having been done the treatment becomes simplified. When diet and regulation of the patient's habits can be relied upon to relieve the condition drugs should not be employed. The patient should be advised to go to stool at a certain hour each day no matter if there is no inclination on the part of the bowels to move, for, if the intestine acquires the habit of evacuating itself at a regular time, fre- quently the mere act of sitting upon the stool will induce a movement. He should also be advised always to heed any inclination to defaecate, at what- ever time it may occur. A regular course of muscular exercise should be prescribed, especially for individuals who are accustomed to a sedentary life. The daily use of light dumb bells or the so-called "setting up" exercises are very efficient; such movements as bending backward and forward from the hips, rotating the body from the hips, rising to a sitting postiu-e with the lower limbs fixed while lying down, etc., are an excellent means of strengthening the abdominal muscles and restoring the tonus of the intestinal muscularis. Bicycling, horseback riding, golf and tennis are to be recommended. The diet should consist to a great extent of such foods as leave behind a considerable undigested residue, such as fruits of all kinds, eaten with the skins when this is possible, and the green vegetables. Brown or whole wheat bread is preferable to white, and gingerbread maybe found useful in children. Honey is laxative as also is molasses. Highly seasoned foods, milk, eggs, pastry and fried foods are constipating. A considerable quantity of water should be taken daily; a glass should be drunk while dressing in the morning and another at night before retiring, with several more during the day. Tea CONSTIPATION. 413 and red wines should be forbidden. Coffee as well as beer and cider may be allowed. Medicinal treatment should, as far as possible, be avoided, but it is often found necessary to employ the milder laxative drugs. Of these rhamnus purshiana holds the first place. Its chief advantage is that, less than other drugs of this class, its continued use is likely to necessitate increased dosage, owing to the establishment of a tolerance on the part of the patient; in addi- tion it has a tonic effect upon the intestine. Its great disadvantage is its very unpleasant taste, but this can be obviated by its exhibition in tablet form and by the use of various palatable preparations which may be procured. The dose of the fluidextract is from ^ to i drachm (2.0-4.0) or more given at night before retiring. Its employment may be continued for a considerable period the dose being gradually lessened as the tendency to constipation disappears. Aloes or its active principle aloin is another excellent drug of the same class. It may be given in various combinations of which the following example may prove useful. I^ aloini, oleoresinae podophylli, extracti beUadonnje, of each gr. ^ (0.008); make one pill. This piU taken at bed time usually brings about a natural movement the next morning, and seldom causes griping owing to the belladonna. Hyoscyamus has the same action in this regard and may be substituted. The list of formulae for laxative pills might be made almost interminable but it is needless to suggest more than the following: I^ extracti colocyn- thidis compositi, gr. i (0.065); extracti rhei, gr. iii (0.20); extracti hyoscyami, gr. ^ (0.033); or I^ aloin, gr. J (0.004); strychninae sulphatis, gr. -gV (o.ooi); extracti belladonna, gr. | (0.008); or I^ extracti rhamni purshianae, gr. ii (0.13); oleoresinae podophylli, gr. | (0.008); extracti hyoscyami, gr. ^ (0.033). For patients who cannot, or who think they cannot, swallow a piU the time- honored mixture of rhubarb and soda combined with fluidextract of rhamnus purshiana, 5 minims (0.33) to each teaspoonful (4.0) may be prescribed. A drachm (4.0) of this compound before each meal often gives good results. Synthetic purgatives such as purgatin and phenolphthalein are useful. The dose of the former is from 15 grains to J a drachm (1.0-2.0) and possesses the disadvantage that it may irritate the kidneys. The latter, given in tablet form is willingly taken by children since its taste is pleasant, and is said to bring about no unpleasant after-effects. Its dose is from i to 15 grains (0.065-1.0). When an atonic condition of the bowel is present physostigmine salicylate in dosage of y^ of a grain (0.0006) may be given separately or added to one of the above formiilae. Compound licorice powder in drachm (4.0) doses is often useful. The stronger purgatives such as castor oil, calomel and the various salines 414 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. are admissible only when the intestine is clogged with faecal matter that requires immediate removal. Laxative mineral waters should not be taken habitually as a rule but in obesity, chronic lithaemic conditions and hepatic cirrhosis their occasional use is of advantage. The waters to be recommended are Carlsbad Spriidel, Hunyadi, Apenta, Villacabras, that of Bedford Springs, Pennsylvania, and Saratoga Congress water. The treatment of constipation at the various spas is unsatisfactory. During the patient's sojourn at the water cure the regular life, exercise and restricted diet, together with the water drunk, regulate the bowels but on returning home the cure is found to be by no means permanent. The continued treatment of constipation by enemata is not to be recom- mended. An injection is, however, a most approved means of removing fjecal impactions and managing the attacks of obstinate constipation that at times occur in the course of chronic states of costiveness. The injection may consist of lukewarm water or of soap suds. If these are ineffectual, the condition can probably be relieved by an enema of 8 ounces (250.0) of olive or cotton seed oil, 2 ounces (60.0) of castor oil, turpentine spirit, ^ ounce (15.0) to the pint (500.0) of warm water or, if the impaction is particularly obstinate, a mixture of i drachm (4.0) of ox gall in a pint (500.0) of water. Rectal enemata should be given from a fountain syringe suspended 4 or 5 feet above the patient and through a soft rubber rectal tube passed high into the rectum. The Davidson syringe if employed should be used with great care, especially in children for if too great force is exerted there is danger of intestinal rupture. Impactions low in the rectum may be relieved by means of suppositories of glycerin or such as the following: I^ glycerini, n\iii (0.2); pulveris aloes, gr. -J (0.022); extracti belladonnas, gr. J (0.016); olei theobromatis, q.s. ad, gr. XV (i.o). Massage of the abdomen is an excellent adjunct to treatment and may be performed either by a nurse or the patient himself. The manipulation should be commenced in the region of the splenic flexure of the colon and carried on along the descending colon toward the rectum; then beginning at the hepatic flexure the endeavor shoifld be made to unload the transverse colon; finaUy the coecum and ascending colon are masseed and the seance is ended by traversing the whole colon from ileo-ccecal valve to sigmoid flexure. The patient also may be instructed to percuss his abdomen with the ulnar border of the hand along the course of the large intestine for a number of minutes night and morning. A vigorous course of treatment of this character may succeed where drugs have failed. Rolling a 5 lb. (2265.0) shot upon the ab- domen for 5 or 10 minutes every morning before rising has been recommended. COLITIS. 415 Hydrotherapeutic measures such as vigorous friction baths, cold or alternate warm and cold spinal douches, hip baths at 50° to 68° F. (10° to 20° C.) of from 2 to 5 minutes duration once or twice a day and a wet abdominal com- press at 50° F. (10° C.) on retiring are approved additions to general hygienic treatment. Electricity in the form of the faradic current may be employed with the object of causing short colonic contractions. One electrode may be applied to the back while the other is pressed deep into the abdomen. The abdominal electrode should not be held stationary for any length of time, but its situation should be rapidly changed. Static electricity in the form of the wave, or the static induced current, is useful, the former in mild constipation, the latter in obstinate chronic cases. When the static wave-current is used but one pole is in contact with the patient, the other being grounded or not; if the latter, the treatment is milder than when the former is the case. The current is transmitted to the patient either through a rectal electrode or a flat electrode applied to the wall of the abdomen, its strength being regulated by the spark- gap between the sliding poles. In using the static-induced current the patient is connected with the outer surface of the Leyden jars, their inner surfaces being connected with the poles of the machine. One electrode is placed upon the bacl^, the other in the rectimi, or both are applied to the back. The treatment of constipation in infants is dietetic when it is possible to combat the condition by this means. Fortunately in breast-fed babies the condition is rare. In bottle-fed children the regulation of the proper propor- tion of fat and proteid will overcome the difficulty. Very often raising the fat percentage or reducing that of proteid is all that is necessary. If the consti- pation is obstinate the use of an occasional teaspoonful of olive oil in conjunc- tion with abdominal massage and, if necessary, the employment now and .then of a suppository constructed of a cone of oiled paper may prove successful. Suppositories of soap or glycerin are irritating to the rectum but those of gluten do not possess this disadvantage and may at times be used with benefit. If laxative medicines are necessary young infants may be given a few grains of sodium phosphate or a teaspoonful or two of milk of magnesia may be added to the last bottle at night. The management of constipation in older children should be carried out along the same lines as those suggested in its treatment in adults; the estab- lishment in early life of a regular habit of going to stool is most important. COLITIS. Most of the Diseases of the Colon are caused by infections. Reference should be made to the section upon Infectious Diseases. 4l6 DISEASES OF THE' DIGESTIVE SYSTEM AND PERITONEUM. DILATATION OF THE COLON. This condition occurs in both an acute and a chronic form; the first as a result of acute obstruction, the second as a sequel of chronic constipation or atony of the bowel. Colonic dilatation is also observed as a congenital defect. Here it usually affects the descending portion or the sigmoid flexiire and is a factor in the production of constipation later in life. Pathology. Any part of the colon or its whole length may be dilated. In chronic cases the muscular coat may be thickened, in acute cases the whole intestinal wall may be thin as a result of stretching or atrophy. Symptoms. There is obstinate constipation, marked abdominal distention and often pressure upward upon the liver, spleen, and thoracic viscera. In severe cases the action of the heart and lungs may be greatly embarrassed, sudden death even having occurred as a result of interference with the heart. In more acute cases vomiting may be present. Examination reveals an abdomen greatly distended and markedly tympanitic, hepatic and splenic dulness often being obsciired. Treatment consists in relieving the constipation by high enemata, in obstinate cases of oil or ox gall (see p. 414) if necessary. These should be given in connection with drug medication given by mouth with a view to over- coming the obstructive condition from above. Having emptied the bowel, remains to bring about as normal an intestinal action as possible. This may be accomplished by the administration of laxatives, castor oil now and then being very effectual, the prevention of distention by means of antifer- mentives such as bismuth tetraiodophenolphthaleinate, gr. v (0.33) with resorcinol, gr. ii (0.13), beta-naphthol, gr. xv (i.o) or bismuth naphtholate, gr. x (0.66). The administration of physostigmine salicylate — gr. t^'o (0.0006) or of strychnine sulphate — gr. ^jj (0.002) is useful in restoring the normal tonicity of the bowel. One should always make a digital exploration of the rectum, for manual removal of faecal impaction is often necessary. The diet should be easily digestible, such as to cause as little fermentation as possible and composed of foods — meat in particular — that leave little residue behind. Surgical procedures such as the formation of an artificial anus or resection of considerable portions of the bowel, when indicated, have given good results. NERVOUS AFFECTIONS OF THE INTESTINES. Of these we may distinguish three types: a. Motor disorders. b. Sensory disorders. NERVOUS AFFECTIONS OF THE INTESTINES. 417 c. Secretory disorders. Of motor disorders there are three classes: 1. Increased peristaltic activity of both small and large intestine re- sulting in the so-called nervous diarrhoea; there is also probably an increased intestinal secretion as well. The condition is seen most often in neurotic and hysterical patients and after unusual mental shocks, such as may be caused by sudden fright, joy, etc. There is no pathological change in the intestine; the attacks of diarrhoea appear without warning and may cease suddenly. The stools vary in frequency from 2 to 15 or 20 during the day and are composed of thin watery matter, mucus being seldom present and blood still more rarely. During the defaecation there may be a considerable expulsion of gas, tenesmus and intestinal rumblings. 2. Peristaltic unrest or tormina intestinorum chiefly involves the small intestine and consists of peristaltic waves passing from one end of the bowel to the other and carrying with them whatever of gas or fluid may be present. The condition occurs both in neurotic and perfectly healthy subjects and concerning its cause we can but advance the theory that it is the result of a hyperexcitability or an increased activity on the part of the nervous mech- anism which presides over peristalsis. The excessive peristalsis may follow emotional shocks, occur at the men- strual epoch or without assignable cause. An attack usually lasts but a few minutes but may be prolonged for hours. It is evidenced by very percep- tible rumbling and gurgling sounds in the abdomen, varying in intensity. Pain is rare but the patient is usually distressed because of the embarrassing amount of attention attracted by the affection. 3. Nervous cramp or enterospasm is an obscure affection consisting of a contraction of the intestine limited to a small portion of the bowel or involving a considerable length of this structure. The spasm is characterized by pain lasting for variable periods; there may be localized distention of the bowel. 4. Intestinal paralysis apparently results from over-irritation of the inhibitory nerves of the intestinal muscularis which may finally undergo atrophy. The condition, when chronic, produces habitual constipation. The treatment of the increased peristaltic activity consists in the employ- ment of means calculated to combat the nervous and hysteric states from which the condition results. Constipating drugs have no effect. Success may attend the use of the bromides and arsenic together with the regulation of the mode of life and attention to general hygiene. Of the treatment of peristaltic unrest the same can be said as regards general management; spa or institutional treatment, with electricity and hydrothera- peutic procedures as adjuncts, often achieves good results. With regard to drugs arsenic, the bromides, valerian, codeine and belladonna have been 27 41 8 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. recommended, with hydrated chloral and opium as last resorts. These last two must be used with great care lest the patient become a drug habitue. In enterospasm aU methods of treatment which increase intestinal irri- tability, such as electricity, massage, cold applications and the like, must be avoided. Marked constipation occurring with this condition should be relieved by oil injections, and the local application of warm compresses and the employment of warm baths are approved methods of treatment. The administration of various drugs has been suggested with the view to lessening the irritability of the intestine; of these opium, belladonna, acetphenetidine (phenacetine) and antipyrine may be mentioned. Intestinal paralysis should be treated by the administration of strychnine sulphate in considerable doses — gr. -^^ to -g-V (0.002-0.003) — 3 times a day and other measures calculated to stimulate and restore the tone of the intestinal musculature, such as massage and electricity. Sensory disorders. Intestinal neuralgia is a painful affection resulting from a hypersensitiveness of the sensory nervous mechanism of the bowel. The condition is distinct from the pain of true colic and is seen in nervous and hysterical individuals, certain nervous diseases, especially locomotor ataxia (tabetic intestinal crises), in gouty conditions and as a result of chronic plumbism. The pain is general, involves the whole abdomen, and is of extremely severe type. It is increased on pressure. Its diagnosis is very difl&cult, there being so many painful abdominal affections from which it must be differentiated that at times an exploratory laparotomy is the only means by which the condition can be certainly diagnosticated. Intestinal hyperaesthesia or abnormal sensations in the bowel occur in hysterical and neurasthenic patients. Of these there is a great variety ranging from feelings of fullness, tickling or throbbing to severe burning or stabbing pain. The condition is the result of some disorder of the central nervous system or of a local derangement of the intestinal innervation. The treatment of both these conditions resolves itself into the proper man- agement of any neurotic tendency which may exist, by means of general measures such as the rest cure, 'institutional or spa treatment. Belladonna may afford relief; opium should never be given on account of the danger of habit formation. Sensory disorders due to tabes, gout or plumbism should receive the treatment which their causes indicate. Secretory disorders are the result of vaso-motor derangements and are very difl&cult to separate from abnormalities of motility and sensation, in fact these conditions often occur simultaneously. Certain influences, however, may cause excessive outpouring into the bowel of large quantities of serous or mucous fluid. The management of such conditions has been discussed under the sections on the treatment of nervous diarrhoea. MALIGNANT GROWTHS OF THE INTESTINE. 419 MALIGNANT GROWTHS OF THE INTESTINE. Carcinomata may occiir in any part of the bowel. They involve, in by far the majority of cases, the rectum, are much less common in the colon and are very rare in the small intestine. Various types of cancer have been observed; those most frequently seen in the small intestine are cylindrical celled epitheliomata or adeno-carcinomata and the most usual site of the neo- plasm is in the duodenum near the opening of the bile-duct. In the colon we find cylindrical celled epitheliomata; the situations most frequently involved are the caput coli and the sigmoid flexure. In the rectum malignant new growths are of more varied type, coUoid, scirrhus and soft carcinomata as well as epitheliomata of the squamous celled type commonly existing in this situation; sarcomata are much more rare but do, at times, occiur. Symptoms. These are by no means typical. The usual cancerous cachexia is usually present, if not at first, in the later stages. To this may be added the symptoms of partial obstruction such as pain, nausea, vomiting and constipa- tion, with the presence of a tumor. This last varies in size and situation, is usually firm in consistency, irregular of surface and generally tender. It is fre- quently movable, but this is not always the case. It is dull on percussion and may seem to pulsate if it is situated over the aorta. Masses of faecal matter l)dng above it in the bowel may obscure the tumor but the administration of irrigations or laxatives wiU remove these, after which the true character of the lesion will become apparent. In cancer low in the rectum digital examination or inspection by means of the proctoscope wiU reveal the presence of a malignant obstruc- tion. The bowel movements are constipated in character as a rule but may be otherwise normal in rare instances. If the neoplasm is in the rectum they are likely to be ribbon- or pencil-shaped as a result of the stenosis. They may contain blood and more or less foetid pus, the former both before and after ulceration has taken place, the latter after this event only. The presence of mucus signifies little else than that an inflammatory condition of the intes- tinal lining is present; the occurrence, however, of sanious pus or muco-pus is of extreme importance from a diagnostic point of view since these appear only in intestinal cancer, in ulcerative colitis and as a result of the rupture of an abscess into the lumen of the bowel. The large amount of the pus in the last case and the unlikelihood of colitis being mistaken for malignant intestinal tumor simplify the differential diagnosis of cancerous conditions. The importance of digital rectal examination, however, in all suspicious cases cannot be over-estimated. The separation of duodenal cancer from pyloric carcinoma is diflacult, the presence of jaundice, lack of early dyspeptic symptoms and normal acidity 420 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. of the gastric contents pointing to, but not rendering certain, the existence of the former condition. Non-malignant Tumors of the Intestine, such as polyps^ fibromata, angiomata, etc., may exist without causing symptoms; they may, on the other hand, produce symptoms resembHng those of mahgnant growths, such as stools containing mucus and blood; there is no resulting cachexia and the neoplasm may be seen or felt upon rectal examination. The treatment of cancers of the bowel consists in removal of the growth by surgical procedures when this is possible. The operation indicated varies with the condition present. Resection of the bowel without the formation of an artificial anus has prolonged life and excellent resvilts may be achieved in favorable cases by rectal resection. When svirgical intervention is for any reason decided against, the patient's general condition should receive attention. His nourishment should be maintained by the administration of easily digested foods given by the mouth or per rectum, and stimulants should be prescribed when necessary. The possibility of obstruction by faecal matter should be provided against by regulation of the bowels so that a sufficient movement is obtained each day. PROCTITIS. Proctitis or inflammation of the mucous lining of the rectum occurs in various types, usually as a part of co-existing colonic inflammation. For a description of these conditions and their treatment the reader is referred to the sections upon dysentery, entero-colitis and intestinal ulceration. HEMORRHOIDS. Synonym. Piles. Definition. Haemorrhoids is the term employed to designate a varicose condition of the veins of the lower rectum. Their most frequent situation is at the muco-cutaneous junction at the anal orifice. Haemorrhoids are internal or external depending upon whether they are developed within the sphincter ani or outside this muscle. Pathology. The haemorrhoidal tumor is composed of dilated blood-vessels, of clots beneath the mucous membrane or of the muco-cutaneous integument of the anal region. It is seldom single; more frequently there are two or more. In shape they are spherical or ovoid, of the size of a small pea to that of a good sized grape or even larger; in color they are reddish or purple, their surface is smooth or lobulated, and in consistency they vary from soft and fluctuating to firm and tense. On section they are found to be filled with venous blood and if of long standing the cavity of the tumor may be intersected with a reticular growth of connective tissue. HAEMORRHOIDS. 421 iEtiology. Haemorrhoids are predisposed to by the erect posture of the body and the anatomical arrangement of the structures involved; the fact that haemorrhoidal veins drain into both the general and the portal venous circu- lation renders the occurrence of piles common in conditions involving venous obstruction, such as cardiac lesions, hepatic cirrhosis, etc. Haemorrhoids are common in both men and women; the former seem to be more frequently affected than the latter, although this may be the result of the natural disin- clination of the female sex to consult a physician concerning such a condition. Chronic constipation is a common predisposing cause of haemorrhoids, the hard faecal masses pressing upon the veins of the rectum and rendering free circulation difficult. Pelvic tumors, uterine displacements, etc., act in the same manner and have the same resiilt; haemorrhoids are a common and often very distressing complication of pregnancy. The tendency of the menstrual flow to relieve congestion of the pelvic region is likely, on the other hand, to militate against the production of piles. Haemorrhoids are also predisposed to by the wearing of over-tight clothing about the waist, by over-eating and drinking and by sedentary habits. Symptoms. Piles may exist for long periods without causing symptoms. Should an external haemorrhoid become congested for any reason the first symptom is pain in the region of the anus, accompanied by sensations of tingling; these increase until sitting becomes impossible and a movement from the bowels attended with excruciating agony. Examination reveals one or more purplish tumors at the anal margin, hard and tense and exces- sively tender. The tumor may gradually disappear and the symptoms abate, abscess formation may ensue and spontaneous cure result after rupture and discharge of the pus, or the circiilation being cut off by the engorgement, the haemorrhoid may ulcerate off. At any time inflammation may recur with its attendant symptoms. Recurrent hemorrhage from the tumors is not infre- quent and is not harmful provided not too much blood is lost. Internal piles may be single or multiple. The symptoms produced by them are a feeling of fulness or tenesmus in the rectum, with dull aching pain and perhaps a mucous rectal discharge. Engorgement with symptoms corresponding to those of external piles may at any time appear and haemor- rhage is not uncommon; this latter may relieve the discomfort but at times so much blood is lost as to jeopardize the health of the patient. Treatment consists in attention to any causative factor in the shape of cardiac, hepatic or pelvic disease, the securing of a normal movement of the bowel each day (see the treatment of constipation, p. 412) and careful daily cleansing of the parts by means of soap and warm water. Painful haemor- rhoids when not acutely engorged may be relieved by various astringents such as liquor ferri subsulphatis; this should be applied 2 or 3 times daily with a brush. Ointments such as the following are often effectual: I^ unguenti 422 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. stramonii, unguenti belladonnas, aa. 5ii (8.0); unguenti gallae, 5iv (15.0); or I^ extract! suprarenalis, 5ii (8-o); adipis lanae hydrosi, 5vi (24.0). These ointments should be applied generously to the affected part, a wad of cotton should be fitted over the anus and held in place with a T-bandage. Inflamed and engorged piles may be relieved by holding a piece of ice in contact with the tumors, by spraying them with a jet of cold water or by apply- ing a compress of gauze impregnated with boroglyceride or by ointments such as the following: I^ morphinae sulphatis, gr. x (0.66); unguenti bella- donnge, unguenti stramonii, aa 5iss (6.0); ichthyolis,5v (20.0); orj^ morphinae sulphatis, gr. iss (o.i); acidi tannici, 5ss(2.o); picis Hquidas, 5ss(2.o); cerati, 5ss (2.0); adipis benzoinati, q.s. ad §1 (30.0). The treatment of piles which are not protruded is practically identical with that already given. The difficulty of applying ointments to the tumors within the sphincter may be obviated by the use of the "pile pipe," an in- strument adapted to the injection of semi-solid materials, and the employment of suppositories; of these the following excellent examples are worthy of trial: I^ ichthyolis, acidi tannici, aa gr. v (0.33); extracti beUadonnae, gr. ^ (0.032); extracti hamamelidis, olei theobromatis, q.s. ad gr. xv (i.o). Fiat suppositoria; I^ iodoformi, gr. v (0.33); olei theobromatis, gr. x (0.66). Fiat suppositoria. Haemorrhage from protruded piles may be controlled by the application of a wad of cotton thoroughly impregnated with iodoform, powdered supra-renal extract, powdered calomel, bismuth subgallate or aristol, or a compress saturated with a 10 percent, solution of calcium chloride; bleeding from the non-protru- ded variety may be stopped by the injection of 5 drachms (20.0) of 10 percent, calcium chloride solution or the introduction of suppositories such as the following: I^ extracti supra-renalis, gr. v(o.33); olei theobromatis, gr. x (0.66) For a description of the treatment of haemorrhoids by injection and radical surgical measures, which are indicated when medicinal treatment fails, the reader is referred to works upon rectal diseases or upon surgery. DISEASES OF THE LIVER. ABNORMALITIES IN SHAPE AND POSITION OF THE LIVER. The most common and important abnormality in the shape of the liver is the result of the constriction of tight waist bands or corsets, the so-called "corset" or "lacing liver." The deformity consists of a division of the right lobe into two parts by a transverse groove of varying depth. At times the furrow is so deep that the right lobe is divided into two more or less equal por- tions by a tendinous band. The symptoms which ensue are usually unimpor- DISEASES OF THE LIVER. 423 tant the chief interest of the condition lying in the fact that the lower division of the lobe, which often reaches to the umbilicus and may extend as low as the iliac crest, is likely to be mistaken for an abdominal tumor or a mis- placed kidney; its margin, however, in most instances, is continuous with that of the left lobe of the liver and the displaced organ descends with inspiration. If the intestine lies in the groove and is tympanitic upon percussion there is an added difficulty in the differentiation of the condition. The symptoms, if any, are those incident to the dragging down of the tumor, and nervous manifestations such as those caused by a movable kidney may be present. At times the corset liver lies almost entirely above the costal margin, it is narrower above than below and the transverse furrow is just superior to the lower margin of the organ. These deformities of the liver are said to offer an obstruction to the normal flow of the bile and consequently to predispose to the formation of hepatic calculi. Abnormalities of Position. The liver may be upon the left side of the abdomen in instances of visceral transposition. Not uncommonly is the organ tilted forward so that, although there is no increase in size, the lower border may be palpable bfelow the costal margin. This tilting may be so extreme that the vertical diameter of the organ may become horizontal. The liver may also be displaced upward by the pressure of abdominal growths or by peritonaeal effusions and downward by fluid in the right pleural cavity or by the expanded lung of emphysema. The movable liver is a rather rare condition, which may be caused by tight lacing and also may occur as a part of a general visceroptosis. The displace- ment of the organ may be slight only or so considerable that the entire liver may fall below the edge of the ribs in which case the coronary and suspensory ligaments are so elongated as to form a mesohepar. Physical examination in instances of marked hepatoptosis reveals an absence of the normal liver dulness and the existence of a tumor having the size and shape of the liver in the abdominal cavity below the normal position of the organ. The tumor is usually freely movable and may be replaced if the patient assumes the recumbent position. The symptoms usually observed are analogous to those of movable kidney, namely a dragging sensation in the abdomen together with the nervous mani- festations which so often are associated with nephroptosis. In a considerable proportion of instances jaundice with pains resembling those of hepatic colic occurs. Treatment consists of the application of a properly fitting belt or bandage calculated to hold the organ in place. When the hepatoptosis is a part of a general ptosis of the abdominal viscera the treatment is that of the viscer- optosis (see p. 367). 424 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. PERIHEPATITIS. Synonym. Capsular Cirrhosis. Definition. A localized peritonitis involving that portion of the membrane which surrounds the liver. Etiology. Perihepatitis is observed as a result of extension of some hepatic inflammation such as abscess; in association with a general peritonitis; as an extension of a pleuritic inflammation through the diaphragm; as a result of trajimatism; as a result of perforation of the stomach, intestine or gall-blad- der or as a part of a general inflammation (panserositis) of the serous mem- branes including the pleura, pericardium and peritonaeum. It has also been considered as due to an arterial nephritis. Pathology. Fibrinous perihepatitis is characterized by the exudation of fibrin upon and the formation of adhesions of the peritonaeal covering of the liver. These adhesions may, in the purulent type of the inflammation, encapsulate collections of pus between the liver and the diaphragm (sub- diaphragmatic abscesses) which may ultimately perforate upward into the pleural cavity. In the chronic form the inflammation consists of a marked thickening of the entire capsifle of the liver with consequent contraction and diminution in the size of the organ which, however, is itself seldom the seat of a cirrhosis. The thickening is often extreme at the hilum of the liver and there may be stenosis of the blood-vessels and bile ducts at this point; adhesions to sur- rounding structures are very common. Symptoms. These are often not in the least characteristic and frequently the condition is unsuspected during life; pain over the hepatic region may be present. In some instances the symptoms are those of atrophic cirrhosis with recurrent ascites but no jaundice. Physical examination may reveal the presence of a friction sound over the liver or over the epigastric region when there is marked general capsular thickening. When there is a purulent exudate between the diaphragm and the liver there is also a septic tempera- ture with chills and sweating; the lower ribs of the right side may be forced outward and the physical signs of pleuritic effusion may be present with flat- ness and absence of voice, breathing and vocal fremitus even as high as the angle of the scapula. Rupture of the pus cavities may take place upward into the pleura, into the abdominal viscera or outward through the skin. The diagnosis between suppurative perihepatitis and pleuritic effusion is sometimes difficult but the early symptoms of the former are abdominal rather than thoracic. The liver is displaced further downward in the former condition. Aspiration may be of assistance in differentiation and it has been stated that the pressure of the out -flowing fluid is increased during the ABSCESS OF THE LIVER, 425 descent of the diaphragm with inspiration in subphrenic abscess while in effusion into the pleura the opposite is the case. The non-purulent perihepatitis with localized thickening is seldom recog- nized during life. The prognosis in the suppiurative type is unfavorable; the localized thick- enings of the hepatic peritonaeum are not prejudicial to life but the generalized perihepatitis with associated thickening of the other serous membranes is a serious and ultimately fatal condition. Treatment. In the more acute instances of perihepatitis before pus- formation the patient should be kept in bed on a light diet. The pain may be relieved by counterirritation in the form of hot compresses, mild mustard poultices, cupping or leeching. The application of straps of adhesive plaster will lessen the movement and prevent stretching of the adhesions but has the disadvantage that the interference with motion tends to per- manency of the adhesions. When pus is present surgical measures should be immediately undertaken with its evacuation in view. In the general thickening of panserositis with ascites the treatment is identical with that of hepatic cirrhosis with peritonaeal exudate (see p. 432). The intake of fluids should be limited, depletion by purgatives and diuresis may be given a trial. Inunctions of 10 percent, iodine in vasogen may be prescribed in the hope of causing absorption of the peritonaeal proliferations. Large accumulations of ascitic fluid necessitate paracentesis. Repeated tappings are sometimes indicated. The treatment of ascites by means of operation will be discussed in the section upon the treatment of hepatic cirrhosis. ABSCESS OF THE LIVER. Synonym. Suppurative Hepatitis. ^Etiology. Hepatic abscess is in all probability, in every instance, the result of microbic infection. The possibility of chemical insult to the organ, however, may be considered. Infection of the liver tissue and subsequent abscess formation may result from a number of causes; of these the most frequent are: 1. Infection with the amoeba coli. In most instances of this form of the affection there is a preceding tropical amoebic dysentery but amoebic abscess of the liver has been observed in the absence of symptoms referable to the intestine. Amoebic abscesses are usually single, of considerable size and as is natural, most common in tropical countries. 2. Pyaemic abscesses occur as a result of the lodgment in the blood-vessels of the liver of septic emboli. These are often multiple and usually of small 426 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. extent. They occur in pyaemia, osteomyelitis, malignant endocarditis, ulcer- ative inflammations of the intestines, pelvic suppuration, peritonaeal inflam- mations, etc. ; when the primary suppurative process is in the area of the sys- temic circulation the infection is brought to the liver by the arterial system as a rifle; more rarely it may be transmitted by means of the inferior cava and the hepatic vein. 3. Foreign bodies, such as hepatic calcifli or parasites may set up an infective cholangitis which may proceed to abscess formation. 4? Tuberculous hepatitis may be characterized by the development of multiple abscesses. 5. The passage of foreign bodies from the oesophagus, stomach or duod- enum into the liver itself, where an abscess may result, or into one of the portal vessels, where an infective pylephlebitis followed by an abscess may take place,. is a rare cause of hepatic suppuration. Hydatid cysts of the liver are subject to infection and subsequent abscess formation. 6. Traumatism over the liver is a recognized cause of hepatic abscess and head injuries may be foUowed by the occurrence of this lesion. Pathology. Abscess of the liver may be single or multiple. Large abscesses are most frequently situated in the thickest part of the right lobe, the cavity being sometimes so large as to involve the whole of this structure. The liver may be enlarged and, if the abscess is near the surface, a fluctuating sweUing may be noted. The lining of the larger abscess cavities is usually ragged and their contents may be thin and foetid or thick and viscid; it is often bile- stained. It often contains cholesterin and bilirubin cr}^stals. The pus of the amoebic abscesses usually contains the amoeba coli. The pus of echi- nococcus abscesses contains the characteristic booklets. Pyaemic abscesses are usually small and mifltiple but they do not often communicate. They begin as a phlebitis which spreads to the adjacent tis- sues. The liver is enlarged but its external appearance may be unchanged; if the abscesses are near the surface there may be capstflar inflammation and adhesions to neighboring structures. Superficial abscesses may be evidenced by the occurrence of yellovnsh spots upon the surface of the organ. In marked instances of suppurative pylephlebitis the liver on section exhibits a number of small yellowish areas, rounded or branching, from which pus exudes on pressure. Careful examination wiU reveal the fact that these small abscesses communicate with the portal vein and are really branches of this vessel in a state of suppuration. Involvement of the entire portal system may be observed and the infective process may extend into the mesenteric or gastric veins. In the multiple abscesses of cholangitis the appearance of the Hver is similar to that just described but the pus is in the bile ducts instead of in the branches of the portal vein. Gall-stones and suppurative cholecystitis are often present. Perforation of large abscesses into the pleura, lung or any of the adjacent ABSCESS OF THE LIVER. 427 viscera, into the peritonseal cavity or through the skin externally may take place. S)auptoms. These may be very indefinite; in rare instances death from rupture and general peritonitis may occur before there is suspicion of the true natiire of the affection. Elevation of temperature is quite constant, the curve being of the pygemic t}-pe and reaching as high, in some instances, as 105° F. (40.5° C). The fever is accompanied by irregular chiUs and sweating, the latter often being marked during sleep. Fever may be sHght or absent in chronic instances of the affection. Jaundice in varying degrees may be present but is a rather incon- stant symptom. There is pain in the region of the liver or it may be referred to the shoulder or back. The patient is often more comfortable when lying on the right side. There is tenderness upon pressure over the liver especially at the margin of the ribs anteriorly. There may be a co-existent diarrhoea, especially in amoebic abscess and the presence of the amoebae in the faeces is a great aid in diagnosticating the condition; Perforation into any of the sttrrounding structures or through the skin may take place. Rupture into the lung is characterized by con\ailsive cough with the expectoration of sputum of reddish brown tint resembling anchovy sauce, and the signs of consolidation at the base of the right lung. The spu- tum may contain the amoeba coli. Physical examination reveals an increase in the size of the liver, usually of the right lobe, which is enlarged upward rather than downward. This enlargement is evidenced by an extension of the normal liver dulness upward; this is especially marked in the mammiUary and mid-axillary lines. Large superficial abscesses may cause a bulging of the overlying surface and it may even be possible to detect fluctuation. • Adhesions to the abdominal wall may take place and as a result of these fremitus may be elicited. The com- pressed lung moves less upon respiration than normally. In some instances of extreme hepatic enlargement the margin of the organ may be palpable below the costal margin; its surface is smooth and tenderness is often present. The symptoms of the multiple pyaemic or pylephlebitic abscesses occur as part of those of a general pus infection. The pyaemic temperature, with its accompanying sweats and chills, is present and the skin may be jaundiced. There is pain in the hepatic region with tenderness on pressiire and the liver is the seat of a uniform increase in size. The diagnosis. Hepatic abscess may be confounded for a time with malarial fever but the absence of plasmodia from the blood and the inefl&cacy of quinine are sufficient to exclude the latter. When upward perforation has taken place and the previous symptoms have not been characteristic the condition may be considered to be an empyaema or pulmonary abscess but 428 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. the presence of the anchovy sauce sputum and of amoebae renders the diagnosis simple. Infected echinococcus cyst may be diagnosticated as abscess but its character is hardly recognizable unless booklets are found in the aspirated pus. The employment of the exploring needle is to be advised in suspected abscess of all varieties but a failure to withdraw pus does not exclude the possibility of its presence. The needle should be of moderate calibre and the operation should be performed under general anaesthesia. The usual points of puncture are bver the point of maximum dulness, in the seventh interspace in the an- terior axillary line or in the seventh space in the mid-axillary line. Hepatic intermittent fever due to the presence of calculi is associated with a history of biliary colic and the presence of more extreme icterus; in other respects, such as in its temperature curve, chills, sweating and liver tenderness, it may resemble the more serious condition of abscess. Leucocytosis is usually marked in abscesses of the liver of the pyaemic variety; it is likely to be absent in those due to the presence of the amoeba coli. The prognosis, since early operation has become the preferred mode of treatment, seems to be more favorable than previously. In any case, however, the condition is a very serious one and the probability of a fatal outcome is great. Treatment. If the patient is seen early he should be kept in bed upon a fluid diet and an ice bag should be applied over the liver; cupping is advised and the application of a number of leeches to the hepatic region and about the anus, In order to relieve the congestion of the portal system, may be em- ployed. The bowels should be kept freely open by the administration of mild laxatives and ammonium chloride in 20 grain (1.33) doses 3 times daily may be given empirically. In the futiire we may be able to treat the condition by means of the hypodermatic injection of a bactericidal serum, examination of the patient's blood revealing the character of the causative micro-organism and the type of serum indicated. As soon as the presence of an abscess is determined surgical measiires should be undertaken. These consist of various procedures such as aspiration, which is most likely to be successful in tropical abscesses; puncture with drainage, a large canula being employed and left in situ — later it may be replaced by a drainage tube of rubber; and free opening with the knife. The interior of the cavity should be thoroughly investigated and neighboring abscesses, if present, also evacuated. After incision free drainage should be provided. Rupture into the peritonaeum, pleura, lung, pelvis of the kidney or pericardium necessitates immediate surgical interference. In rupture into the intestine without peritonaeal involvement, operation need not be undertaken unless the contents of the gut enters the abscess cavity and pro- CIRRHOSIS OF THE LI\^R. 429 duces a gangrenous process; here external opening and drainage are indi- cated. During convalescence the patient should seek a change of climate, either at the seashore or the mountains, and tonics with abundant nourishing food should be prescribed. Multiple pyaemic and pylephlebitic abscesses are fatal, usually without exception, and unless signs of localization become evident, radical measures are hardly ad\dsable, the treatment being that of ordinary pyemia. CIRRHOSIS OF THE LIVER. Synonyms. Interstitial Hepatitis; Gin-drinker's Liver; Hob-nail Liver; Sclerosis of the Liver. Definition. A chronic inflammation of the connective tissue framework of the Hver resulting fiirst in an hypertrophy of the organ and later, because of the tendency of the newly produced connective tissue to contract, in a diminution in its size and a consequent compression of its parenchymatous structure. .Etiology. The causation of this disease has been in too great a degree attributed to the abuse of alcohol. WTiile there is no doubt that alcoholic beverages exercise a certain amount of influence in its aetiology, it is probably true that this influence is rather the result of their adulteration with deleterious substances and the fact that many wines are to-day artificially made from \'ine- gar, logwood, etc., mixed with alcohol, than due to the alcohol itself. It is also true that hepatic cirrhosis may be artificially produced in the lower animals in a short time, without the use of alcohol, by the administration of lactic, but}Tic, acetic and valerianic acids. Of these substances, aU except the last may, in the human organism, result from digestive disorders, which are frequently caused by the ingestion of sophisticated wines, such as those mentioned above, beers adulterated with picrotoxin, aloes, glucose, etc. Con- sequently the tendency to take a broader view of the disease should be encour- aged and the cause should be sought in the alimentary canal. SyphiHs, particularly of the congenital t}"pe, is not an infrequent cause of cirrhosis, especially in children, and chronic malarial poisoning must be con- sidered as a factor in the astiolog}^ of this condition. Trauma cannot be considered a true cause of hepatic cirrhosis but it may result in a localized perihepatitis beneath which a patch of interstitial cica- tricial tissue may exist. This however never spreads through the organ. The disease is usually seen in adults and in males more often than in females. It does, however, occiir in children, in whom it may or may not be the result of congenital syphilis. 430 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONAEUM. J Pathology. The liver after death may be found to be either enlarged, of normal size, or contracted. Its surface may be smooth or nodular. On section it may be yellowish-red — especially in alcoholic patients — or yeUow as a result of staining with bile pigments. The chronic productive inflammation results in an increase in the connec- tive tissue stroma of the organ. This new tissue may surround groups of the liver acini or may be diffusely distributed among the liver cells, which are constricted by it and it may be the seat of a fatty degeneration. The flow of blood through the organ is obstructed by the new growth of tissue and as a result of this the spleen becomes enlarged, there may be ascites and the lining of the stomach and intestines becomes congested. The increase of the stroma in the liver also may obliterate the small bile ducts and the large ones frequently are the seat of a catarrhal inflammation. In many patients there is a general accompanying increase in the connec- tive tissues throughout the body resulting in arteriosclerosis, fibromyocarditis, nephritis, etc. Symptoms. The symptoms of hepatic cirrhosis may be classed as follows : 1. Those due to the co-existent inflammation of the gastric mucosa. 2. Those due to the interference with the secretion of bile. 3. Those due to the interference with the portal circulation. 4. Those due to the accompanying connective tissue inflammations in the heart, arteries, kidneys and lungs. The gastric symptoms may by several years antedate those of the cirrhosis itself, and usually are those of a chronic gastritis, with nausea, and vomiting — which may often be the early morning "water brash" of alcoholic gastritis — eructations and constipation. The gastric symptoms are more pronounced in patients with an enlarged liver. Jaundice of greater or less degree is a common symptom and occurs more frequently in the presence of an enlarged liver than in the atrophic form of the inflammation. With this symptom the urine contains bile and the faeces are more or less clay-colored. In certain cases a rapidly fatal form of jaun- dice occurs with emaciation, fever, and marked gastric and cerebral symptoms. This variety resiilts in death within a short period. Haemorrhages from the oesophagus, stomach, intestines and more rarely from the uterus, nose, kidneys and bladder, are symptoms referable to the obstruction of the portal circulation by the new growth of connective tissue. They may be large and at times alarming but only seldom result fatally, their usual effect being beneficent since they relieve the portal congestion. Dilatation of the superficial veins of the epigastrium and lower part of the chest is due to the damming back of the blood in the portal into the systemic circulation. This in extreme cases may result in the formation of the caput CIRRHOSIS OF THE LIVER. 43 1 MeduscB, the name given to the plexus of largely dilated veins about the umbilicus. Ascites of greater or less degree is a common symptom of cirrhosis with a contracted liver. The abdominal fluid results from the portal obstruction and varies in quantity from a pint (^ litre) or two to an amount so large that the abdomen is distended to such an extent that there is protrusion of the umbil- icus. Hydrothorax may occur and oedema of the legs may result from the pressure exerted by the ascitic fluid upon the veins returning the blood from the lower limbs. These symptoms are more frequently seen in the atrophic variety of the disease. Splenic enlargement exists in a considerable number of cases, especially when the Hver is smaU; often the presence of ascites makes examination of the spleen, as weU as of the Hver, so unsatisfactory that it is necessary to wait until paracentesis has been performed. The erflarged liver may be tender and is usually smooth of surface, while the atrophic organ may be nodular. The blood usuaUy shows a considerable diminution in both red cells and haemoglobin. The urine of the hypertrophic liver is usually of normal specific gravity and is not likely to contain albumin. Bile pigment is frequently present. The urea content is not usually diminished. In the urine of atrophic cases, bile pigment is seldom present, the specific gravity is low, albumin and casts may exist, the urea is usually diminished, and in the later stages of the disease blood may be found. The symptoms of the concomitant connective tissue inflammations of the lungs, heart, arteries, etc., are those of these conditions when they occur sepa- rately. Rise in temperature is not a feature of the disease but may occur when death is about to take place. Physical Signs. These differ greatly in different cases and with the stage of the disease. On inspection the patient's skin and mucous membranes are usuaUy seen to be pale; jaundice of the skin may be present or there may be merely the sub-icteroid hue and slight yellowness of the whites of the eyes. There may be oedema of the feet or general anasarca. When much intra- abdominal fluid is present the abdomen is likely to be prominent and tense; its superficial veins are dilated and at times the varicose condition of these structures known as the caput Medtiscs is present. Palpation may reveal a large, small or normal sized liver with a rough or smooth surface. The spleen may or may not be palpable. Percussion may give us additional information as to the size of the liver and spleen and when ascites is present the note, while the patient lies upon his back, wiU be flat over the flanks, while that over the umbilical region, unless the abdominal cavity is entirely 432 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONAEUM. filled with fluid, will be tympanitic. Upon turning the patient's body to its side the flatness in the flanks will be found movable if the fluid does not wholly fill the abdomen. The physical signs of the accompanying heart, arterial, kidney and pul- monary involvement will likewise be present (see the sections upon the diseases of these structures), as well as those due to displacement of the ab- dominal viscera by the ascitic fluid. The prognosis. Cirrhosis of the liver is a serious, though by no means always fatal condition. In certain cases the progress of the inflammation may cease and the patient may die of some other disease. Its course is usually chronic, lasting a year or two, although cases proving rapidly fatal have been reported. The hypertrophic form seems more rapid in its evolu- tion than does the atrophic. Treatment. The treatment of this condition may be separated into the following heads: 1. The diminution of the excessive connective tissue in the liver. 2. The treatment of the symptoms of the disease as they arise. 3. The prevention of further connective tissue change in the liver and consequent destruction of its parenchyma. Toward accomplishing the first of these objects it is hardly probable that much can be done. The absorption of connective tissue growth, especially when syphilitic in origin, should always be attempted by the use of some form of iodine. Consequently this drug should be given tentatively whenever specific disease is even suspected. To achieve any effect its administration should be continued for a very considerable period. In all cases it is wise to give this agent a thorough trial. In the opinion of the author the preferable method of administering iodine is in the ofl&cial S}Tupus acidi hydriodici of the pharmacopoeia. It should be given in doses of one drachm (4.0) well diluted I hour before each meal, and is preferable to potassium iodide, being less likely to cause iodism. The Treatment of Symptoms. Ascites. This symptom may be treated by, a. Depletion by means of diuretics and purgatives : Free diuresis may be produced and moderate ascites diminished by the administration of the Guy's diuretic piU — calomel, powdered digitalis, powdered squill, aa i grain (0.065) — '^ith the addition of j grain (0.016) of extract of hyoscyamus to pre- vent griping. One of these piUs should be given 3 times a day for one week, then omitted for a week, repeated for a week and so on. Numerous other diuretic drugs may be employed in this connection. Of the potassium salts the acetate, bitartrate, or citrate may be employed; the preference is in favor of the first. It may be given in doses of 20 grains (1.33) 3 times a day. Theo- bromine has given different results in the hands of different observers but the consensus of opinion that it is inferior in ascites due to hepatic cirrhosis CIRRHOSIS OF THE LIVER. 433 to a number of other diuretics. Small doses of calomel frequently repeated increase the excretion of urine. Citrated caffeine in doses of from 2 to 5 grains (0.13 to 0.33) may be employed. The fluid extract of apocynum can- nabinum is an active diuretic in ascites, but should be given with care on account of its tendency to disturb the digestion. Its dose is from 10 to 20 drops (0.66 to 1.33). The resin of copaiba increases the secretion of the kidneys but on account of its liability to cause gastric irritation should be given in capsules coated with keratin, 10 to 20 grains (0.66 to 1.33) in each capsule. The fluid extract of asparagus in drachm (4.0) doses is a diuretic drug which may be tried. Depletion by means of pvirgatives may be used as an adjunct to that by means of diuresis and numerous drugs of this class may be employed. Epsom salts, 2 ounces (60.0), dissolved in 4 ounces (120.0) of boiling water and allowed to cool, if given in the morning before breakfast, no liquid having been drunk since supper the night before, will produce 5 to 6 watery stools during the dav. This mbcture given twice a week will often ward off tapping for some time. Sodium phosphate is also an excellent purge and an hepatic stimulant as weU; it may be given in doses of ^ to 2 drachms (2.0 to 8.0) at var^-ing intervals according to the effect produced. Laxative mineral waters or their artificial salts may also be employed in this connection. Vegetable cathartics such as cascara sagrada, rhubarb, aloes and jalap may be used alternating with the salines. It is unwise to endeavor to remove ascites by marked purgation by means of the stronger hydrogogues for the attempt may be made at the sacrifice of the patient's strength. Diminution of the ingested fluids in ascites is hardly to be advised since, while it may reduce the quantity of the transudate, this good is more than counterbalanced by the resulting diminution in the urine and tendency to constipation. The treatment of dropsical conditions by the elimination from the diet of chloride containing substances is receiving much attention and for it great claims are made. As a tentative meas\u-e it can do no harm in cirrhotic ascites and futiire research may throw more light upon the subject. For a consideration of the dechloridation treatment the reader is referred to the section upon chronic nephritis. b. Abdominal paracentesis or tapping. At the present time it is considered wise to tap the abdominal cavity as soon as the fluid is of sufficient quantity to annoy the patient; the old statement that a patient seldom survived two tappings no longer holds, perhaps because of the present lessened danger of infection and the fact that the procedure is not now employed as a last resort. Accordingly, paracentesis should be performed as soon as the fluid causes any mechanical interference with the functions of the abdominal or thoracic viscera. Complaint of discomfort on the part of the patient is an 28 434 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. indication for the operation as well as a diminution of urine due to pressure upon the vessels of the kidneys by the fluid, interference with digestion or respiration due to the same cause, pulmonary congestion, as evidenced by the presence of rales at the bases of the lungs posteriorly, etc. In cases of ascites with haematemesis due to venous congestion in the mucous membrane lining the stomach the procediu-e is also indicated. Technique of Abdominal 'Paracentesis. The only apparatus needed is a trocar and canula of rather small calibre (-^ to \ in.) and of sufficient length to J)enetrate the abdominal wall of the case in hand, and a few feet of rubber tubing to be attached to the canula, after the puncture, to lead the fluid to a vessel of sufficient size which is placed upon the floor. The patient's bladder should be emptied, and the site of the intended puncture sterilized by scrubbing with soap and hot water, alcohol, aether and 1-5000 mercury bichloride solution. The usual site is in the mid-line of the anterior aspect of the abdomen about equidistant between the os pubis and the umbilicus; the situation chosen must be flat upon percussion. If no fluid is obtained at the situation above mentioned the puncture may be made at about the same level either to the right or left. The right iliac fossa should be carefully avoided because of the possibility of puncturing the coecum in this vicinity. The trocar and canula and the operator's hands having been properly sterilized and the site of the intended puncture anaesthetized by the application of the ethyl chloride spray or the subcutaneous injection of a few drops of a 4 percent, solution of cocaine hydrochloride, the puncture is made, the trocar removed and the rubber tubing attached. The patient may remain in a sitting or semi-reclining position during the procedure and as the fluid is drained an abdominal binder, which is tightened from time to time, to prevent sudden intestinal distention, is applied. Should the fluid stop flowing before the abdominal cavity is empty the canula may be cleared by passing the trocar through it to dislodge any impediment. When sufficient fluid has been removed the canula should be withdrawn and the puncture dressed by the application of a bit of sterile gauze or cotton held in place by adhesive plaster or collodium. The patient should wear the abdominal bandage for several days following the operation. When a trocar of small calibre is used there is little danger that the puncture will not heal without leakage. The consti- pation which may follow tapping of the abdominal cavity and the possible tympanites may be relieved by saline laxatives. c. The treatment of ascites by operation with the view of establishing a collateral circulation between the systemic and portal veins, the so-called Talma's operation, has been much discussed but its results from a curative standpoint are not all that could be desired, which fact in the opinion of some observers, is due to the procedure being usually employed as a measure of CLREHOSIS OF THE LI\^R. 435 last resort. It is possible that the results might be more favorable were the operation undertaken early in the disease. For the description of the opera- tive technique of omental anastomosis and epiplopexy the reader is referred to works upon abdominal surgery. Hcematemesis. The treatment of this distressing symptom of cirrhosis of the Uver differs little from that of the haematemesis of gastric ulcer, see p. 352. The patient should receive no food by the mouth for three or four days following the haemorrhage and during this period food may be admin- istered per rectum. The first food allowed should be in fluid form and may consist of milk, gruels, and broths, if possible partly predigested by peptoniza- tion. Gradually the patient should be brought back to solid diet (see feeding in gastric ulcer, p. 353), and after about 10 days he may be allowed to leave his bed. The after treatment consists in a regulation of the diet, only easily digested and non-irritating foods being allowed, and the administration of tonics. The patient should be advised to conduct his habits and mode of life in accordance with hygienic principles. Hcemorrhage evidenced by the appearance of blood in the stools. Blood so changed by the fluids of digestion that it presents a tarry appearance may be voided with the faeces even when there has been no vomiting of blood. After such hemorrhage the patient must remain quiet for a number of days and his feeding should be carefully conducted. Otherwise the treatment consists in meeting the indications as they arise. The management of rectal hemorrhage due to the presence of haemorrhoids consists in treatment of this complication in accordance with ordinary methods, (see the section on haemorrhoids.) The treatment of concomitant digestive disturbances. Alcoholic drinks are contraindicated and the diet shoifld be so regulated as to prevent the formation in the digestive tract of such products of- fermentation as lactic, acetic and butyric acids. The accompanying chronic gastritis with the excessive production of mucus which is of frequent occurrence may be relieved by the drinking of a glass of hot water before each meal, which tends to dissolve the mucus from the wall of the stomach, or by gastric lavage. Fermentation may also be relieved by the administration of drugs of the class of internal antiseptics such as phenyl salicylate, resorcinol, sodium phenol- sulphonate and the bismuth salts, particularly the naphtholate. Small re- peated doses of calomel are useful in this connection, gr. y-Q (0.006). The use of this drug will also tend to prevent constipation. The bowels should not be allowed to become constipated for this condition favors the production of the toxic substances above mentioned. Constipation may be prevented by the moderate use of salines such as sodium phosphate or sulphate, the laxative mineral waters, etc. The drinking of plenty of ordinary water is to be recommended. 436 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. Atonic conditions of the stomach call for the administration of smaU doses of strychnine, y-^^ to -g^ of a grain (0.0006 to o.ooi). The use of pepsin and other artificial digestants, in the opinion of the most advanced observers, is unnecessary. The administration of drugs prepared with alcohol is to be avoided in so far as possible. The prevention of further connective tissue growth in the liver is to be brought about by attention to the gastric condition, the treatment of which has been dealt with above, and by regulation of the diet and mode of life. Alcohol should be forbidden and the patient should become a total abstainer. Tobacco should be used in moderation only, if at all. The interdiction of alcohol, of course, does not apply to those late stages of the disease where its use as a stimulant is necessary. Some patients, no matter what is said by the phy- sician, will insist upon taking a certain amount of alcohol; such should be directed to take it largely diluted and upon a full stomach. Diet. Certain observers consider an exclusive milk diet the ideal in cir- rhosis of the liver, which it no doubt is, but it will be found difi&cult in private practice for obvious reasons to enforce so restricted a regime. Certain patients either cannot or think that they cannot take milk, others refuse to undertake such a rigid diet. Where milk is not well borne it may be taken in the form of skim-milk — which reduces its fat content — diluted with carbonic, Vichy or other mineral water. Kumyss or matzoon may be agreeable temporary substitutes for milk, but the former possesses the great disadvantage that it contains alcohol. The quantity of milk necessary is from 2 to 3 quarts (2 to 3 litres) every 24 hours, and it is best borne when taken in small quantities at a time. At times it may be advantageous, especially when digestion is impaired, to partially predigest the milk by peptonization. Various semi-solids such as gruels, junket, etc., which have milk as their basis often furnish a pleasing variation to the routine. At the beginning of treatment a milk diet shotdd usually be prescribed, to be followed, as the patient improves, by a gradual return to solids. The easily digested cereals, soft boiled eggs, vegeta- ble puree soups, may be given first, to be followed by a more liberal diet. All highly seasoned or spiced foods are to be forbidden, but the patient may be allowed fish or meat at one meal dviring the day and a moderate amount of carbohydrate food in the form of green vegetables and stewed fruit. A moderate amount of white bread either toasted or not may be permitted. Fats must be restricted since when digestion is impaired they are very prone to give rise to the fermentation products which are such a considerable factor in the causation of hepatic cirrhosis. Too much starchy food must not be given on account of the likelihood of consequent gastric and intestinal fermentation. With regard to beverages, cocoa made with milk, tea and coffee, with the addition of plenty of milk, may be allowed. THE FATTY LIVER. 437 The patient's mode of life should be modeled on hygienic lines of which regularity is the key-note. Regular hours for eating, exercise and sleep should be insisted upon. With regard to exercise a moderate amount of bicycling, walking or golf may be suggested. Water cures at various springs and baths may often be taken in the early stages of the disease with good results. In the United States, Saratoga may be recommended and the continental spas at Carlsbad, Vichy, Marienbad and Hombiirg may be mentioned in this connection. It is quite as likely that the regular mode of life prescribed at places of this sort will do as much for the patient as will the bathing in or drinking of the waters. Massage and passive muscular exercises in cases too weak to take active exercise are a useful adjunct to treatment, and abdominal massage is im- portant in relieving the common symptom of constipation. Drugs, other than those hitherto mentioned, have been employed in consid- erable number with the object of combating the disease. Claims have been made for ammonium chloride, iodoform and nitrohydrochloric acid. The administration of iodoform has been undertaken on account of its content of iodine but potassium iodide is quite as effective and better tolerated. Nitro- hydrochloric acid may be given in as large doses as the patient will tolerate. Organotherapy by the administration of macerated pig's liver and by hypodermatic injection of liver extract has been attempted and good results have been reported by a number of French observers. Apparently this form of treatment does no harm other than causing looseness of the bowels, and future experimentation may throw more light upon this interesting subject. THE FATTY LIVER. .etiology. Fatty infiltration is to some extent present in the normal liver, tiny droplets of oil being always contained in the hepatic cells. In such con- ditions as obesity and chronic alcoholism the liver cells contain more thai their normal amount of fat, the excessive quantity ingested or produced by metabolism being stored in this situation. In cachectic states such as chronic tuberculosis, extreme anaemia, etc., there is an interference with oxidation and the ingested fat accumulates in the liver. A. third type of the fatty liver is that which occurs in phosphorus poisoning and is analogous to the change which takes place in acute yellow atrophy. The substance of the cell is converted into fat — and perhaps other substances — and necrosis follows. This is a more serious condition than the fatty infil- tration observed in obesity and cachectic states. Pathology. The fatty liver is uniformly one of the largest met as a result of pathological change. Its consistency is soft and its surface smooth; its color is light and in the later stages yellowish. Its cut surface is dry and 438 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. greasy. The increase in fat results in such a decrease in the specific gravity of the organ that it floats in water. Symptoms. These are not characteristic. Jaundice is absent and although the faeces may be light in color there is little interference with the formation of bile. There is no ascites and the spleen is not increased in size. In obese patients the hepatic enlargement may be impossible of demonstration but in emaciated subjects the enlarged organ is easily palpated. Its consistency is inclined to be soft and its surface smooth. The diagnosis of the fatty liver is usually not difi&cult. It may be difler- entiated from the amyloid liver by its less firm consistency, the absence of splenic enlargement and albuminuria (see also the diagnosis of cancer of the liver, p. 445). The prognosis is that of the associated disease. Patients with fatty liver bear surgical operations poorly and often fall an easy prey to intercurrent disease, especially pneumonia. Treatment. The treatment of the affection is that of the primary cause, such as tuberculosis or obesity. In the former condition a limitation of the ingested fats, codliver oil, etc., has been suggested. In the instances of fatty degeneration resembling acute yellow atrophy the treatment is that of this disease. THE AMYLOID LIVER. Synonyms. Waxy, Lardaceous or Albuminoid Liver. Definition. An affection of the liver characterized by various degrees of infiltration of the substance of the organ by amyloid material. .etiology. Amyloid liver occurs as a part of the generalized waxy degen- eration of the viscera which is associated with cachectic states, particularly those characterized by prolonged suppuration. It is especially common in tuberculous bone disease but is less frequent with pulmonary tuberculosis. Of other causes tertiary syphilis is important and the condition is also observed in cancerous cachexia, rickets and in protracted convalescence from the acute infectious diseases. Pathology. The liver is greatly increased in size, it is smooth of surface and firm of consistency and its cut section has an anaemic waxy appearance. Treated with iodine tincture it turns a mahogany brown color. The degen- erative process may be localized to one part of the organ and it may be asso- ciated with fatty infiltration. In instances due to syphilis the surface may be studded with nodules (gummata). The amyloid change involves the walls of the small blood-vessels, but not the liver cells. The first vessels to be attacked are those of the median portion of the lobule, later the capillaries between the lobules and their supporting connective tissue are affected. SYPHILIS OF THE LIVER. 439 Symptoms. These are not definite and consist chiefly of the manifestations of the primary disease. There is no jaundice but the faeces may be of Hghter color than normal; the secretion of bile is not stopped. Ascites is absent but the spleen may be enlarged; this organ, with the kidneys, is usually the seat of associated amyloid degeneration. Albuminuria may be present. Physical examination reveals a much enlarged liver of increased hardness and smooth surface, except in syphilis, when nodules may be present. The edge of the organ is often sharp and firm. There is no tenderness. The diagnosis. An enlarged, smooth liver in a tuberculous, syphilitic or otherwise cachectic patient is almost invariably the seat of waxy degenera- tion. For further points in difi'erentiation the reader is referred to the para- graph upon the diagnosis of cancer of the liver (p. 445). The prognosis is that of the primary condition. Treatment consists in removal of any responsible focus of suppuration by surgical means; the appropriate treatment of pulmonary tuberculosis by means of diet, tonics and change of climate, and of syphilis by potassium iodide is necessar}^ should either of these diseases be the causative factor. The mode of life should be regulated in accordance with hygienic principles; plenty of fresh air, moderate exercise, if the patient's physical condition is fit, and simple nourishing food in proper quantity should be prescribed. Iron, arsenic and the bitter tonics may be administered and any digestive disorders should be corrected by the usual means. SYPHILIS OF THE LIVER. Syphilis of the liver may be hereditary or acquired. 1. Hereditary syphilis of the liver occurs in an early or congenital type and as delayed heretary syphilis {syphilis hereditaria tarda). The congenital form is characterized by a diffuse or localized cellular infiltration. The former results in slight if any change in the gross appearance of the organ other than moderate enlargement and an increase in density; later the size of the organ may be diminished and its shape distorted due to the connective tissue proliferation and its subsequent contraction. The circumscribed infiltration is rare and produces the gumma, a manifes- tation seldom observed in hereditary syphilis. In tardy congenital syphilis the liver is also enlarged and may be the seat of gummy nodules. Its subjects are poorly developed and there may be clubbing of the fingers. 2. In acquired syphilis of the liver the organ may be involved diiring the secondary stage but tertiary lesions are much more common. With the erup- tion there may be jaundice and slight enlargement of the organ, acute yellow 440 DISEASES OF TELE DIGESTIVE SYSTEM AND PERITONEUM. atrophy may ensue but this is extremely infrequent, secondary syphilis of the liver being usually a mild affection. Tertiary hepatic syphilis is not very uncommon. It may occur as a diffuse increase in the connective tissue of the organ analogous to that of ordinary cirrhosis. The new connective tissue is often unevenly" distributed; most commonly, however, tertiary syphilitic disease of the liver is characterized by the incidence of gummy tumors. These are nodular growths of size varying from that of a small pea to that of a base ball; they are situated in various parft of the organ, favorite sites being the upper surface near the suspensory ligament and upon the inferior surface in the connective tissues at the hilum; gummata also are found in the parenchyma of the liver. The larger tumors tend to undergo cheesy degeneration and sometimes subsequent calcification. Following the degeneration the nodules contract and tend to distort the shape and reduce the size of the organ. On section of the liver, bands of connective tissue and the cicatrices which have resulted from the contraction of the shrunken gummata may be observed. Symptoms. These may not suggest the nature of disease in any manner whatever unless there are manifestations of syphilitic disease elsewhere in the body. Usually the first symptoms are those of obstruction to the portal circulation; ascites may be present and there may be slight jaundice. The patient is often anaemic and his appearance and symptoms suggest malignant disease. Physical examination may reveal the presence of a much enlarged liver with bulging of the lower ribs on the right side and prominence of the epigas- trium. The organ is hard and palpable; nodules may be palpable upon its surface. The spleen may be increased in size. The diagnosis in the presence of a specific history and associated lesions is simple. The test of treatment will often render the diagnosis clear. The prognosis in congenital syphilis is fairly good under proper treatment although in many instances the child dies within a few days of birth. In tertiary syphilis of adult life in otherwise healthy patients the prognosis under energetic treatment is also favorable but marked hepatic and splenic enlarge- ment and jaundice are considered symptoms of bad omen. Treatment. In the congenital form of the affection the usual treatment of hereditary syphilis in infants is indicated. Mercury may be given either by inunction or by the mouth, the former being preferable, each inunction consisting of about 15 grains (i.o) of the ofl&cial ointment, a fresh site being chosen for the successive frictions as suggested under the treatment of con- stitutional syphilis. If it is preferred to give the drug by mouth hydrargyrum cum creta is as good a preparation as any, the dose for a child of 2 months or less being ^ a grain (0.032) twice daily; an older child may receive i grain (0.065). The treatment by means of mercury should be continued daily ACUTE YELLOW ATROPHY OF THE LIVER. 44I for several months, when intermissions of increasing length are to be advised. During the second year potassium iodide, in small doses, should be added and during the third year should be increased in amount. In the fourth year the mercury may be stopped but it is advisable to continue the administration of the iodide. Tertiarv^ S}^hilis of the liver in adults should be treated according to the usual methods employed in the third stage of the disease (see section upon the treatment of S}'philis). ACUTE YELLOW ATROPHY OF THE LIVER. Synonyms. Acute Parenchymatous Hepatitis; Icterus Gravis; Malignant Jaundice. Definition. An acute destructive affection of the liver characterized by necrosis and atrophy of the organ and associated with marked constitutional symptoms. .Etiology. The disease is more common in women probably because of its frequent association with pregnancy; it is most usual in early adult life but has been observed in young children. It has occurred during the course of the acute infectious diseases, hepatic cirrhosis and syphilis; alcoholism and mental emotion have been considered as factors in its production. Micro- organisms, more especially the colon bacillus, have been found in the liver post mortem but are believed to have no connection with the causation of the disease. Pathology. After death the liver is found to be much smaller than normal, reduction to even one-fourth of its usual weight having been observed. The capsule is loose and wrinkled, the organ is greenish-yellow in color, is flat- tened and flabby and there is no distinct demarcation between the lobes. The condition is similar to that which occurs in phosphorus poisoning as a result of a toxaemic catarrhal process in the smaller bile ducts. The cut sec- tion of the organ is yellow or yellow and red, the former color evidencing an earlier state of the affection. Under the microscope the liver cells are found to be in various stages of disintegration, only a few having retained their normal condition. Areas of complete necrosis are seen in which the hepatic cells have been replaced by degenerated matter consisting of fatty granular debris, bits of connective tissue, bile pigment, and crystals of leucin and tyro- sin. There is a catarrhal inflammation of the finer bile passages and there may be haemorrhages between the hepatic cells. The gall-ducts and bladder are empty. In certain instances in which the coiurse of the disease is not acute, attempts at repair may take place either by h}''perplasia of the remain- ing normal liver cells or reproduction of cells resembling those of the liver from those of the bile passages between the lobules. 442 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. The skin and the organs are usually bile-stained, there is splenic enlarge- ment with granular degeneration of the renal epithelium and fatty infiltration of the cardiac muscle. There are haemorrhages into the various tissues and the fluid in the serous sacs may be increased. Symptoms. The first of these are those of a gastro-duodenitis with in- creasing jaundice. These persist from a few days to several weeks; there are headache, anorexia, nausea, vomiting and epigastric distress; these are fol- lowed, sometimes suddenly, by constant vomiting and at times by hsemateme- sis, delirium, tremors, convulsions and perhaps coma. The jaundice increases, there are haemorrhages into the skin and mucous membranes and in women abortion may take place. Fever is not characteristic and may be absent; a moderate ante mortem temperature seldom rising above ioi° F. (38.2° C.) is not uncommon. The pulse becomes gradually weak and rapid and the so-called typhoid state becomes evident. The diminution in the size of the liver is rapid and the shrunken organ may be impossible of demonstration by percussion owing to the tympanitic note over the hepatic region resulting from the intervention between the liver and the abdominal parietes of distended intestine. The spleen is enlarged. The urine is of high specific gravity, colored with bile pigment and may contain casts as a result of the concomitant degeneration of the kidneys. The urea is markedly diminished, even absent at times, but the ammonia is increased. Leucin and tyrosin crystals are usually present and may be demonstrated by allowing a few drops of urine to evaporate upon a slide and examining the result with the microscope. The faeces are usually light colored. The diagnosis. In the early stages it is impossible to separate acute yellow atrophy from acute catarrhal jaundice and it must be remembered that cere- bral symptoms may occur in this latter affection; usually the concurrence of icterus with decrease in the size of the liver, the presence of leucin and tyrosin in the urine and the symptoms of a severe intoxication render the diagnosis in the later stages simple. The small liver will differentiate the condition from hypertrophic cirrhosis, and acute phosphorus poisoning, which closely resembles acute yellow atrophy in many respects, may be separated by the absence of leucin, less amount of tyrosin, the less rapid shrinkage of the liver, the more severe gastric disturbance, the history and the milder cerebral symptoms. The prognosis is extremely unfavorable but a few instances of recovery have been observed. The usual duration of the disease is several weeks. Treatment. The patient should be kept at rest in bed, the diet should consist wholly of milk and other easily digestible fluids and measures should be taken to disinfect the intestinal tract and favor the elimination of toxic products from the blood. The former consideration may be carried out NEOPLASMS OF THE LIVER. 443 most effectually by the administration of bismuth naphtholate or bismuth tetraiodophenolphthaleinate (eudoxin) either alone or combined with phenyl salicylate in proportions of 5 grains (0.33) of one of the bismuth salts to 3 to 5 grains (0.2 to 0.33) of the latter substance. A dose should be given 3 or 4 times a day. The bowels should be kept freely open by means of purges, especially calomel, which is best given in fractional doses. Elimi- nation through the kidneys should be promoted by diuretic drugs such as caffeine, by frequent draughts of water and by large high enemata of hot normal saline solution; the latter is a most effective means of promoting diur- esis and may be employed as often as 2 or 3 times daily, 8 quarts (litres) or more of the solution being given at each occasion. The hot saline is also taken up by the blood and serves to dilute the toxins circulating in this fluid; this latter consideration may also be favored by hypodermatoclysis or intravenous infusion of normal saline solution. The vomiting may be controlled by rest, judicious feeding (diluted or pep- tonized milk), pellets of ice, small doses of dilute hydrocyanic acid or of cocaine hydrochloride, menthol -3V of ^ grain (0.002) or a teaspoonful (4.0) of hot water frequently repeated. For the nervous symptoms the bromides and warm baths are often effective; hydrated chloral and morphine should be employed only when absolutely necessary. In the incidence of heart weakness or collapse free stimulation is indicated. NEOPLASMS OF THE LIVER. Cancer of the Liver. Of the malignant tumors of the liver carcinoma is by far the more common type, and carcinoma of the liver of internal carcinoma is only less frequent than that of the uterus and stomach. The affection is rarely primary, being in most instances secondary to similar disease of other structures. Most often it is secondary to carcinoma elsewhere in the portal area, particularly of the stomach. It is most common in men in advanced adult life but it has been observed in children. A hereditary predisposition is considered to be of some influence in its incidence. Pathology. Primary hepatic carcinoma occurs in three types: 1. Massive carcinoma which is characterized by marked increase in the size of the organ and in which the new growth is distributed uniformly through a considerable portion of the liver. On cut section the growth is firm and of grayish-white color and the line of demarcation between it and the adjacent hepatic tissue is sharp. 2. Nodular carcinoma. In this type of the disease nodular growths of 444 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. varying size are distributed through the organ. One of the nodules is often firmer and larger than the others and is the primary growth from which the others have sprung. 3. Adeno-carcinoma with interstitial hepatitis. This is a very rare form of carcinoma of the liver in which the organ is usually small, its surface is greenish and mottled and studded with nodules. Cut section reveals firm growths in great numbers between which are bands of connective tissue. The liver parenchyma may be the seat of hypertrophy. Secondary carcinoma of the liver is characterized by extreme enlargement, its surface is studded with nodules which are also distributed evenly through the substance of the organ; rarely one lobe only may be affected. The nodules vary in size and consistence, are whitish or yellowish in color and those just beneath the capsule may be felt through the abdominal parietes and are at times umbilicated (Farre's tubercles). Vasciilar rupture with heemorrhage beneath the capsule into the gall-bladder or peritonaeal cavity may take place. Histologically hepatic carcinomata are epitheliomata of the alveolar or trabecular t}'pe. The cells are of different types, polyhedral, giant or more rarely cylindrical; at times different varieties of cells are seen in the same growth. Degeneration may take place in both the primary and secondary tumors but the latter are more particularly susceptible. The changes which may take place are of different varieties, fatty and hyaline degeneration, sclerosis and haemorrhage, at times succeeded by suppuration, having been described. Sarcoma of the liver is very rarely primary; secondary hepatic sarcoma is not especially uncommon. Melano-sarcoma is the most frequent type although instances of lympho-sarcoma, myxo-sarcoma and gho-sarcoma have been observed. Melano-sarcoma is usually secondary to similar growths in the orbit or it may occur in association with generalized melano-sarcoma. The occurrence of melanotic tumors in the skin may suggest the possibility of similar growth in the liver. Symptoms. These consist of progressive emaciation, weakness and pros- tration, with hepatic enlargement. Digestive disorders are common, such as anorexia, nausea, vomiting and pain or a feeling of weight in the epigastrium or in the region of the liver. The pain varies; it may be wholly wanting or it may be of severe character and is sometimes referred to the right shoulder. Jaundice of moderate degree may be present ; it is said to exist in about 50 per- cent, of cases. The urine is colored with bile pigments if there is jaundice but the stools are seldom clay-colored. Ascites occurs both in the rare forms of cancer with cirrhosis and as a result of pressure upon the portal vein or of peritonaeal metastases. If tapping reveals the presence of blood- tinged fluid in association with a growth of the liver the probability of malignant tumor is great. CANCER OF THE LIVER. 445 The blood is that of a secondary anaemia and consequent oedema is fre- quent. A febrile movement is not uncommon especially in the late stages; it is often continuous — ioo° to 102° F. (37.8° to 38.9° C.) — but may be inter- mittent. Chills may be noted. Physical Examination. Upon inspection the patient is seen to be emaciated and cachectic in appearance. The skin may be of icteric color and there is usually a prominence of the upper abdomen with a dilatation of the superfi- cial veins. Palpation reveals the edge of the liver from an inch or two below the margin of the ribs to the level of the umbilicus or even lower. The surface of the organ may be smooth but in nodular cancer the prominences and some- times the depressions in their centers may be felt. Tenderness may be present. The increase in size is also evident upon percussion and it usually involves the whole organ but may affect one lobe more than the other. Splenic enlargement is not characteristic nor frequent. Primary neoplasms may be difficult of differentiation from those of secondary type unless there is a demonstrable primary growth elsewhere in the body. The diagnosis may be 'difficult in the absence of primary carcinoma of other structures. The presence of firm nodules on the siurface of the organ simplifies the diagnosis but the smooth cancerous liver is a more complicated problem. It may be differentiated from the fatty liver by its hardness, the absence of cachexia and jaundice. These two latter are also absent in the amyloid liver and here the spleen is usually enlarged. In abscess we have the history of colitis or the presence of a septic temperature to aid us, the organ is usually soft and fluctuation may be elicited. The nodules which occwi in hydatid disease with an enlarged liver are soft, the cachexia is not present and the course of the disease is more protracted than that of cancer. Aspiration of one of the cysts may show the presence of booklets. Another difficult problem is the separation of the amyloid liver with a surface studded with gummata. Here the presence of a history of S}^hilis and the benign course of the affection are diagnostic points. In hypertrophic cirrhosis we have an enlarged liver vnih jaundice but the onset of cachexia is deferred, wasting is not extreme, pain is absent, the liver is smooth and the ascitic fluid does not contain blood nor cancer cells; the spleen is usually enlarged. That form of carcinoma which is associated with cirrhosis is extremely difficult of differentiation from atrophic cirrhosis; the emaciation is, however, more rapid in the former affection. Melano-sarcoma usually follows pigmented growths in other parts, partic- ularly the choroid of the eye and the skin; there is great enlargement in the liver and often metastatic growths in the kidneys, lungs and other organs are present. The importance, in instances of hepatic affection in which a malignant nature is suspected, of thoroughly searching for the presence of primary cancer 446 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. elsewhere, cannot be over-rated. The stomach, uterus and rectum, in partic- ular, should be investigated by all the means at our command. The prognosis of hepatic cancer is, of course, distinctly unfavorable, the condition usually resulting in death in a few months; exceptionally life may be prolonged for a year or slightly longer. Treatment. Medical treatment can be but palliative. For the pain the hypodermatic administration of morphine may be prescribed without com- punction for the character of the disease is such as to render the induction of theihabit harmless. The addition of small quantities of atropine to the former drug will lessen the tendency to constipation. This symptom, when present, is preferably treated by means of the vegetable purges such as cascara, senna, aloes, etc.; the saline waters, according to German observers should not be employed. Hepatic pain may be relieved by the application of hot or cold compresses, poultices, anodyne plasters or counterirritants such as tincture of iodine, or liniments. The appetite may be improved by the vegetable bitters and dilute hydro- chloric acid — 10 drops (0.66) in a glass of water with each meal. Vomiting may be controlled by the administration of bits of cracked ice, sodium bicarbonate and cerium oxalate in milk, small doses of dilute hydro- cyanic acid or of creosote. Gastric lavage is often effective. Intestinal fermentation is benefited by the bismuth salts especially the naphtholate or iodophenolphthaleinate in doses of 5 grains (0.33) 3 times daily. The pruritus which sometimes accompanies the jaundice may be relieved by warm baths containing sodium carbonate, lotions of i to 50 phenol and the other means suggested under the treatment of catarrhal jaundice. Calcium chloride, 15 grains (i.o) 3 times daily and hypodermatic injections of pilocarpine, | of a grain (o.oii), are said to be effective. The diet should be nourishing and easily digestible. Frequent small meals are preferable to larger ones at longer intervals. Milk when well borne is very valuable but if large amounts are taken at once heavy curds may form in the stomach. To obviate this Vichy or lime water may be added. Kumyss and matzoon are excellent substitutes when the patient cannot take milk or is tired of it. Meat and fats are often not well tolerated but the various meat extracts may be employed if desired. Cereals and gruels are excellent. Usually the patient may be allowed to select the foods which he likes if they are not disturbing to the digestion. Surgical treatment may be effective when the growth is single, primary and in a favorable situation. Recovery has followed in at least one instance of secondary tumor, the primary growth in the stomach having been excised and at the same time a secondary nodule in the liver was extirpated. The advances which are daily being made in surgical technique lead us to hope that it may PARASITES OF THE LIVER. 447 soon be possible to undertake operations upon the liver which were previously considered impracticable. If marked ascites is present repeated tapping may be necessary. PARASITES OF THE LIVER. Echinococcus Disease of the Liver. Synonym. Hydatid Disease of the Liver. Definition. \ disease of the liver due to invasion of the embryo or larva of the txEnia echinococcus and characterized by the formation of cysts within the substance of the organ. .Etiology and Pathogenesis. The tcenia echinococcus is a minute cestode of three or four segments and about \ of an inch (4 to 5 mm.) in length; the head is small and possesses four sucking disks and a rostellum with two rows of hook- lets. The natural habitat of this parasite is the upper intestine of the dog. The worm is rarely met in the United States possibly because it is so small as to be easily overlooked. Echinococcus disease is most common in those countries Avhere the relation between dogs and men is intimate, as in Iceland and Aus- tralia. The terminal segment of the parasite, containing several thousand eggs, is cast off by the dog in the intestinal evacuations of this animal and entering the human alimentary tract with food or drink, the egg shell is dissolved and the larva is liberated. . It bores its way into some branch of the portal circulation and is carried by the blood stream to the liver. Here it lodges and the booklets, by means of which it entered the blood-vessel, disappear. The embryo now becomes a small cyst consisting of two layers, the external or ectocyst which is laminated and cuticular in structure and the internal or endocyst, a parenchymatous or germinal layer. The fluid of the cyst is clear and the w^iole vesicle is enclosed by a capsule of connective tissue which develops as a result of inflammatory reaction. When the primary cyst has increased to a diameter of y to -|- of an inch (15 to 20 mm.) buds develop from the germinal layer which gradually become cysts themselves with a structure identical with that of the primary vesicle. These daughter cysts are at first attached to the lining of the mother cyst but later free themselves and become in turn the parents of a third generation of vesicles. From the granular inner layer of parent and daughter cysts brood capsules develop by a budding process, and from their lining membrane projections are formed which ultimately become scolices which really are the heads of tanicB echinococci with their suckers and booklets. These when freed and ingested by the dog may develop into the adult parasite. The preceding is the usual form of the development of the echinococcus in 448 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. man; at other times the daughter and granddaughter cysts remain within the parent and in animals the buds may force their way between the two layers of the cyst waU and grow outward — the exogenous type. In still another type — the multilocular — the buds which are formed from the parent cyst become completely cut off and are enclosed by a fiirm connective tissue capsule; a number of these may unite and form a dense mass of fibrous tissue in the meshes of which are spaces of about the size of a large pea in which at times booklets and scolices may be found. The fluid contained in the young cysts is clear, of a specific gravity of 1005 to 1009 or slightly higher and contains no albumin except after a number of tappings; at times traces of sugar, succinic acid and hsmatoidin are present. Scolices and booklets are usually found and are characteristic of hydatid disease. The cysts vary in size from that of a pin head to 5 inches (12 cm.) or more in diameter and are of slow growth; the parasite may remain alive perhaps as long as 20 years. When death finally takes place the cyst walls contract and the contents becomes inspissated; partial calcification may occur. Rupture into the bile ducts, the vena cava, the intestine and elsewhere may happen and is a serious complication; the same is true of suppuration. Symptoms. Small cysts are often unsuspected until revealed at autopsy. The larger ones give rise to the symptoms of hepatic tumor associated with a very slow and gradual decline in health. The large cysts cause a dragging sensation referred to the region of the liver, jaundice, if there is obstruction to the flow of bile, and when there is interference with the action of the heart or lungs, dyspnoea and irregular cardiac action. Suppuration gives rise to a septic temperature with rigors and sweats and if rupture takes place various symptoms result depending upon the site of the rupture. Invasion of the lungs may be accompanied by the expectoration of sputum containing booklets; rupture into the bile passages is succeeded by jaundice and by the evacuation of faeces in which booklets may be found; rupture into the stomach may be followed by vomiting of booklets and cysts; the bursting of a cyst into the vena cava causes interference with the right heart action and thrombosis of the lungs due to the lodgment of cysts. The cysts may also rupture into the pericardium in which case pericarditis ensues ; into the peritonaeal cavity with resulting peritonitis; or externally through the abdominal wall. Urticaria may appear coincident with rupture or even with aspiration due perhaps to the absorption of a toxic material contained in the fluid. The physical signs depend upon the situation of the tumor. Cysts near the upper surface of the liver may manifest themselves by demonstrable elastic or fluctuating swellings and may give the so-called hydatid fremitus which is elicited by applying one hand to the tumor and at the same time percussing ECHINOCOCCUS DISEASE OF THE LIVER. 449 lightly with the other. The fremitus is evidenced by a vibrating or trembling movement thought to be produced by the impact of the daughter cysts against one another. The diagnosis often requires puncture and aspiration of the cyst contents for its confirmation; the characteristics of the fluid withdrawn are as described above. The presence of booklets is pathognomonic and that of glucose, probable evidence of hydatid disease. Hepatic syphilis may be differentiated by its history, and cancer of the liver by the more rapidly developing cachexia. The prognosis in instances of the affection which are characterized by evident symptoms is unfavorable, unless operative interference is undertaken, except in the instance of spontaneous external rupture. Treatment. Prophylaxis consists in impounding and destroying stray dogs and also in decreasing the number of these animals by means of an in- creased license fee. Strict cleanliness should be observed by those who keep dogs in the house as the ova are to a very great extent conveyed by the faeces of these animals. Where the disease is prevalent all drinking water should be filtered and boiled and all fruit and vegetables which are eaten uncooked must be thoroughly washed with filtered and boiled water. Meat should be inspected for the echinococcus and all the offal of infected sheep and oxen should be burned lest they be eaten by dogs. Pet dogs should receive an anthelmintic about once a year. Numerous drugs have been employed in the treatment of echinococcus disease but none of them has proved of any benefit, the only efficient curative means which we possess being surgical. Simple aspiration of the cyst contents, a canula of moderate size being employed, may result in cure but is not to be undertaken without due con- sideration, for death has been known to follow the operation. Aspiration is contraindicated if suppuration is present. Aspiration with injection of anti- septic solutions such as i to 1000 mercury bichloride, 5 percent, copper sul- phate and 0.5 percent, beta-naphthol has been recommended but is not with- out danger and is to be avoided. The treatment by means of electrolysis is carried out by passing two needles, each connected to the negative pole of a galvanic battery, into the cyst, while a sponge electrode attached to the positive pole is applied externally to the abdomen or over the cyst. Success has followed this method in a few instances but it is not to be advised. Radical surgical treatment should always be employed when possible, the object being to remove the cyst wall and its contents entire; if this is imprac- ticable simple evacuation of the fluid may result in cure. When suppuration has taken place the management of the condition is identical with that of abscess. 29 450 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONJLUM. Other Parasites of the Liver. 1 The liver is subject to diseases due to other forms of parasites but these are rare and of interest rather to the pathologist than the practitioner. The pentastomiim denticulatum, the larva of the pentastomum or lingelata tcBnioides may be found in the organ. This is a lancet-shaped worm, the male being slightly less than an inch (1.8 to 2.5 cm.) long vv^hile the length of the female is from 3 to 5 inches (8 to 13 cm.). ^he coccidium oviforme is common in the liver of the rabbit and may be found in the human being where it produces whitish nodules varying in size from that of a pin head to that of a small pea. The accompanying symp- toms are intermittent fever, nausea, diarrhoea and enlargement and tenderness of the liver. The cysticercus celluloscz is rarely observed in the liver of man. DISEASES OF THE HEPATIC BLOOD-VESSELS. Anaemia of the liver is productive of no especial symptoms. The aneemic condition which is observed after death in the liver of amyloid or fatty degen- eration is probably not an index of the state of the organ during life. Hypersemia of the liver occurs in two varieties : I. Active Hyperemia takes place after eating a full meal and is especially marked in individuals who eat and drink excessively; in these subjects the condition may even be continuous. If the over-eating and drinking is persis- ted in, functional disturbances and even organic structural change, consisting in an over-production of connective tissue, may resiilt. Active hypersemia also occurs in diabetes mellitus and in the acute infectious diseases and also as a result of suppressed menstruation and after the suppression of a haemor- rhoidal flux. Symptoms. These are not marked nor important. The condition may be the cause of the distress and feeling of weight of which persons who habitually eat and drink too much complain and which is referred to the region of the liver. The size of the organ is probably subject to daily fluctuations. Treatment consists chiefly in dietetic measures; a moderate and easily digestible diet comprised of milk, thin soups, etc., should be substituted for that to which the patient has been accustomed. Plenty of water should be taken but alcohol, vnth fats and sugar, should be forbidden. The pain and discomfort over the liver, if severe, may be relieved by the application of flaxseed poultices, cold compresses or dry cups. Intestinal antiseptics especially bismuth naphtholate or phenolphthaleinate (eudoxin) in doses of 5 grains (0.33) 3 times a day should be given, any gastric irritation should receive appropriate treatment and the bowels should be kept freely DISEASES OF THE HEPATIC BLOOD-VESSELS. 45 1 open by means of fractional doses of calomel and the saline laxative waters. Ammonium chloride in 20 grain (1.33) doses is said to have some influence in decreasing the congestion of the affected organ. In many instances a sojourn at one of the spas such as Saratoga, where the Hathorn water is particularly indicated, is advisable; Vichy upon the continent of Europe is recommended as a resort for these patients. 2. Passive Hypercemia is a much more common and important affection than the foregoing. iEtiology. The condition is the result of obstruction to the flow of blood through the liver to the heart. The chief cause is valvular endocarditis but passive congestion of the liver also occurs in pulmonary emphysema and sclerosis, thoracic tumors, pleuritic diseases and any condition in which pressure is exerted upon the vena cava. Pathology. The Hver is increased in size, firm in consistence and dark reddish in color. Its vessels are distended with blood, the intralobular vein and the neighboring capillaries being especially affected in this respect. On section the " nutmeg" appearance, which is the resiilt of the alternating hyper- aemia and anagmia of the hepatic and portal districts, is apparent. The in- creasing distention of the vessels in the central portions of the lobules finally results in an atrophy of the adjacent liver cells; there is a deposition of dark pigment, the blood-vessels are finally occluded and there is an increase of con- nective tissue. In the final stage of chronic passive congestion the organ is decreased in size but its surface is smooth in contradistinction to the condition obtaining in atrophic cirrhosis in which the surface of the liver is roughened. Symptoms. There is usually gastric irritation with vomiting, sometimes of blood; ascites, at times followed by general oedema, is common in the later stages. There may be slight jaundice, with dark urine and light colored stools. The physical signs consist of a primary enlargement of the liver, often with tenderness, followed by a contraction of the organ. The enlarged liver may pulsate as a result of the regm-gitation of blood from the right side of the heart. This is not to be confounded with the throbbing which may be transmitted from the over-acting heart. In this latter condition the liver appears to move downward while in the former the organ appears to dilate uniformly. The spleen is often increased in size. Treatment consists in restoring the circulation to its normal state which is often possible, when the condition is the result of vahoilar heart disease, by the administration of cardiac tonics. Co-existing pulmonary disease should receive appropriate treatment and abdominal paracentesis may be necessary. Confinement to bed is usually indicated. The congestion of the liver may be further relieved by saline laxatives and hydrogogue cathartics such as elaterium, jalap, etc. Calomel and blue 452 DISEASES or THE DIGESTIVE SYSTEM AND PERITONEUM. I mass are also valuable. The method of depletion advocated by Hay, which consists in the administration before retiring of 2 ounces (60.0) of magnesium sulphate which have been dissolved in boiling water and then allowed to cool, is an excellent method of relieving the portal congestion. The general dropsy may be diminished by eliminating the chlorides from the diet (see the section on the treatment of the oedema of chronic nephritis). The withdrawal of from 15 to 20 ounces (450.0 to 600.0) of blood directly from the liver may be practised but is not without danger. The pain over the liver may be relieved by the means suggested in acute hepatic congestion (p. 450). The diet shoiild be nourishing and easily digestible because of the possibility of increasing the dropsy. During convalescence a residence at one of the water cures suggested under the treatment of active hypersemia is often of benefit to the patient. Thrombosis and Embolism of the Portal Vem. Thrombosis of the small branches of the portal vein occurs as a result of the obliteration which takes place in hepatic cirrhosis; obstruction of larger branches may foUow cancerous invasion, the lodgment of a parasite or of a calculus which has iilcerated through the vessel waU. The blood may coagu- late in the vein in cirrhosis and syphilis of the liver or the vessel may become occluded as a result of a proliferative inflammation of its wall. Collateral circulation may become established around the obstruction and the affected vessel may degenerate into a fibrous cord. Symptoms. Associated with those of cirrhosis or of another of the causa- tive conditions the sudden occurrence of ascites, extreme distention of the branches of the portal circulation with splenic enlargement, haematemesis and bloody stools is suggestive of portal thrombosis. The diagnosis is a very difi&cult one. Hepatic infarct is not common and is of no especial clinical importance except when the embolus is septic. Pylephlebitis is probably consequent upon portal thrombosis but is of no particular significance unless the thrombus is infective. Septic pylephlebitis follows the lodgment of an infective embolus from some part of the territory of the portal circulation. It may occur in dysenteric conditions or in sepsis of the umbilical vein in the new-born; its chief importance is its relation to hepatic abscess. The symptoms are the usual ones of pyagmic infection, irregular tempera- ture with rigors, sweats and prostration. There is usually pain over the liver and jaundice with the manifestations of portal obstruction. Co-existent purulent peritonitis has been observed. Changes in the Hepatic Artery and Vein are uncommon. The artery DISEASES OF THE BILIARY TRACT. 453 may be the seat of dilatation in cirrhosis of the liver. Arteriosclerosis and endarteritis as well as aneurysm of the hepatic artery have been observed. The last of these is evidenced by an expansile tumor over which a bruit may be audible. Its symptoms are pain over the liver, jaundice from obstruction of the biliary ducts due to pressture, melaena, and the vomiting of blood. The hepatic vein may be dilated in conjunction with right cardiac enlarge- ment. Embolism from the right auricle has been noted and a stenosis of the openings of the veins has been described as occurring in connection with a fibrous obliteration of the inferior vena cava. DISEASES OF THE BILIARY TRACT. JAUNDICE. Synonym. Icterus. Definition. A condition, rather symptom than disease, characterized by a yellowish discoloration of the skin and other tissues, as well as of the body secretions, by the bile pigments. Jaundice was formerly considered as occur- ring in two types, hepatogenous, or obstructive, and hcematogenous. At present it is held as probable, if not certain that there is no hsematogenous jaundice but that obstruction is responsible for the condition in all instances. Obstruction to the normal flow of bile and consequent jaundice may result from various causes of which the following are the most frequent: i. Inflammation with accompanying sweUing of the duodenal mucous membrane or of the lining of the bile duct. 2. Pressure upon the bile ducts exerted from without such as may occur in instances of tumors of the gall-bladder, liver, pancreas or stomach, particiflarly cancer of the pylorus. Omental tumors, displaced kidneys, enlarged glands in the fissvire of the liver, faecal masses, the pregnant uterus and aneurysms of the abdominal vessels are less common external causes of obstruction. 3. Obstruction of the biliary passages from internal causes such as calculi, parasites, inflammatory stric- tures or tumors of the duct itself or of the duodenum at its orifice. 4. Reduced pressure in the hepatic blood-vessels, while a higher pressure obtains in the bile passages, favors the resorption of bile from the latter. Acute Catarrhal Jaundice. Synonyms. Duodeno-cholangitis; Icterus Catarrhalis; Inflammation of the Common Bile Duct. Definition. An affection characterized by icterus of the tissues occurring as a result of an obstruction to the flow of bile due to a catarrhal inflammation of the mucous membrane of the bile ducts and of the duodenum. .Etiology. Cholangitis is usually a sequence of the extension of an inflam- 454 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. I mation of the gastric and duodenal lining into the common bile duct. These latter conditions may be caused by exposure, errors in diet, over-indulgence in alcohol, tea or coffee, over-work, mental emotion, or they may complicate the acute infectious diseases such as pneumonia and enteric fever. The passive congestion which occurs in chronic endocarditis and nephritis may also result in jaundice of this type. An epidemic catarrhal jaundice has been described. Pathology. The distinctive lesion is a swelling and congestion of the mucous linfng of the common bile duct; the process may extend to the cystic duct or even to the hepatic duct and its ramifications. The lumen of the duct is usu- ally filled with mucus, a plug of which often occludes its orifice. This plug may be expelled by pressure, following which free passage is afforded to the bile. The liver itself may be slightly swollen, its color is lighter than normal and its tinge icteroid. If the affection is protracted the retained secretion may cause sufficient irritation to bring about an increase of the connective stroma of the organ and a consequent cirrhosis with atrophy of the hepatic cells may result. Symptoms. Usually manifestations pointing to gastric disturbance, such as anorexia, a coated tongue, nausea, vomiting and constipation, are first noticed. Pain is not common but there may be slight epigastric tenderness; a shght febrile movement is not infrequent. Following these symptoms the jaundice appears. The sclerotics may be first discolored, the face and neck are also early involved; thence the yellow color spreads over the whole body including the mucous membranes. Even the perspiration may be tinged. In instances of long standing the color deepens to a brownish or greenish- yellow. The urine is dark reddish-brown or dark green and when shaken its foam is of a yellow color. In protracted instances albumin and casts may be found, the latter often being bile stained. Constipation is usually present, the stools are foul of odor and light grayish or clay-colored. Rarely there may be diarrhoea. Infrequently the tears, saliva and milk are tinged with yellow. The pulse rate is slowed, at times being even as low as 30 beats per minute. The respiration is unaffected. There is often an annoying itching of the skin and such cutaneous lesions as urticaria, furunculosis, lichen and xanthelasma, a manifestation consisting of slightly elevated yellow macules occurring upon the eyelids and rarely upon other parts, may be observed. In grave instances of the affection ecchymoses and even large haemorrhages may appear in the skin and mucous membranes. Symptoms referable to the nervous system are common. The spirits are depressed and the patient may be melancholic. The temper is irritable and headache and dizziness are common. Visual disorders may occur, objects may appear to be of a yeUow color, the patient may see better by a ACUTE CATARRHAL JAUNDICE. 455 dim light or vision in the dusk may be indistinct. Marked and severe nervous symptoms occur in grave instances of jaundice but more particularly in asso- ciation with acute yellow atrophy, carcinoma and fatty degeneration of the liver than in catarrhal inflammation of the bile passages. These symptoms are acute delirium, convulsions or suddenly appearing coma. Usually there are accompanying fever, rapid pulse and prostration, which with the nervous manifestations, comprise the symptom complex to which the term cholmmia has been applied; this condition is probably due to the presence in the blood of some poisonous constituent of the bile. Physical examination may reveal the presence of a more or less enlarged and tender liver; sometimes the gall-bladder is distended and palpable. The diagnosis. Jaundice occurring acutely with symptoms of gastro- duodenitis, a history of dietary indiscretions and in the absence of manifesta- tions suggestive of acute yellow atrophy, carcinoma or hepatic cirrhosis is distinctive of catarrhal obstruction of the bile passages. The pigmentation of the skin of Addison's disease may be mistaken for jaundice but in the former condition the eyes are not colored and the faeces are not clay-colored. The same is true of the cutaneous discoloration observed in uterine affections, malaria and cancer. The prognosis of uncomplicated catarrhal jaundice is uniformly favorable. The duration of the disease is usually from 10 days to 8 weeks; if the course is protracted beyond this limit the possibility of mistaken diagnosis must be considered. A febrile movement and the incidence of haemorrhages are unfavorable manifestations. Treatment. The patient should be kept in bed while there remains any elevation of temperature and while there are active symptoms of gastric irrita- tion. While there is interference with the flow of bile the food should be such as does not need this secretion to promote its digestion and assimilation, conse- quently fats are to be avoided. Milk, however, while containing a certain amount of fat, seems to be well borne, and while it may seem advisable to remove the cream, this need not be done. Other substances which are allowable are egg-albumin and meat broths. As the digestive irritation diminishes and the flow of bile increases the diet may be more liberal and we may add eggs, fish and other non-irritating foods. When the bile stasis persists for some weeks and a generous diet is needed to maintain the patient's nutrition the fats should be replaced by carbohydrate foods. In convalescence small meals taken frequently are to be preferred to those of large amount at more infrequent intervals. The diet in any individual instance should be governed by the condition of the stomach and intestine, consequently it may be said that the feeding in catarrhal jaundice after the acute stage is passed is that of gastro-intestinal catarrh. At the beginning the bowels should be freely opened by small repeated 456 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONAEUM. doses of calomel — J grain (0.016) every ^ hoiir until 6 doses have been taken — followed by a saline; here we may give the natural Carlsbad salt in doses of 2 or 3 drachms (8.0 to 12.0), Hunyadi, Apenta or any of the similar laxative waters. During the progress of the affection free daily evacuations should be induced by the administration of sahnes such as magnesium or sodium sulphate, sodium phosphate, Carlsbad salts or Vichy, Hunyadi, Friedrichshall, Rubinat or Saratoga Hathorn waters. By this means the catarrhal process in the duodenum is lessened and the mucus is dissolved from the lining of this visciis. The drastic vegetable purgatives should be avoided on account of their irritant properties. The patient's thirst may be relieved by any of the palatable alkaline waters such as Vichy, and frequent draughts will aid in freeing the duodenum from its accumulated mucus, thus acting in connection with the laxatives suggested above. In relieving the stasis of bile and hastening the flow of this secretion no drug is more active than salicylic acid in doses of from 10 to 20 grains (0.66 to 1.33). Calomel, also, has been suggested in this connection but its cholagogue action is disputed in the light of oiir present knowledge. Its effect is evidenced by a retiu-n of the stools and urine to normal color rather than by a disap- pearance of the jaundice. High rectal enemata of ice water may assist in removing the plug of mucus from the opening of the bile duct; their action is probably due to a stimulating effect upon peristalsis. Massage over the region of the gall-bladder may be employed in the hope of stimulating the flow of bile and the same may be stated concerning the faradic current, which should be used in considerable strength. While not much is to be expected of these latter measures their employment is, to say the least, harmless. The gastric irritability may be relieved by regulation of the diet and by the administration of sodium bicarbonate in watery solution or in connection with cerium oxalate — 20 grains (1.33) of the former and 10 grains (0.66) of the latter being added to each glass of milk that the patient takes. Plain water, taken in considerable amount and as hot as possible, is often effective. If there is uncontrollable vomiting all food should be stopped, the patient being allowed to suck bits of cracked ice; small doses of dilute hydrocyanic acid may be effective in combating this symptom. Diarrhoea is uncommon but if present may be controlled by means of bis- muth subsalicylate or subnitrate in the usual doses or still better by such intes- tinal antiseptics as bismuth naphtholate — gr. 5 (0.33) three or four times a day — combined with an equal amount of phenyl salicylate (salol) or 2 or 3 grains (0.13 to 0.2) of resorcinol. When the symptoms of gastro-intestinal irritation have ceased we may substitute for the remedies previously given for their relief a bitter tonic such as the following: ^ acidi nitrohydrochlorici diluti, 5vi (24.0); fluidextracti TOXIC JAUNDICE. 457 nucis vomica, fluidextracti gentiainae, aa 5i (4.0); aquae cinnamomi q.s. ad §iv (120.0). One teaspoonful to be taken in a little water before each meal. Instead of this 10 minims (0.66) of dilute hydrochloric acid may be added to a tumblerful of water and drunk with the meals. The pruritus may be relieved by warm baths to which a pound (1500.0) of sodium bicarbonate has been added, by lotions of i to 60 phenol, 10 percent, menthol in albolene, by powdering the skin with talc, bismuth subgallate or zinc stearate and by the administration of calcium chloride in doses of from 15 to 20 grains (i.o to 1.33) 2 or 3 times daily or of a powder containing 10 grains (0.66) of sodium bromide and five (0.33) of antipyrine at similar intervals. In persistent instances of the disease the patient will usually derive much benefit from a stay at one of the spas such as Saratoga or Bedford in the United States, Harrogate in England or Vichy or Carlsbad upon the continent. Here the good effect of the internal use of the waters, of the bathing and of the systematic life will soon be felt. Toxic Jaundice. This type of jaundice, formerly considered haematogenous in origin, is now held to be the result of biliary obstruction caused by increased viscidity of the bile accompanied by angio-cholitis. Toxaemic jaundice is produced by the following causes: 1. The action of such poisonous substances as arsenic and phosphorus. 2. Specific infectious diseases such as yellow fever, malaria, enteric and typhus fevers, pyaemia, scarlatina, etc. 3. Obscure conditions, probably of infectious origin such as Weil's disease or acute febrile jaundice, and acute yellow atrophy of the liver. The poisons are believed to cause obstruction in the following way: there is destruction of the blood by haemolysis which results in the liberation of haemoglobin and an increased production and excretion of bile pigment ; the bile becomes more viscid and produces a transient obstruction with reabsorp- tion of bile and consequent jaundice. As the toxaemia disappears the viscidity of the bile becomes diminished, the secretion flows more freely and the jaundice disappears. The symptoms of toxic icterus are less marked than those of the more truly obstructive type of the affection; while the skin may be yellowish the stools are seldom clay-colored and, although the lurine may be darkened, there is a conspicuous absence of bile pigment. In some instances there are extremely severe constitutional symptoms such as high fever, great prostration, marked mental disturbances, coma, aniiria and haemorrhages into the skin and from the mucous membranes. 458 DISEASES OP THE DIGESTIVE SYSTEM AND PERITONEUM. Icterus Neonatorum. Jaundice is a common manifestation in newly-born infants. It occvirs in both a mild and a severe t}'pe. The former is quite common and often makes its appearance within 2 or 3 days of birth. Its causation is not definitely known but it is probably due to biliary stasis in the smaller bile ducts. Certain authorities have attributed it to the destruction of red blood cells by haemolysis^ the jaundice resulting in the same fashion as in toxic icterus. The condition is characterized by yellowish discoloration of the skin, darkened urine and light colored stools. There is seldom any digestive disturbance and the symptoms usually disappear within a week or two. The grave type of jaundice of the newly-born may be the result of con- genital absence of the common or hepatic ducts, congenital syphilitic inflam- mation of the liver or of septic phlebitis of the umbilical vein. The outcome is usually fatal. Treatment. The mild form of infantile jaundice needs no treatment. Treatment of the severe form is fruitless unless the condition is due to syphil- itic hepatitis, when antiluetic measures are indicated. ACUTE CHOLECYSTITIS. Synonyms. Acute Infectious Cholecystitis; Acute Inflammation of the Gall-bladder. Definition. An acute inflammation of the gall-bladder resulting from the invasion of pathogenic micro-organisms. Etiology. Although the presence of biliary calculi in the bladder itself or in the ducts leading to this structure, is an important predisposing cause of infectious cholecystitis, the inflammation may occur in their absence. The direct cause of the affection is infection with some one of the pathogenic bacteria, especially the streptococcus, the staphylococcus, the pneumococcus and particularly the colon bacillus and the bacillus of enteric fever. As pre- disposing factors other than biliary calculi all obstructive influences, such as inflammatory adhesions or catarrhal inflammation of the lining of the cystic duct, must be considered since they diminish the local resistance to bacterial infection. Pathology. This depends upon the activity of the infective process. Usu- ally the gall-bladder is distended and tense, its lining is congested and its cavity contains dark muco-pus, sanious pus or pus. Gangrene with perfora- tion may take place in which case the contents of the gall-bladder is of foul odor. The perforation may be shut off by adhesions and form a localized abscess cavity or it may result in a generalized infection of the peritonaeum. Inflammatory adhesions to adjacent structures, particularly the colon and ACUTE CHOLECYSTITIS. 459 omentum, are common. The cystic duct may be occluded by an impacted calculus or by inflammatory swelling of its wall. Symptoms. The affection may first indicate its presence by perforation but usually the earliest symptom to be noted is pain, often sudden and parox- ysmal, referred to the region of the liver. In some instances the pain is farther to the left than this situation and it may even be as low as the right iliac region. There are early symptoms of gastric irritation such as nausea and vomiting, there is prostration with a rise of temperature often accompanied by rigors and sweats. The pulse is usually accelerated but at times may be extremely slow. Jaundice is rare unless the hepatic or common duct is involved. Palpation of the abdomen elicits tenderness, often extreme and generally localized, but at times in an unexpected situation. There is rigidity of the abdominal muscles and the distended gall-bladder may be felt. Adhesions between the intestine and the gall-bladder may result in the partial or entire occlusion of the bowel with attendant symptoms. The diagnosis. Here the history is of great value, symptoms suggestive of cholecystitis and yet resembling those of appendicitis or those of intestinal obstruction when occurring after pneumonia, enteric fever or previous affec- tions of the biliar}^ tract, being much less puzzling than when they appear inde- pendently. In the absence of history it is often very difficult to differentiate acute cholecystitis from appendicitis, pancreatitis and localized peritonitis. Jaundice is more likely to appear in pancreatic disease but the true nature of the condition is often not determined until laparotomy has been performed. The prognosis naturally depends upon the type of infection and its severity; the acute suppurative form is a grave condition on account of the probability of perforation peritonitis, local or general; in the latter instance death is certain unless operation is undertaken. Treatment. The mild types of the affection in which there is no distinct evidence of suppuration should be treated by rest in bed and light diet. Sali- cylic acid or sodium salicylate, preferably the former, should be given 3 times daily in doses of about 10 grains (0.66) in order to increase the bile flow and to prevent extension of the inflammatory process into the ducts. The bowels should be kept open by means of mild laxatives and the pain may be relieved by the application of hot or cold compresses; morphine should not be given unless absolutely necessary for it is apt to obscure the symptoms. Nausea and gastric irritation may be controlled by the usual means. Meth- ylthionine hydrochloride (methylene blue) in capsules containing i grain (0.065) 3-nd sodium succinate in doses of 5 grains (0.33) have been recom- mended. Upon the incidence of the slightest signs of suppuration immediate surgical interference, consisting of free incision and drainage of the gaU-bladder, is indicated. 460 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. CHOLELITHIASIS. Synonyms. Gall-stone Disease; Biliary Calculus; Hepatic Calculus. .Etiology. Biliary calculi are either (i) hepatic in source, originating in the bile ducts because of a slow catarrhal process which results in the secretion of an albumin substance, which in combination with the bile precipitates a bilirubin-calcium calculus, or (2) are formed in the gall-bladder because of a low grade catarrhal process which induces a secretion of cholesterin from the muious glands and cells of its waUs. Of these the former origin is by far the more frequent. This explanation of the source of gaU-stones also accounts for the fact that oftentimes after the performance of a cholecystotomy gall- stones continue to be discharged from the fistula for weeks and even months. It also points out why removal of the gall-bladder itself is not followed by a cessation of attacks of gall-stone colic. The recognition of the microbic origin of biliary calculi dates only to 1886. In 1897 it was clearly shown that the colon baciUus could be responsible, gaining access by either (i) the intestinal canal by way of the common duct, or (2) through the portal vein. Although jaundice as a sequel to enteric fever had been observed as early as 1826, it was not until 1889 that the typhoid bacillus was recognized as a causative factor entering by way of (i) the portal vein, (2) the hepatic artery, or (3) the common duct. That other infections are also directly responsible has been shown, for low grade cholecystitides have been observed after acute infectious pneumonia, acute rheumatic poly- arthritis and chronic tuberculosis. That gaU-stones do not oftener result, the explanation may be that acute suppurative inflammations of the bile ducts or gaU-bladder do not result in calculi but rather these are due to atten- uated infections. The mechanical causes of gaU-stones: (i) Foreign bodies if sterile are harmless. If they produce stagnation they favor catarrhal processes and so give opportunity for infection. (2) Stagnation of bile in itself does not favor calculus formation but since stagnation favors infection it may lead directly to the formation of stone. (3) Chronic venous congestion of the portal system is a more potent cause of the production of gall-stones since it is the great underlying cause of cholelithiasis. The congestion of the portal circulation may occur as a result of (a) chronic heart disease — especially mitral obstruction — (b) chronic pulmonary disease — particularly chronic emphysema and chronic interstitial pneumonia — (c) intestinal catarrhs due to the abuse of alcohol, gluttony and rarely to the excessive employment of vigorous purgatives; a more common cause of intestinal catarrh than either of the preceding is constipation which not only predisposes to infection but offers opportunity for auto-intoxication. (4) Of mechanical causes not hitherto enumerated worthy of mention are (a) pregnancy, (b) visceroptosis — CHOLELITHIASIS. 46 1 Glenard's disease — (c) over-fitted hepatic flexure of the colon, (d) displace- ments of the duodenum, all of which may cause biliary stasis and, as above mentioned, predispose to the production of gall-stones. (5) Of extraneous causes anything vi^hich reduces the vitality of the individual such as (a) anxiety, (b) bodily exhaustion from excessive physical or manual labor, or (c) wasting diseases may be mentioned. Gall-stones may be single or multiple; they are usually brownish in color, rounded, oval or polyhedral in shape. In size they vary from that of a millet seed to even 5 inches (12 cm.) in length. The small calculi are often very numerous, thousands having been found in a single gall-bladder. A number of stones impacted together become faceted as a result of their pressure upon one another. Irregular (mulberry) calculi are sometimes found. Section of a gall-stone reveals a nucleus usually consisting of bile pigment or more rarely a foreign body. Collections of micro-organisms are said to have been found at the nucleus of certain kinds of gall-stones. Chemically the calculi consist chiefly (70 to 80 percent.) of cholesterin arranged concentricaUy. In some instances the stone is composed wholly of this substance, usually, however, other constituents such as bile pigment, calcium carbonate, magne- sium salts, fatty acids, organic matter and traces of copper and iron, are found. Rarely calculi may be composed almost wholly of bilirubin-calcium. The most common type of gaU-stone is the mixed cholesterin calculus; these are yeUow, brown or white and are generally faceted. Mixed bilirubin and cholesterin stones consist of a nucleus of the latter substance covered by dark brown material. Calculi are formed in the gall-bladder where they may exist, as stated, in enormous number; they may also be formed in any part of the biliary tract either without or within the substance of the liver. Lodgment of calculi often takes place in the cystic and common ducts. In the latter the point of lodgment is usuaUy in the ampulla of Vater; dilatation of the duct behind the obstruction may take place. Obstruction of the cystic duct, if permanent, results in dilatation of the gall-bladder, which may be so distended as to be mistaken for an ovarian cyst. The contents of the bladder is a colotless, sometimes viscid, fluid of neutral or alkaline reaction and contains albumin. The gaU-bladder which contains calculi is not enlarged except in so far as the contained stones increase its size (Courvoisier's law). Ulceration or suppu- ration may restilt from the presence of a calculus and rupture may take place into any adjoining structure. Symptoms. In many instances the presence of biliary calculi causes no symptoms as is shown by the facts that post mortem records prove that from 6 to 10 percent, of aU cadavers evidence the existence of gaU-stones, while not more than i person in 20 of those who carry calculi becomes aware of their presence through any symptoms which may result from them. 462 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM. The manifestations of the presence of gall-stones may be considered under several headings : 1. Biliary colic is due to acute impaction resulting during the passage of stones through the larger bile ducts. The passage of the calculus usually gives rise to severe attacks of pain which are sudden in onset and referred to the epigastrium or right h}q3ochondrium whence it may radiate to the right shoulder or to any part of the abdomen. The pain is excruciating and lan- cinating in character and may cause syncope. The liver may be enlarged, tenderness is usually present and the gall-bladder may be palpable; there is abdominal rigidity; nausea and vomiting occur. There are often chills; the temperature rises to 102° to 103° F. (38.9° to 39.5° C.) or even higher. The fever may be intermittent in t}^e but is more apt to assume this form in pro- tracted obstruction due to chronic impaction of calculi (intermittent hepatic fever). There may be circulatory depression with rapid and feeble pulse. There is usually splenic enlargement and if the attack is prolonged, jaundice is likely to appear, particularly if the stone becomes impacted in the opening of the common duct. The paroxsym of colic varies in duration from a few hours to a week or more; it may recur at intervals, the symptoms ultimately disappearing with the passage of the calculus. Rupture may take place at the site of the obstruction with death from peritonitis as a result; convulsions have been observed. The diagnosis is seldom difficult; the site of the pain is characteristic and its occurrence with tenderness over the liver, a chill and jaundice leaves hardly room for doubt. The history is often of marked assistance. Renal colic is accompanied by pain radiating downward to the groin or testicle and by bloody urine which often contains pus cells. Appendicitis, while possibly associated with pains similar to those of hepatic colic, is not attended with jaundice. The pseudo-biliary colic which may occur in women may be differ- entiated by the absence of jaundice and the presence of nervous symptoms of various kinds. Finding calculi in the feecal discharges is confirmatory of the diagnosis of gall-stone colic. A search for these should always be made in suspicious instances during the three or four days following an attack. The stools should be washed upon a fine seive until aU soluble matter has been flushed through. The prognosis as to recovery from the paroxysm is favorable, death from syncope, perforation or convulsions being a rare occurrence. 2. Chronic Impacted Gall-stone: During the passage of a calculus through the ducts toward the duodenum impaction not infrequently takes place. The impaction may occur, a. . In the Cystic Duct. Symptoms. These may resemble in greater or less degree those of acute im- paction with added dilatation of the gaU-bladder {hydrops vesiccs fellece). The CHOLELITHIASIS. 463 dilatation is the result of the accumulation of the exudation due to inflammation of the lining mucous membrane plus the bile that was present when the obstruction took place. The increase in the size of the gall-bladder may be crreat and the condition has been mistaken for ovarian cyst. On opening the gall-bladder the fluid contents is found to consist chiefly of mucus of alkaline or neutral reaction. Jaundice may not be present and, while at times the dis- tended gall-bladder may not be palpable, it may often be felt as a rounded or Tamidal tracts of the spinal cord. etiology. This is a disease of adult life, akhough it has been observed m children; heredit>^ seems to exert an influence in some cases. The condition seems sometimes to occur as a result of syphilis, trauma, exposure, excessive muscular exertion, chronic plumbism and the infectious diseases. The so-caUed Little's disease is akin to lateral sclerosis, but is a congenital affection and the result of a lack of development of the lateral tracts or due to prema- ture or instrumental delivery. Pathology. The sclerotic change in the lateral pyramidal tracts usuaUy begins in the lumbar cord and involves the crossed pyramidal tracts as well. The degeneration extends upward and the myelin is graduaUy replaced by connecttve tissue. Other lesions such as myelitis, meningomyelitis and multiple sclerosis often co-exist and when the process reaches the cervical cord the anterior median columns may be affected. Symptoms. The patient's attention is first caUed to the existence of this disease by a feeling of fatigue in the legs, this progressively increases until walking becomes difficult owing to the increased spasticity and paralysis. The gait is characteristicaUy "spastic," that is the toes drag, the knees are but little flexed and overlap one another, the feet are hardly lifted and the motion is stiff. Contraction of the muscles of the calf may compel the patient to walk on his toes. Motor paresis is a characteristic symptom but at times is absent, yet the spastic condition is sufficient to disorder the gait, even though the patient may be able to walk considerable distances. In marked degrees of paresis the muscles are firm and tense and the legs are held permanently extended, the feet being in a position of plantar flexion. Sudden attempts to flex the knees or the feet upon the legs are resisted but, if force is exerted gradually, the effort will be successful. The patellar reflex is markedly exaggerated, ankle clonus and the Babinski reflex (upturning of the toes, especiaUy the great, when the sole is stroked) are present. The reaction of degeneration is absent, the bladder and rectal functions are normal, ^ there are no sensory disorders nor does atrophy appear until late in the disease. The disease progresses but slowly, the patient, in the later stages being unable to walk or stand. The muscles of the arms are seldom affected, but when this does occur, the extensors are first and chiefly involved, the paresis and exaggeration of the tendon reflexes being analogous to that found in the lower extremities. Hysteria may exactly reproduce the symptoms above described (hysteric spastic paraplegia) but the differential diagnosis, while not easy, may be made upon finding other hysterical manifestations. The prognosis. The progress of this disease is slow and prolonged and re- coverv is not to be expected. The general health and the mind are not disturbed. 744 DISEASES OF THE NERVOUS SYSTEM. Treatment. If syphilis is suspected the patient should be put upon mer- curial inunctions and potassium iodide; the spastic condition of the limbs may be lessened in certain cases by conium extract, gr. ^ to i (0.032-0.065), the bromides or hydrated chloral; the latter drug, however, should be given with the greatest caution lest the habit become established. Galvanism and farad- ism ma^ be employed and while they are likely to accomplish little in the ordinary type of the disease, in hysterical spastic paraplegia they are very useful on account of the impression made upon the patient. Massage and passive movements, when not too vigorous, may lessen the spasticity and the patient should be encouraged to do a moderate amount of walking so as to keep the legs as limber as possible. Warm baths lasting from twenty to forty minutes at a temperature of 92°-98° F. (33. 3°-36. 7° C), during which passive movements are practiced, are often of benefit. Braces and other appliances are useful in special cases and tenotomies may become necessary in order to straighten the limbs. AMYOTROPHIC LATERAL SCLEROSIS. Synonym. Charcot's Disease. Definition. A chronic disease characterized by degeneration of the lateral columns of the spinal cord, associated with atrophy of the motor cells in the anterior horns and medulla, and a consequent progressive atrophy of the muscles. ^Etiology. This disease is most frequently met in males from twenty- five to fifty years of age. Its actual cause is unknown but it is probably the result of an imperfectly developed nervous system. Contributory causes are said to be exposure, over-exertion, the abuse of alcohol, chronic metallic poisoning and injury. Pathology. The essential lesions are a sclerotic degeneration of the crossed pyramidal tracts of the lateral columns, a like change in the anterior median columns of the spinal cord and an atrophy of the motor cells in the anterior horns; the changes are most frequently found in the cervical cord but may, in old cases, involve the lumbar region as well. The sclerosis in the motor columns may extend to the motor cells of the cerebrum, through the medulla, pons, crura cerebri, capsule and corona radiata, involving on its way the cranial nerve nuclei in the floor of the fourth ventricle. The sclerosis consists, first, of a wasting of the normal nervous substance and secondly in a re- placement by connective tissue. Symptoms. These depend upon the portion of the nervous system first affected by the disease. When the disorder begins in the cervical cord and the anterior horn cells, the muscles of the arms become stiff and their reflex irritability is exaggerated, this is accompanied by a certain amount of paresis. LOCOMOTOR ATAXIA. 745 followed by atrophy of the muscles of the hands, the extensors being involved before the flexors; as the paresis extends further up the arm the atrophy also progresses and is especially marked in the deltoid. Fibrillary contractions appear early, and the fingers are often held in a position of mid-flexion, and the muscles being rigid, it may be difficult for the observer to straighten them. The symptoms later involve the legs, but in rare cases the lower limbs may be first affected. The symptoms referable to these extremities are fatigue, a stiff gait, difficulty in rising from a sitting posture, tremor, paresis and atrophy; one limb, either upper or lower, may be much more seriously affected than the others. The electric excitability of the muscles is diminished and the reaction of degeneration may be present. The knee jerk is exaggerated, and ankle clonus and the Babinski symptom are frequently to be obtained. Sensation remains unaffected and there is no disturbance of bladder or rectum except that, in lumbar involvement, there may be nocturnal incontinence of urine. The sexual power may be lost. Late in the course of the disease bulbar symptoms may appear, speech becoming disordered, swallowing difficult and there may be dripping of the saliva. Atrophy of the tongue and lips may occur and, the patient being unable to properly masticate and swallow his food, nutrition becomes impaired. The pupils may be unequal and while there is usually no loss of mental power, dementia of mild type may develop. The prognosis is not favorable, although the patient's life may be pro- longed and much may be done to make him comfortable. Death occurs from exhaustion, intercurrent disease and not seldom from foreign body pneu- monia due to the disturbance of swallowing. Treatment should be carried out along the same lines as in lateral sclerosis. Feeding by means of the stomach or nasal tube may be necessary if advanced bulbar symptoms are present. LOCOMOTOR ATAXIA. Synonyms. Tabes Dorsalis; Posterior Spinal Sclerosis; Duchenne's Disease. Definition. A chronic disease of the posterior columns and nerve roots of the spinal cord, characterized by sensory and trophic symptoms and dis- turbances of coordination. .etiology. This affection is most often seen in middle life but may occur as early as the tenth or as late as the sixty-fifth year. Heredity is a negligible factor save as regards inherited syphilis. Exposure, excessive exertion, both physical and mental, and sexual excesses have been considered to have a place in the causation of locomotor ataxia, but the most important factor in its 746 DISEASES OF THE NERVOUS SYSTEM. aetiology is syphilitic disease. Various observers state that syphilis is an element in the causation of from 60 to 90 percent, of all cases. It seldom occurs within five years of the primary lesion and often not until a much later period and seems to appear more frequently in individuals whose secondary period has been characterized by mild symptoms. The disease seems to be rather a result o| luetic infection than a syphilitic affection of the spinal cord. Pathology. On microscopical inspection the cord is found to be dimin- ished in calibre and the posterior columns may be noticeable as a grayish band^ the pia mater is usually thickened and less transparent than normal and its vessels are sclerosed. Section of the cord reveals an atrophy of the posterior columns and of the posterior nerve roots. Microscopically the posterior columns are seen to be the seat of sclerosis, their normal structure having been replaced by connective tissue. The same condition obtains in the posterior nerve roots, a degenerative neuritis may involve the sensory fibres of the larger nerve trunks and the finer sensory nerves may contain degenerated fibres. The process usually begins in the lateral zone of the column of Bvu-- dach and in the column of Lissauer at about the level of the second and third lumbar segments, thence it spreads through the middle zone of Burdach's column to the column of Goll and finally to the posterior zone of the column of Burdach. The disease at the same time is extending upward, and al- though the process may take years, eventually the entire area of the posterior columns is involved, together with the posterior nerve roots, the posterior horns of the cord and the medullated fibres of Clarke's column. Ultimately there may be changes in the brain itself. Symptoms. These are best classified according to the time of their inci- dence, the disease developing in three more or less distinct stages. a. The Stage of Pain. Most of the symptoms of this stage are sensory. There are various paraesthesiae, such as numbness and tingling of the feet, a sensation as if cotton were being trodden upon, sensations of burning or of cold and pruritus over various areas, notably the scrotum and at the anus. Pain is an early and prominent symptom and may continue throughout the course of the disease. It usually begins in the thighs or lower legs and extends as the disease progresses. In certain cases it may be slight or wholly absent, particularly when the onset of the disease is characterized by optic nerve atrophy. The pain is sharp, lightning-like, lancinating, cutting or boring in character, often beginning on the outside and anterior surface of the thigh and later extending to the feet, and usually appears in repeated paroxysms lasting from a second or two to half a minute, or it may occur in attacks lasting, without remission, for hours or days. There is no tenderness. There may be aching pain in the back and loins, or girdle sensations about the legs, ascending to the body as the disease involves higher levels of the cord. The patellar reflex is lost (Westphal's symptom) ; spinal myosis (contracted pupil) LOCOMOTOR ATAXIA. 747 may be present; the pupil reacts in accommodation but not to light (Argyll- Robertson pupil); the control of the bladder may be partly lost; this symptom progresses until complete incontinence results. Sexual impotence is not rare. b. The Stage of Ataxia. The symptoms of the first stage persist and in addition disturbances of sensation appear. Sensitiveness to pain is lessened and delayed, a pin prick may not be felt until after a perceptible interval, or hyperalgesias may be present in rare instances, pain being caused by even the touch of a finger. The temperature sense is disturbed, the patient becom- ing very susceptible to cold, while heat is felt less than normal; ultimately the limbs become wholly anaesthetic. The muscular sense is impaired, the position of the body in space is not correctly perceived, the patient consequently walks unsteadily, especially in the dark when sight is unable to assist the muscular sense, and is unable to accurately touch objects when his eyes are shut; for instance he has difficulty in placing his finger upon the tip of his nose when blindfolded; finer move- ments of the hands and fingers are performed inaccurately; difficulty is experi- enced in picking up a pin or other small object, in buttoning the clothes and in writing. The gait is characteristically ataxic, the patient walks with the legs widely separated and the body poorly balanced, he lifts the feet too high and plants them too forcibly, bringing down the heel with a stamp, the steps are irregular in length, he staggers and cannot walk in a straight line, especi- ally if the eyes are closed. When the feet are placed closely together and the patient stands with eyes closed, he reels and may fall (Romberg's symp- tom). Various ophthalmic disturbances may occur, such as optic nerve atrophy, with resulting blindness, ocular nerve paralyses with consequent ptosis and strabismus, convergent with contracted pupil when the sixth nerve is affected, divergent with dilated pupil with involvement of the third; unilateral deafness may develop due to auditory nerve atrophy. The other cranial nerves may be affected. During this stage the so-called "crises" may appear. These are probably due to a complicating pneumogastric neuritis and are of various types. The gastric crisis is the most frequent and is characterized by sudden severe pain and vomiting which may persist for several hours or even a day or twoj intestinal and rectal crises are associated with pain, diarrhoeal tenesmus or a sen- sation of a foreign body in the rectum; laryngeal crises are characterized by sud- den cough, stridor, glottic spasm and dyspnoea; cardiac crises resembling attacks of angina pectoris, and vaginal crises, characterized by pain and copious mucous discharge, have also been observed. Trophic disorders, evidenced by the so-called " Charcot joint," an affection probably having its origin in a traumatism which is disregarded by the patient because of disturbance of his 748 DISEASES or the nervous system. pain sense, and which is characterized by entire absence of pain, great swelling and copious effusion, occur. The knee is most frequently affected but the condition may involve the ankle, elbow or WTist. The ligaments, cartilage and bone are gradually destroyed and spontaneous fracture or dislocation may result. Perforating ulcer of the foot, resulting from a neglected injury often of slight character, may occur. Other trophic disturbances are rar- efaction of the bones, with resulting fractures, irregular atrophy of muscles and various skin eruptions. c. The Stage of Paralysis. The ataxia gradually increases until the patient becomes helpless; the bladder and rectum are incontinent and bed sores are apt to develop; cystitis with consequent pyelitis may result from the use of the catheter; the patient is confined to his bed, even though his general nutri- tion remains good. The prognosis. The course of the disease is chronic and may extend over twenty or thirty years. The first stage lasts from a few months to fifteen or ttt^enty years, the second may develop slowly or rapidly and the third stage is soon terminated by death. The prognosis should always be guarded; it is believed that recovery has never taken place but the progress of the disease may be stopped or at least delayed. The thoroughness with which syphilitic disease of late years has been treated seems to have borne fruit in that mild t^-pes of locomotor ataxia are becoming more frequent. Treatment. In all cases in which there is suspicion of syphilis, appropriate treatment in the form of mercurial inunctions — one drachm (4.0) of the oint- ment should be thoroughly rubbed into the inner aspect of the thigh or arm daily until the gums become sore, when mercury bichloride may be substi- tuted — gr. ^ (0.003) three times a day — and the internal administration of potassium iodide in ascending doses should be begun. The dosage of the latter must be governed by its effect, as much as possible being given without inducing iodism; after the limit is reached the doses should be diminished by about one-half and continued for several months. If the primary specific lesion is not of recent date certain authorities are inclined to omit the mer- cury and depend chiefly upon the potassium iodide, others consider the use of the former drug to be contraindicated in cases with optic nerve atrophy on the ground that it may hasten the process. Mercury biniodide may at times be employed with good effect in doses of gr. ^ (0.003) three times a day and a change of the potassium iodide to the strontium salt (gr. xx to XXX — 1.33-2.0 — three times a day) or to the swup of hydriodic acid, i drachm (4.0) at the same interv^als, may prove beneficial. The disadvantages of antis}^hilitic treatment are that it may cause diges- tive disturbances which result in an impairment of nutrition and that excessive administration of merciu*}^ may produce distressing neurasthenic conditions. When after thorough trial it is certain that no benefit from this form of treat- LOCOMOTOR ATAXIA. 749 ment is to be expected it should be stopped; if it acts favorably it shoiild be continued, the mercury being alternated with the iodide, a period of three months being devoted to each, or the two should be given simultaneously for three months, omitted for a like period, then repeated and so forth. Various other drugs have been from time to time exploited as efhcacious in locomotor ataxia; of these those most likely to be affective are arsenic, in the form of Fowler's solution rq_ v(o.33), arsenic trioxide, gr. -3L to gV (o-oo2- 0.003) or sodium arsenate, gr. J^ to -^ (0.002-0.006) three times a day, aluminum chloride gr. iii to x (0.2-0.66) three times a day, strychnine, gr. -3V (0.002) or less thrice or four times daily, calcium glycerophosphate, gr. iii to V (0.2-0.33) and calcium h}^ophosphite, gr. X to xxx (0.66-2.0). Silver has been advocated but it, barium, gold, ergot and physostigma are prob- ably of no effect and are little used. Much can be done in this disease toward mitigating the symptoms; the pains may be controlled by the coal tar analgesics, antipyrine, acetanilide, acetphenetidine, salophen, salip^Trine, or aspirin in the usual doses; this symptom at times may yield to a drachm (4.0) of sodium bicarbonate; codeine, gr. J to -J (0.016-0.032) may prove effectual, as also may extract of cannabis indica (gr. -j to | (0.016-0.032) or cocaine, hypodermatically, gr. -gtoj (o.oii- 0.016). The Paquelin cautery applied once or twice a week is a useful agent in the severe pains; cups, leeches and blisters may also be employed with good effect. Morphine in the severe pain may become necessary, it should be given under the skin and only after all other means have failed, on account of the danger of establishing the habit. The insomnia may be relieved by the bromides, veronal, gr. x to xv (0.66-1.0), sulphonethylmethane in the same doses or siilphonmethane, gr, xx (1.33). Hydrated chloral may in ex- treme cases be combined with the bromides. The bladder disturbances may be rendered less distressing by the adminis- tration of hyoscyamus combined with the balsams, and small doses of strych- nine, gr. y-i-g- (0.0006), may be given if sexual weakness is present. Neu- ralgic pains in the rectum often disappear after an enema and a thorough evacuation. Suppositories containing iodoform, codeine and belladonna may be efficacious. In the crises a hypodermatic injection of morphine is often the only thera- peutic measure which will relieve the patient. From the beginning of the treatment the physician should insist upon the importance of systematic rest. It may be advisable to put the patient to bed for a number of weeks. If so drastic a measure is not necessary a regular life should be prescribed, with moderate exercise and avoidance of all mental and physical labor. The excessive use of alcohol and tobacco must be for- bidden as well as more than moderate venery. Institution treatment for a number of months each year is often of great beneiit. 75° DISEASES OF THE NERVOUS SYSTEM. Electricity is useful for its tonic effect upon the muscular and nervous systems and if employed perseveringly may benefit the lesion itself. Galvan- ism (15 to 30 milliamperes) may be administered by applying the anode to the side of the neck and moving the kathode up and down the spine and limbs. Both the constant and the interrupted currents may be employed in this manner; the former may be effective in the pains and the latter is indicated in vesical vi^eakness. Hydrotherapeutic measures are often beneficial but have disadvantages, in that the patient often fails to react after the cool bath and the warm bath is likely to prove enervating. Oftentimes, however, a daily lukewarm bath lasting for fifteen or twenty minutes, after which a cool douche is applied to the spine and the patient is vigorously rubbed, is an excellent procedure. Wet compresses to the limbs are often useful to ease the pains and douches neither hot nor cold often affect the patient favorably. Spa treatment with systematic bathing may confer benefit but probably rather from the regular life led at such resorts than from any effect of the bathing itself. Treatment by suspension was much advocated a mmiber of years ago. The patient was harnessed about the neck and shoulders with a specially constructed apparatus and was by this means lifted from the floor. This was done for a minute or two, two or three times a week for eight or ten weeks, and after an interval of several months, the procedure was repeated. This method seemed to benefit some cases but is little employed at present. It is useless in the stage of paralysis. Treatment by means of education of the muscular sense (the method of Fraenkel) is often valuable. This consists of systematic exer- cises calculated to educate certain nerve fibres of the cord so that they may be able to perform the function of those which have been destroyed. The idea is to train the patient in certain motions requiring coordination. The exercises may be greatly varied, among those applicable are to require the patient to walk a straight line drawn upon the floor, to draw sets of parallel lines with one hand, then with the other, etc. For an extended list the reader is referred to Dana's Textbook of Nervous Diseases. This method, while it does not influence the lesion, often enables the patient to use his limbs to better advantage and is particularly effective in patients in the latter part of the iirst or early in the second stage. There is no special diet to be prescribed. The patient should eat regularly a sufficient quantity of nourishing and easily digestible and assimilible food. Fats, starches and proteids are all allowable. Patients should be encouraged to use every means to combat their disease and to carry out a systematic treatment. Those who have the courage and energy to do this will, after a time, reap the benefit of their perseverance and reach a condition in which they may lead comparatively comfortable lives. Friedreich's ataxia. 751 FRIEDREICH'S ATAXIA. Synonyms. Hereditary Ataxia; Hereditary Ataxic Paraplegia; Family Ataxic Paraplegia; Friedreich's Disease. Definition. A chronic disease of the spinal cord, occurring hereditarily and characterized by ataxia and paraplegia. etiology. The direct causative factor of this disease is unknown. It seems to occur rather more frequently in males than in females; it may occur in infancy but the greater number of cases develop between the ages of three and fifteen years. It very rarely appears after the age of twenty-five. The condition is probably due to lack of, or to poor development of certain tracts in the spinal cord. It sometimes follows an acute infectious disease, and alcoholism, syphilis and the neurotic tendency in the parents, seem in some measure to be predisposing factors. Pathology. The lesions of Friedreich's disease are found in the posterior and lateral columns of the cord and consist of a degeneration involving these tracts and at times also the columns of Clarke and Gowers. On examination the cord is found to be smaller than normal and the pia, over the posterior columns especially, is thickened. The normal tissue is seen to be degenerated and to some extent replaced by neuroglia, the cells in the anterior and poste- rior cornua are atrophied and this change affects also the anterior and posterior nerve roots. Symptoms. These are, as would be expected, a combination of those of lateral sclerosis and locomotor ataxia — paraplegia with ataxia. Pains at the onset are infrequent, the first symptom noticed being a gradual loss of coor- dination first affecting the legs. The patient totters and with diflSculty maintains his equilibrium, he sways in walking and may fall. Romberg's symptom may be present; the patellar reflex is usually absent, but rarely may be exaggerated. The ataxia of the arms is characterized by choreic and irregular movements; in grasping objects there seems to be an excess of move- ment. As the disease progresses the jerky movements involve the head and there may be accompanying tremor, nystagmus is present when the eyeballs are moved but is absent when they are at rest. The pupils are usually normal and optic atrophy is very rare. Scanning speech with elision of syllables may occur late in the disease. The paresis appears later than the ataxia and chiefly affects the legs; the power of the muscles, the flexors more than the extensors, is impaired and consequent talipes may occur; if the muscles of the body are affected, curva- tures of the spine result. The nutrition of the muscles is little if at all impaired. There is a lack of sensory symptoms except, at times, cramp-like muscular contractions in the earlier stages which may cause discomfort. Rarely there 752 DISEASES OE THE NERVOUS SYSTEM. are disorders of the pain and temperature senses and sensation mav be slightly delayed. The mind is not materially affected, but children in whom the disease appears early in life, seldom attain normal development in this regard. The prognosis as regards recover}^ is utterly imfavorable but the progress of the affection is slow and may be interrupted by periods of remission; patients who are^ttacked in the earlier years of life seldom survive to attain maturitv. Treatment is of little avail. With regard to prophylaxis, we should, when the disease has occurred in one member of a family, endeavor to impress upon the parents the necessit}- of especial care in the feeding and general manage- ment of the others. Breast-feeding should be insisted upon, all infections and traumatisms guarded against and excessive physical exertion avoided. Patients affected -n-ith the disease should receive nourishing and easily-digest- ible food and live in as hygienic a manner as possible. Nerve tonics may be employed and may be of some benefit, suspension may be tried and has seemed to act favorably in certain cases. The therapeutic means applicable to locomotor ataxia are worthy of trial. Tendency to contractures and defor- mity may be combated by orthopedic methods and apparatus. HEREDITARY CEREBELLAR ATAXLA.. This is a condition characterized by all of the symptoms of Friedreich's disease with the exceptions that in the former aff'ection there are various ocu- lar disturbances such as atrophy and paralyses, together with an increased patellar reflex. The condition usually appears after the age of twenty and is the result of congenital defect in or incomplete development of the cerebellum. Recent research seems to tend to draw cerebellar ataxia and ataxic para- plegia more closely together as regards lesions and symptoms and it is quite possible that they "^-ill come to be regarded as types of the same disease. Like Friedreich's ataxia, this disease is progressive and -with, regard to treatment one can hardly do more than maintain the patient's nutrition. Otherwise the affection may be managed in a manner identical with that described under the treatment of the former condition. BULBAR PARALYSIS. Synonym. Glosso-labio-lanmgeal Paralysis. Definition. A progressive paralysis invohdng the tongue, lips, throat and larynx and in advanced cases the muscles of the lower part of the face. ^Etiology. This disease occurs most frequently in middle age. Syphilis,, ACUTE ASCENDING PARALYSIS. 753 exposure, and mental and physical over-work have been considered possible causative factors but the direct jstiology of the condition is unknown. Pathology. The morbid change which characterizes this disease consists in degeneration of the nuclei of origin of the motor nerves which supply the lips, tongue, throat and lar}'nx. In certain cases the lesion spreads to the cranial nerve nuclei on the floor of the fourth ventricle of the medulla in- volving the vagus, the fifth in its motor fibres, the seventh, the ninth, the twelfth, and exceptionally the abducens and motor-oculi. The degenerative change is characterized by a wasting of the normal nerve tissue and a re- placement of it by neuroglia, with connective tissue increase in the walls of the blood-vessels. Symptoms. These usually begin with disturbance of the speech, there is difficulty in articulating the linguals, R, L, D, T, the voice is nasal in quality, the tongue becomes atrophied and paralyzed; swallowing is difficult and mastication imperfect. Wlien the muscles of the lips become involved the articulation of the labials, B,F,P,V, becomes imperfect and the lips are thin and tremulous, the facial expression is changed and the saliva dribbles. With involvement of the phar}Tix and larynx swallowing becomes impossible, food may be regiirgitated, or drop into the larynx and cause foreign body pneumonia; the voice becomes low, monotonous and is finally lost. Fine con- tractions of the involved muscles may be observed. There are no changes of sensation and taste is not affected. The course of the disease is chronic and may last over a period of several years. The prognosis is hopeless, death taking place from obstruction of the lar}Tix by food particles, septic pneumonia or exhaustion. Treatment consists in the employment of all possible means to maintain the patient's strength, and in the use of tonics, such as iron, arsenic, quinine and strychnine. \Vlien there is a s>T)hilitic element in the history the use of mercury and potassium iodide is indicated. Electricity may confer some benefit; the galvanic current may be employed by placing the electrodes, one at each mastoid process, and f aradism may act as a tonic upon the affected muscles. Galvanism may aid the patient in swallowing, the anode being placed at the back of the neck and the cathode at the side of the lar}^nx; when the latter is moved along this organ it causes a reflex deglutatory act. It is often advisable to begin to feed the patient by means of the stomach tube early in the disease. ACUTE ASCENDING PARALYSIS. Synonym. Landry's Paralysis. Definition. An acute disease characterized by rapidly advancing paralysis beginning in the legs, progressing upward to the body and finally reaching the arms, causing death by involving the respirator}^ center in the medulla. 48 754 DISEASES OF THE NERVOUS SYSTEM. Etiology. This disease affects males more often than females and is usually seen in healthy individuals in the prime of life (twenty to forty.) Cases have been observed in which the abuse of alcohol has seemed to be a considerable factor in predisposing to the condition and the same may be said of syphilis. Of late there is more and more inclination to attribute the affection to a toxic infection of the peripheral nerves and spinal cord, since it, at times, occui's as a sequela of microbic diseases such as enteric fever, erysipelas, epidemic influenza, etc. Pathology. The lesions found post mortem differ but it seems sure that the peripheral motor neurons are the seat of chief involvement; changes are also observed in the spinal cord resembling those of acute general myelitis or very similar to those occturring in peripheral neuritis. Symptoms. Prodromata, such as loss of appetite, rise of temperature, pains in head and back, general malaise and tingling sensations in the extrem- ities, lasting from a few hours to several days, are usually present. Follow- ing these a rapidly augmenting weakness of the legs appears, which, within a few hours or a few days, may become a complete paralysis. The paralysis soon extends to the trunk and in a day or two, or even less time the arms are involved. As the muscles of the neck and face become affected breathing is interfered with, the speech becomes indistinct, swallowing is difficult and other symptoms of bulbar paralysis develop and death occurs from respiratory paralysis. The reflexes are diminished or lost but may later return and become exaggerated, the sphincters remain continent, there is no musciflar atrophy or tendency to bed sores and the electric reaction usually remains normal but exceptionally there is loss of faradic excitability. As a rule sensation is not affected, except for the tingling occurring at the onset and the develop- ment of certain hyperaesthesias. Vaso-motor disturbances evidenced by oedema and h}^eridrosis may be present. There is no mental impairment and seldom any febrile movement. Rarely cases have been observed in which the paral- ysis has been of the descending type, the upper part of the body being involved first. Death may supervene here from involvement of the medulla before the paresis reaches the lower limbs. The course of the disease may last but a few days before the fatal outcome or it may continue for several weeks, depending upon whether or not the vital centers are affected. The prognosis is generally very unfavorable but in rare cases the symp- toms have gradually ameliorated and recovery has ensued. Treatment. The patient should be confined to his bed and counterirri- tation applied to the spine by means of dry cupping, mustard pastes or the thermo-cautery. The bowels should be opened by repeated small doses of calomel foUowed by a saline and the activity of the skin and kidneys stimu- lated by diaphoretics, the warm bath, and the potassium salts (potassium SYRINGOMYELIA. 755 citrate or acetate, gr. X to XX — 0.66-1.33 — three times a day) in order to assist in the elimination of the toxin causative of the disease. If there is suspicion of syphilis mercury biniodide, gr. -^^"-g-V (°-°°^2"~°-°°2) three times a day should be given. The use of ergotine is recommended by Gowers, he having administered gr. xx (1.33) in divided doses hourly with improvement of the symptoms, followed by recovery. The salicylates also are advocated and iron perchloride may be employed although it is probable that these drugs will influence the progress of the disease but little. The symptoms of respiratory or cardiac failure should be combated by the application of the electric current to the muscles of the chest and to the phrenic nerve and in the cases which survive the acuity of the disease this means should be employed to aid muscular and nerve regeneration. The patient should lie upon the side rather than upon the back since the latter position tends to augment the congestion of the spinal cord. When swallowing becomes difficult the use of the stomach tube may be necessary in order to maintain the patient's nutrition and to prevent the lodgment of food particles in the respiratory tract. SYRINGOMYELIA. Definition. A condition of the spinal cord characterized by the existence in its substance of abnormal cavities which usually contain liquid and are surrounded by an increase of neuroglia tissue. .Etiology. This disease may exist as the result of a congenital anomaly, of the degeneration of embryonal or gliomatous tissue in the cord or of a hasmorrhage, traumatic or due to arterial disease, into the cord substance. Pathology. The spinal membranes remain normal but the surface of the cord is irregular, protuberances being seen in certain places, retractions in others. Over the prominences fluctuation may be obtained and puncture may reveal the presence of serous fluid. The cavities may be multiple, extending considerable distances up or down the cord, being usually largest in the upper dorsal and cervical regions and may involve nearly the whole diameter of the structure even to the pons, converting it into a tube. The cavity may appear to be a dilatation of the central canal or it may be situated in the posterior portion displacing the central canal forward. The cavity is lined with neuroglia which may, before it degenerates and becomes softened, interfere with the function of the normal tissue of the cord. Upon the out- skirts of this neuroglia the blood-vessels are more numerous than normal, they may be dilated and their walls may be the seat of sclerotic change. Symptoms. While mild types of the disease may be evidenced by no symp- toms, the onset usually occurs at from twelve to twenty vears of age and is 756 DISEASES OF THE NERVOUS SYSTEM. of gradual development. The symptoms depend upon the situation of the lesion and consequently the neck, arms and upper thorax are most affected. The characteristic symptoms are disorders of sensation, particularly of the pain and temperature senses; touch is seldom affected but may be rendered less acute than normal. These distiirbances chiefly involve the upper part of the body, but areas of pain sense disturbance may be observed in any part. "Muscular weakness may occux and trophic changes in the skin and nails as evidenced by thickening, eruptions, or superficial gangrene of the former and corrugation, Assuring or even loss of the latter. The absence of pain sense may result in neglect of injuries and consequent superficial infectious processes and ulceration. Sweating, blueness, coldness, oedema and other vaso-motor distiurbances may be observed. The joints of the upper extremities may become swollen, their cavities filled with fluid and their articular surfaces absorbed, a change analogous to that occurring in locomotor ataxia. The bones become brittle and are easily fractured and spinal curva- tures may appear as a result of the atrophy of the muscles or involvement of the vertebrae. Secondary contractures of the hands may develop. When the disease aft'ects the medulla there may be partial laryngeal paral- ysis, dysphagia, lingual and facial paresis and disturbances of the heart action and respiration. The pupils may react sluggishly or be unequal. Involvement of the lumbar cord may produce paralyses of the rectum and bladder. The prognosis. The course of the disease is chronic, extending over from ten to twenty years; its development is slow but as it nears its termination it progresses more rapidly. The ultimate result is invariably fatal, death super- vening from exhaustion or involvement of the medulla. Treatment. This is entirely without avail as far as checking the disease is concerned. The patient's strength should be maintained by nourishing food, tonics may be given and the administration of arsenic and silver has been recommended. The patient should be warned of the danger of trau- matism and fracture and he should be protected against possible injur}-. Otherwise the treatment consists in the relief of the symptoms as they appear. MORVAN'S DISEASE. This is a condition analogous to s}T:ingomyelia and characterized by prac- tically identical symptoms; necrotic infections due to trophic disorders are likely to be more severe. The bacillus leprce has been found in the degener- ated tissue in the cavity of the cord in certain cases. It is probable that further study will show that the so-called Morvan's disease is identical with syringomyelia. HuEMOKRHAGE INTO THE SPINAL CORD. 757 HEMORRHAGE INTO THE SPINAL CORD. This is of rare incidence; it is met most frequently between the ages of twenty and forty although it has been observed during infancy. The condition may result from traumatism, it may occiir in haemophilic subjects, in conditions of asphyxia, illuminating gas poisoning, for instance, in the severe convul- sions of epilepsy, eclampsia, tetanus, etc., after excessive coitus and as the result of aneurysmal rupture or arterial disease. The haemorrhages may be single or multiple, are usually in the gray matter and may be sufl&ciently large in quantity to burst through the white substance to the pia. After the extravasation of the blood the tissues of the cord become soft, degenerated red blood cells and leucocytes and small round cells are seen and the cord substance is tinged with the coloring-matter of the blood. Later the involved area may develop into a connective tissue cicatrix, become the seat of fatty degeneration, or the clot may be absorbed, leaving a cavity behind. Symptoms. The onset of this condition is usually sudden with feelings of numbness quickly followed by paralysis of the lower limbs, with loss of sensation and, perhaps, ataxia; there is loss of vesical and rectal control, the reflexes are lost but soon return and become increased; there may be severe pain referred to the spine or to the abdomen, chest or limbs. If the upper dorsal or the cervical region is involved the arms and chest are affected. The acuity of the symptoms lessens after about a week and the condition then resembles that present in chronic myelitis. Spasmodic contractions may' appear and muscular atrophy may ensue resulting from injury of the anterior horn cells. If the extravasation of blood is large improvement may not take place and the affection may result in death with symptoms of acute myelitis. The characteristic symptoms of spinal haemorrhage are the very sudden onset and the pain. The prognosis is dependent upon the situation and volume of the hem- orrhage. It is least serious in the dorsal region, most in the cervical. Treatment. The patient should be put to bed and kept absolutely at rest, cold applications should be made to the spine in the form of ice bags and the circulatory irritability should be lessened by the administration of aconite; restlessness may be controlled by the bromides. Otherwise the treatment is entirely symptomatic. Ergot has been recommended and may be tried. The treatment of the chronic stage consists in the exhibition of the iodides in the hope of lessening the tendency to the production of connective tissue growth at the site of the lesion, together with the employment of the other means discussed under the treatment of chronic myelitis (p. 738). 758 DISEASES OF THE NERVOUS SYSTEM. CAISSON DISEASE. Synonym. Diver's Paralysis. Definition. A disease caused by suddenly emerging from air under high pressure into that of normal pressure and characterized by dizziness, pains in the head and joints, especially the knees and elbows, and in severer cases by moto/ and sensory paralyses of the legs of greater or less degree. .Etiology. This condition is met in artisans who have been working under heavy atmospheric pressure in caissons such as are employed in the construc- tion of bridges, piers, foundations of buildings and the like. The disease seems to depend upon distiurbance of the central nervous system caused by the sudden change of atmospheric pressure attendent upon emergence from caissons, in which the pressure may be as high as 60 lbs. to the square inch, into the ordinary atmosphere. Some persons seem to be more susceptible to the disorder than others and it is unlikely to occur unless the individual has been subjected to the pressure for an hour or more. Those unaccustomed to working under pressure are more likely to be attacked than those regularly engaged. Pathogenesis and Pathology. The pathogenesis of this disease is not definitely known; one theory, however, is that under high pressure the blood is forced from the peripheral into the internal circulation, particularly that of the brain and spinal cord, causing a dilatation and a paresis of the blood- vessels; when the pressure is relieved the blood rushes to the peripherv and upon this occurrence the circulation of the central nervous system becomes sluggish and a condition of stasis results. The hypothesis has also been advanced that the manifestations of the disease are the result of the freeing of nitrogen into the substance of the cord, this gas ha\ang been forced into the blood by the high pressiure to which the latter has been subjected. In favor of this explanation is the fact that gas has been demonstrated in the tissues upon emergence from high into ordinary air pressure. The findings in fatal cases have consisted in a diffuse parenchymatous myelitis with degeneration in the posterior and the adjoining lateral columns. Symptoms. The onset of the disease takes place within a half hour of emergence from the excessive pressure and in the milder cases may consist merely of dizziness and neuralgic headache with joint pains. In cases of severer type this pain may be extreme, accompanied by nausea and vomiting, earache, and abdominal pains, followed by motor and sensory paralysis of the lower limbs. Temporary mono- or hemiplegia may occur. The sphincters may be incontinent and unconsciousness followed by coma and death has been observed. The milder cases usually recover within a day or two, but the severe types of the disease may continue for weeks or months, recovery COMPRESSION OF THE SPINAL CORD. 759 ensuing as a rule, although death may supervene or the patient may remain permanently paralyzed. Treatment. Prevention of the condition consists in arranging chambers containing lessening degrees of atmospheric pressure through which the workmen must slowly pass before returning to the ordinary air. Exertion in climbing ladders seems to predispose to the affection, consequently an elevator should be employed whenever possible. The hours of work under high pressure should be short. Patients are often relieved of the symptoms by a return to the atmosphere of high pressure and the idea of arranging a chamber at the surface within which the air pressure can be raised is an excellent one. The severe pains often necessitate the administration of morphine h}^o- dermatically. The joint pains may be relieved by the faradic current, mas- sage and especially by baking as employed in chronic rheumatic conditions. The patient should be kept quiet and hot compresses should be a^^pli^d to the spine and to the extremities. Ergot has been recommended and mtfan? should be employed to relieve the disordered circulation by bleeding it me heart is over-worked and the arteries are tense and full. The chronic symp- toms, paralyses, sensory disorders, etc., should be treated by the means appli- cable in myelitis. COMPRESSION OF THE SPINAL CORD. Synonyms. Compression Myelitis; Pressure Paralysis of the Spinal Cord. Compression of the spinal cord may be caused by various lesions and results in paralyses differing in degree and character. Among the causes of cord com- pression may be mentioned neoplasms, syphilitic and inflammatory thickenings of the spinal membranes, spondylitis, particularly that due to tuberculous processes (Pott's disease), malignant new growths and injuries of the verte- brse, cysts of the spinal canal due to the echinococcus or the cysticercus, erosion of the vertebrae and consequent pressiue upon the cord due to aortic aneurysms, malignant retroperitonaeal neoplasms and collections of pus, retropharyngeal abscesses, etc. Pathology. At the site of the compression the cord may be smaller in size than normal, and irregular in outline on cross section; in recent lesions it may be softened but in compression of long standing its consistence may be harder, due to the replacement of previously degenerated areas by connective tissue. Microscopically the nerve fibres are swollen and fatty degeneration may be observed, later this condition is replaced by a growth of connective tissue of more or less firmness depending upon the duration of the pressiire. Ultimately secondary ascending and descending degenerations may occur. Symptoms. In the most common variety of compression myelitis — that 760 DISEASES OF THE NERVOUS SYSTEM. resulting from Pott's disease — the deformity may have existed for a long period before any symptoms resulting from cord compression appear, while in cases due to intrathoracic or abdominal lesions the cord symptoms may be noted first. Pain is an early symptom and varies in degree from a dull ache at the site of the pressure to very marked pain. The discomfort is increased by bending the back. If the pressure is upon the nerve roots the pain may be situated ?n the distribution of the nerves having their origin in the roots affected. There are sensations of numbness and tingling. Sensation is not likely to be disturbed although anaesthesia may occur in lesions of long standing. Later, symptoms of motor disturbance, usually not symmetrical at first but affecting one leg or arm before the other, may be noted; these consist of muscular stiffness and varying disorders of motility ultimately becoming complete paralysis. As would be expected the symptoms differ with the area of the cord affected. When the pressure is exerted upon the upper part of the cord just below the medulla, movement of the neck may be accompanied by pain and the neck muscles may be the seat of spastic contractions; in marked cases it may be impossible to move the head. If the lesion is in the lower cervical cord the muscles of the neck may be rigid while sensory and motor disturbances of the arms occur. The skin and tendon reflexes are increased, because of interference with the passage of inhibitory influences, the knee jerk is exag- gerated and ankle clonus is present. In pressure upon the dorsal and lumbar regions the legs only are affected although in lesions involving the dorsal cord only, there is likely to be pain in the distribution of the intercostal nerves, the girdle sensation may be present, and there is ankle clonus with augmented patellar reflex. In involve- ment of the lumbar cord there are motor and sensory disturbances in the legs, the reflexes are diminished and vesical and rectal incontinence, pre- ceded by difficult micturition and constipation, may occur. Trophic disorders evidenced by a tendency to bed sores, atrophy of the muscles of the paralyzed parts, skin eruptions, desquamation and dryness of the nails may be observed. The prognosis in compression due to Pott's disease is good because of the possibility of removing the cause of the lesion, in that due to other causes it is unfavorable. It is possible for the symptoms to disappear even after they have endured for months. Treatment varies with the cause of the condition; that of Pott's compres- sion consists of the use of appliances calculated to reduce the deformity and the administration of antituberculous medication, codliver oil, creosote, especially in the form of the carbonate, iron, arsenic and other tonics com- bined with plenty of fresh air, proper exercise and nourishing food. Suspen- sion has been employed with good results in the earlier stages. When the TUMORS OF THE SPINAL CORD AND ITS MENINGES. 76 1 condition is the result of syphilitic gummata or meningitis the administration of mercury and potassium iodide is indicated. The pain may be relieved by the coal tar analgesics, such as salipyrine, acetphenetidine, acetanilide; hydrated chloral and morphine may be employed as last resorts only, on account of the possibility of habit formation. When this symptom is due to cervical meningeal thickening counterirritation by means of the electro- or thermo-cautery may be beneficial. The muscular tv^itchings should be combated by the bromides. Rest and hydrotherapeutic measures, especially warm baths, are impor- tant adjuncts to treatment. Massage and electricity influence the course of the disease not at all but may be used to maintain the nutrition of the atrophied muscles. Compression by neoplasms necessitates surgical intervention. The removal of non-malignant growths may be followed by recovery, that of malignant tumors by temporary benefit only, as a rule. Laminectomy is necessary in conditions of fracture and dislocation com- pression and has been employed in tuberculous spondylitis. Surgical treat- ment is also indicated in pressiure upon the cord resulting from intrathoracic and intraabdominal abscesses. Aneurysmal compression may be treated by the various operations advocated for the relief of the primary condition. TUMORS OF THE SPINAL CORD AND ITS MENINGES. Tumors causing symptoms referable to the spinal cord are of various types and origin. They may arise from the bones, cartilages, or ligaments of the spinal column — enchondroma, sarcoma, carcinoma — in the tissues of the extradiual space and from the outer surface of the dura — sarcoma, carcinoma, lipoma and tumors resulting from the growth of hydatids or cysticerci — in the spinal membranes — sarcoma, tuberculoma, syphiloma and parasitic growths — in the substance of the cord — glioma, tuberculous and syphilitic tumors, sarcoma and myxoma. Mixed tumors in any of these situations may occur. The tumors most commonly found are those due to syphilis and tuberculosis, and sarcomata. Parasitic growths are seldom met. New growths also develop in the spinal nerve roots inside the dura; these may be myxomata, fibromata, lipomata, neuromata or tumors of mixed character. Spinal neoplasms are usually single but multiple neuromata or sarcomata sometimes occur. In size they seldom reach a greater diameter than two inches and frequently they are much smaller than this; when within the spinal canal their growth is limited by its calibre. Symptoms. Slowly developing tumors may exist for considerable periods before causing noticeable symptoms; when these appear they depend upon the site of the growth and the presstue exerted by it. 762 ■ DISEASES or THE NERVOUS SYSTEil. The chief symptoms are senson- and motor. Pain is likely to be the earliest of these and is usually due to the pressure of the tumor upon the sensory ner\"e roots. It is of varying character. It may be a dull ache or a burning, stabbing pain or a girdle sensation. Its situation differs in accordance with the nerA"e roots involved, it may affect one or both sides of the body, and appears first at the termination of the neri^es upon which the pressure is exerted. There may be anaesthetic and h}-peraesthetic areas. Spinal pain, increased upon motion, and tenderness are sometimes present. Motor S}-mptoms consist of spastic contractions, marked oftentimes, if the tumor is meningeal, and muscular rigidit}' at the level of the lesion; this may aid in diagnosticating the site of the tumor. Spasm of the arm and leg of one side suggests a tumor on the corresponding side somewhere in the cervical region, whereas if the muscles of the leg only are affected the growth is likely to be in the dorsal cord. Paralysis gradually develops as the tumor increases in size and may finally become complete. If the neoplasm is in the cervical region this s}Tnptom affects both arms and legs, if below this level the lower limbs only. The paralysis may be more marked on one side if the tumor presses more upon one side of the cord than upon the other. Sensation is finally lost in the paralyzed parts if the tumor is below the sixth dorsal segment, but if it is above this point and eccentric, the senson' disturb- ance is likely to be greater upon the side affected by the smaller amount of motor disturbance. Vaso-motor disorders, oedema, mottling of the skin, etc., may occur and if the lesion affects the cells of the anterior horns muscular atrophy results. Ascending and descending degeneration of various tracts of the cord may occur in cases of long standing, and true myelitis may at any time be engrafted upon the primar}- condition and obscure the diagnosis. The t}-pical manifestations of spinal tumor are the gradual appearance of s\-mptoms referable to the spinal ner\-e roots, first of one side, later of the other, and the development of motor and sensory paralysis. The fact that the pain is, as a rule, at the level of or shghtly below the growth (it is never above), is of practical value in ascertaining the seat of the growth. The char- acter of the growth is difiScult of diagnosis unless a histor}' of s^-philis or the presence of tuberculous disease in other parts of the body can be made out. Treatment. This depends upon the cause of the compression and natur- ally should be directed toward the relief of that condition. The treatment of Pott's disease compression consists in the aUe^'iation of the deformity by orthopedic apparatus and constitutional treatment directed against the causa- tive tuberculous infection. The means at our disposal are the administration of codliver oil and other tonics, the insistence upon proper hygiene and plenty of nourishing food. Compression resulting from growths of 5}-philitic tissue necessitates vigor- SPIXAL MEXIXGITIS. -63 0U5 antiluetic treatment; in that due to tumors of gliomatous or sarcomatous t}-pe arsenic and silver nitrate may be administered, with Httle hope of benefit, however. The consideration of surgical interference is pertinent in all forms of neoplasmic compression and the earlier this form of treatment is under- taken the more likely will it be to reHeve the condition. Tumors outside the dura are not difficult of removal, and even those in the cord substance may be operated upon vnth some benefit. "WTien there is certaintv of the presence of a new growth exploraton* operation is justifiable and when done by skillfiol hands is of comparatively slight danger. SPINAL MENINGITIS. SPINAL PACHYMENINGITIS. DefLrdtion. An inflammator}- condition of the dura mater of the spinal cord. ^^^lile attempts have been made to separate the inflammations involving the outer la^er of the spinal dura, such as those resulting from the extension of inflammations, especially tuberculous, of the bones of the spinal canal, from those involving the inner layer of this structure, it is both difficult and unnecessary from a symptomatologic as weU as from a pathologic standpoint to do so since the pachymeningitis externa rarely exists as a distinct entity, the inflammation extending in almost ever\- case to the inner laver of the dura, a pachymeningitis interna, resulting, with, oftentimes, an involvement of the pia of the cord as well. Of pachymeningitis interna, two forms are distinguished; cervical h^-per- trophic pachymeningitis and haemorrhagic internal pachymeningitis. The former is a chronic inflammation due to S}-phiIitic infection, the abuse of alcohol or exposure to cold. The dura of the cer^dcal region is involved to a greater or less extent of its area and pathologically the process consists of an exudation of fibrinous tissue, occurring in successive layers upon the inner surface of this membrane and, at times, resulting in adhesions between it and the adjacent pia. Symptoms. These are referable to the compression of the cord bv the fibrinous exudate and consist of pain in the arms, and in the back of the neck and head; with this, disorders of sensation, numbness, tingling and herpetic eruptions may be obsen-ed. These symptoms are due to pressure upon the roots of the nen^s supplying the affected parts. After the pain has been present for a period of from a few weeks to several months, paralysis with muscular atrophy, resulting from pressure upon the anterior ner\-e roots, appears. In consequence of the location of the lesion 764 DISEASES OF THE NERVOUS SYSTEM. the arms are chiefly affected, they become weak, and atrophy, resulting in contractures of different sets of muscles, takes place. Sometimes there mav be areas of cutaneous anaesthesia. Still later, if the gro"?v1:h of new tissue increases further, a spastic paralysis, due to interference with the motor tracts of the cord, occurs; the reflexes are exaggerated; there is no atrophy but in cases of long standing there may be anaesthesia, rectal and vesical paresis and a tendency to the development of bed sores. While the course of the disease is chronic it does not in itself jeopardize life and treatment may result in improvement. Treatment. If the disease is of syphilitic origin the treatment consists in the employment of usual means adapted to specific disease. The pains may be relieved by antipjTine, acetphenetidine, codeine, etc. Hydrotherapeutic measures and electricity are to be recommended, together with the applica- tion of counterirritation, especially the Paquelin cautery, to the back of the neck. Where the condition is the result of bone disease, tuberculous or other- wise, orthopaedic or other surgical treatment is indicated. HcBmorrhagic pachymeningitis is very rare and is seldom diagnosticated intra vitam. It may occur at any level of the cord, its symptoms resemble those described above and it frequently co-exists with haematoma of the cere- bral dura. ACUTE SPINAL LEPTOMENINGITIS. Acute inflammations of the pia mater of the cord, aside from cerebrospinal meningitis of the epidemic type, occur as the result of tuberculous infection, secondary to the acute infectious diseases, following exposure to cold or injury and from the extension of infections of the cerebral meninges. Pathology. The membrane is first swollen and h}-peraemic, later there is exudation of serous or purulent fluid into the meshes of the pia and the arach- noid; these membranes are infiltrated with round cells and adhesions and thickenings result. Secondary changes may take place in the cord and spinal nerve roots, the final pathological change consisting of areas of scle- rosis in these tissues. Symptoms. These are, at the onset, those of acute inflammatory' processes of other parts, namely, a chill, followed by rise of temperature, headache, malaise and general pains, these last occur especially in the back and limbs and are increased by motion. There are stiffness and muscular rigidity of the spine as well as sensitiveness of the spinal nerves. Kernig's sign — an inability of the patient, when the thigh is flexed at a right angle to the body, to extend the leg upon the thigh — is present. The reflexes are often increased, later, however, loss of reflexes with paralysis occurs, shoiild the inflammation be of severe type. There may be vesical and rectal disturbances and trophic ACUTE SPINAL LEPTOMENINGITIS. 765 disorders evidenced by blueness or pallor of the skin and a tendency to bed sores may appear. The course of the affection varies; death may supervene within from a few days to several weeks, due to involvement of the cranial nerves by reason of extension of the inflammation to their foci of origin. Complete recovery may take place in mild cases while after attacks of severe t}-pe the patient is often left with permanent localized motor, sensory or trophic lesions. Lumbar puncture reveals the presence of an increased quantity of cerebro- spinal fluid which escapes in drops through the needle, or if there is a consider- able augmentation in its amount, the fluid will spiurt forth in a stream of more or less force. Bacteriological examination of the fluid may show the cause of the lesion and by cytological examination more or less light may be thrown upon the setiological factor of the inflammation. If meningitis is present the fluid is rarely clear and contains no sugar. Tuberculous fluid is, as a rule, quite tiurbid; in acute processes the number of leucocytes is likely to be large and chronic meningitis is usually evidenced by a relative increase in the number of mononuclear lymphocytes. Fresh blood is usually due to the puncture while decomposed blood may be found following injviry or in cases of pachymeningitis. The prognosis is, as a rifle, unfavorable, especially in the tuberculous form. Cases secondary to the infectious diseases may recover. Treatment. This consists in absolute rest in bed in a dark room, the employment of sedatives and of the other therapeutic means discussed under the treatment of epidemic cerebrospinal meningitis (p. 100). Chronic Spinul Leptomeningitis may result from the continuation of an acute process particularly epidemic cerebrospinal meningitis, from the exten- sion of chronic cord inflammations, syphilitic infection and chronic alcoholism. When this condition exists the membranes become thickened and opaque, adhesions to the surface of the cord are formed and the cord itself under these adhesions may be the seat of an inflammator}- process (meningomyelitis). The walls of the blood-vessels are thickened and in cases due to s}^hilis gum- ma ta may be found; frequently there is a co-existent chronic inflammation of the cerebral meninges. Symptoms. These are not well marked and consequently the condition is seldom diagnosticated. A chronic and obstinate stiffness of the back and limbs is the principal manifestation and with this are cramp-like pains, sen- sory and motor disorders and, when the lower segments of the cord are affected, there may be vesical and rectal disturbances. Lumbar puncture reveals an increase of the cerebrospinal fluid. Treatment consists in the employment of every possible measure to main- tain the patient's general health. In s}^hilitic cases appropriate specific treatment in the form of mercurv and the iodides should be administered. 766 DISEASES OP THE NERVOUS SYSTEM. Warm baths should be taken either at home or at natural springs. These not only in themselves benefit the patient but are an important adjimct to the antisyphilitic treatment. Coimterirritation by means of the Paquelin cautery is often useful. HEMORRHAGE INTO THE SPINAL MEMBRANES. Synonyms. Hsematorrhachis; Meningeal Apoplex}\ Spinal meningeal haemorrhage occurs either without the dura — extramen- ingeal — or between the dura and the pia — intrameningeal. The former condition, as a rule, is due to injury — fracture, gunshot- wound or puncture — or is the result of aneurysmal rupture. Intrameningeal hsemorrhage is not often seen but may occur in malignant forms of the infectious diseases, or due to rupture of aneurysms of the basilar or vertebral arteries. It has been observed post mortem in conditions associated with con\TjJsions, such as tetanus, str}'chnine poisoning or epilepsy. In extradural haemorrhage the blood is extravasated from the veins which surround the dura; the quantity of the blood varies from a small amount forming a clot which covers but a small area to a quantity sufl&ciently extensive to extend the entire length of the cord, in which case it may cause a consid- erable compression. It most frequently occurs in the cervical region. The quantity of subdural haemorrhage is also variant. The clot may be so small as to extend along the cord for an inch or two or of sufficient size to fill the entire subarachnoid space; rarely it may extend into the ventricles of the brain. Symptoms. These may be wholly absent unless the haemorrhage is of sufficiently large amount to compress the cord. In this case they vary from hardly recognizable manifestations to those of marked compression — sudden severe pain in the back extending to the lower part of the trunk or to its ventral surface, muscular twitchings or even a local or general convulsion. Following these symptoms motor and sensory paralyses develop, seldom, however, are these complete. The S}Tnptoms differ with the location of the extravasation, cervical haemorrhage being evidenced by pain or anaesthesia in the neck and arms, which may be followed by paralyses of both arms and legs, there may be difficulty^ in respiration and deglutition and pupillary dis- turbances. Dorsal haemorrhage is accompanied by pain in the back, thorax and abdomen, followed, it may be, by paraplegia, the reflexes remaining normal. In haemorrhage in the lumbar region the pain and paralysis affect the legs, the reflexes are lost and there are vesical and rectal disturbances. Death may occur wdthin a few hours if the haemorrhage is of large extent, while small clots may be absorbed, the svmptoms disappearing as this takes place; in other cases the patient lives but permanent paralytic conditions DISEASES INVOLVING CHIEFLY THE PERIPHERAL NERVES. 767 remain. Cervical haemorrhage is most serious on account of the likelihood of involvement of the medulla. Treatment. The patient should be kept absolutely at rest and preferably upon his side or face lest the blood accumulate along the posterior columns of the cord; the bovsrels should be kept open by the administration of fractional doses of calomel and the milder salines. Counterirritation to the spinal region by means of leeches or dry cups may be employed but the use of ice bags is preferable. The nervous and circulatory excitation may be controlled by small doses of the bromides (10 grains — 0.66 — ever}^ two or three hours) and aconite tincture (5 drops— 0.33 — every two hours) until the desired effect has been accomplished. Later, potassium iodide or the s}Tup of hydriodic acid may be given in the hope of facilitating absorption and when the acute stage has passed the usual means— massage, electricity and hydrotherapeutic measures — calculated to bring about a return of normal muscular and nerv- ous tone may be employed. In massive haemorrhages with symptoms of marked compression operative intervention with a view to the alleviation of this condition may become advisable. DISEASES INVOLVING CHIEFLY THE PERIPHERAL NERVES. NEURITIS. Definition. An inflammatory process affecting a nerve. The inflamma- tion may involve one nerve (localized neuritis) or many {multiple or poly- neuritis). When the condition affects only the tissue surrounding the nerve it is spoken of as a perineuritis, inflammation of that tissue within the nerve which encloses the bundles of nerve fibres is termed interstitial neuritis, while a parenchymatous neuritis is an affection of the nerve fibres themselves. .etiology. Neuritis may be caused by exposure to cold; by injuries to a nerve trunk from contusions, wounds or stretching, such as may occur in fractures or dislocations; by pressure from aneury^sm, new growth or the con- stant use of a crutch or tool; by extension of inflammation of adjoining parts; by the poisons of acute infectious diseases, _ t}^hoid fever, diphtheria, etc.; by gout, purinaemic conditions and s}'philis. It also occurs, more especially in its multiple form, as a result of alcoholism and of chronic metallic poisoning, particularly that due to arsenic and lead and may rarely follow long con- tinued use of sulphonmethane or sulphonethylmethane. Pathology. The affected nerve is first red, swoUen and congested, the perineurium and nerve substance are likely to be infiltrated with extrava- sated white blood cells and there may be an increase in the neuroglia tissue. The process having reached this stage either undergoes resolution, goes on 768 DISEASES or THE NERVOUS SYSTEM, to complete destruction of the nen'e or the increase of connective tissue con- tinues until the nerve undergoes atrophy and is wholly replaced by this sub- stance. In the parenchymatous variet}", the employment of the microscope reveals a swelling and opacit}^ of the myelin substance and later a granular degeneration; finally the myelin and the axis cylinder degenerate, only the nen'e sheath remaining, this later becoming converted into connective tissue. Symptoms. In localized neuritis pain, increased on motion, and tender- ness along the course of the nen'e extending even to its termination, are the .dominant symptoms. The pain is usually worst at the site of the inflamma- tory process although it may affect the distribution of the nerve as weU, and more rarely the entire limb. In ver}- mild cases there may be only numb- ness and tingling but in those of severer t}-pe it is apt to be aching, burning or lancinating in character; it is usually worse at night. Trophic changes occur such as oedema, glossing of the skin, sweating, increased surface temperature and muscular wasting. !Motor disturbances such as spasmodic contractions or partial paralysis are not infrequent. The electric reaction may be unchanged in mild types; in severer cases the response to electric stimulus is slow and the reaction of degeneration, i.e., loss of faradic excitability in both muscle and nerve and of galvanic reaction in the nerve, vrhile the galvanic excitability of the muscle is changed so that the cathodal closure contraction is less than or about equal to the anodal closure contraction, is observed; the cathodal closure contraction is greater in the normal muscle than the anodal closure contraction. The course of the disease varies, some cases recovering within a few weeks, while others continue to the chronic stage, recovering gradually after months of disability; cases due to injur}- or cold are favorable while those resulting from the extension of adjacent inflammation are the most severe. WTien recover}- is imminent the reaction of the nerv-e to galvanic stimiflation gradu- ally reappears. Symptoms of Neuritis of Special Nerves. Facial neuritis is particularly likely to result from exposure to cold and is accompanied by paralysis of the muscles supplied by the ners^e. Median -neuritis is evidenced by pain and motor s}-mptoms in the palmar surface of the thumb, index and middle fingers and radial side of the ring finger. In ulnar nerve involvement the s}Tnptoms are confined to the ulnar side of the ring finger and the little finger with atrophy of the muscles supplied by this ner\-e. Musculo-spiral neuritis is characterized by pain affecting the arm and forearm with motor disturbances in the muscles supplied. Wrist drop may occur in severe cases. In neuritis of the circumflex nerve the motor and sensor}- disorders are confined to the region of the deltoid and teres minor muscles. Inflammations of the hrachiil plexus produce a combination of the S}-mp- NEURITIS. 769 toms ascribed above to affections of the various branches of this structure, numbness and tingling in the arm, pain upon axillan,- pressure and upon raising the limb, loss of muscular power and trophic disorders. Treatment. This consists in eradicating the cause, if possible, in relieving ihe pain, in combating the inflammatory process and in assisting the regenera- tion of the diseased nerves. WTien the condition is dependent upon constitutional disorders such as syphilis or purinEemia appropriate treatment should be employed; inflamma- tions of adjoining structures should receive attention, fractures and disloca- tions should be reduced and causes of pressure removed. The importance of rest cannot be over-estimated. The h'mb may be put up in splints or sand bags may be applied along its sides; the advantage of the latter procedure b'eing that it renders the employment of local measures more easy. The pain may be controlled by various local applications such as compresses of 10 to 20 percent, ichthyol ointment, hot compresses or poultices of flax seed, or ice bags. The actual cautery is useful, its applica- tion being rendered painless by means of the ethyl chloride spray. Rubbing with counterirritant liniments such as that composed of equal parts of menthol, hydrated chloral and camphor may be effectual. In cases of severe pain the administration of the coal tar analgesics is indicated; of these salip}Tine (gr. X — 0.66) given ever)' hour until relief is experienced is perhaps the best; acetphenetidine, gr. v to x (0.33-0.66) three times a day, acetanilide, gr. v (0.33) every four hours or antip\Tine, gr. x (0.66) three times a day may be em- ployed. If there is any tendency to heart weakness these drugs shoifld be used with caution and it is vn.se oftentimes to add a grain (0.065) of citrated caffeine to each dose. Codeine or morphine in small doses may be added to any of the above drugs if their analgesic effect is insufficient. Codeine alone mav be employed (gr. i-ii — 0.065 ^o o-^S) ^.nd when the pain resists all less potent remedies, recourse to morphine may become necessan,'. This drug should be given h}-podermatically and with extreme caution since the liability to establishment of the habit is great. Under no circumstances should the patient be allowed to use the s}Tinge. H}"podermatic injections of cocaine hydrochloride, gr. ■!• to ^ (0.008-0.022) and of beta eucaine hydrochloride in the same dosage may be useful. The injection should be given at the seat of the pain. Potassium (not sodium) salicylate may be given with benefit in certain cases and massa hydrarg}Ti, one or two grains (0.065-0.13) daily has been recommended. \\Tien the acute stage of the inflammation is past measures should be taken to bring about a regeneration in the affected nen-es. Here potassiujn iodide may at times be found useful but the so-caUed nerve tonics — stnxhnine in moderately large doses (gr. -gL — 0.002 — three times a day) either alone or com- 49 77© DISEASES or THE NERVOUS SYSTEil. bined with quinine and phosphorus, — are more usually efl&cacious. The tendency to atrophy of the muscles and the loss of nutrition of the affected parts indicate the employment of electricity, massage, hydrotherapeutic measures and passive movements. These, however, should not be instituted while tenderness persists or if they seem to exhaust the diseased parts. Elec- tricity may be given, in proper 'cases, daily but for not more than a few moments. The faradic current is an excellent means for restoring both sensation and motility, but it should never be given strong enough to cause discomfort. The interrupted galvanic current is indicated if there is no response to faradism, but the latter should be substituted as soon as regen- eration has so far taken place as to bring about a return of faradic irritability. Warm baths, massage and movements also aid in restoring the normal con- dition of the part by stimulating the circulation and thus improving the dis- ordered state of the nutrition. MULTIPLE PERIPHERAL NEURITIS. Synonyyyi. Polyneuritis. DefLnition. An inflammation of a number of the peripheral nerves at the same time. Etiology. ^lultiple neuritis may result from various poisonous substances introduced into the body; of these the most common is alcohol; other exogen- ous causes are lead, arsenic, carbon bisulphide and monoxide, anilin, copper, zinc, mercur}', phosphorus, ergot, morphine, aether, sulphonmethane, sul- phonethylmethane, etc. The condition may occur as a complication of the infectious diseases such as enteric fever, influenza, diphtheria, leprosy, measles, sepsis, etc., and here is due to the specific toxin of the infection. Beri-beri is a partictilar form of neuritis and is probably caused by a specific organism. Poisons formed in the body in certain constitutional states, e. g., diabetes mellitus, gout and purineemic conditions, may cause neuritis and finally, it mav occur in the chronic wasting diseases, anaemia, tuberculosis, cancerous states and general malnutrition. The disease, except the form which is a sequela of diphtheritic infection, and that occurring with anterior poliomye- litis, is one of adult life and is seen most commonly between the ages of twenty and fiftv vears. The great majority of cases are the result of alcoholism and women seem particularly prone to this t\-pe of neuritis. Exposure to cold may act as a predisposing factor. Pathology. The inflammation is usually of the parenchymatous t}-pe and the changes in the ner\-e substance are identical with those described on pages 767 and 768. Symptoms. The onset of the disease may be acute or subacute. In the MULTIPLE PERLPHEEAL NEURITIS. 77I acute form there are chilly sensations followed by a moderate rise of tempera- ture — 102° to 104° F. (38.8°-4o° C.) — with general pains, malaise, etc. At times the onset may occur without febrile movement. Sensory symptoms appear early; there is severe pain in the limbs, increased by movement or pressure; there is tenderness along the comrse of the affected nerves and there may be various parsesthesiae, such as tingling, numbness, sensations of cold and girdle sensations about the limbs or body. Anaesthesia begins at the fingers or toes and extends symmetrically up the limbs. Motor Symptoms. Following the disturbances of sensation muscular weakness appears which soon may develop into complete paralysis of the limbs so that the patient may become unable to move in bed; the extensors may be more severely affected than the flexors and in consequence, -^vTist and foot drop occur. Atrophy soon appears with diminution or loss of the deep reflexes. There may be ataxia evidenced by inability to perform fine movements and loss of muscular sense. There are no vesical or rectal dis- turbances. Trophic Symptoms. These occur as a result of vaso-motor paralysis and there may be resulting oedema, glossiness of the skin, sweating, skin eruptions and roughened nails; bed sores are unlikely to develop. The paralysis often does not affect all the nerves of a limb but is as a rule, symmetrical. The cranial nerves are at times affected and as a result of their involvement there may be facial paralysis, nystagmus or strabismus and disturbances of heart action due to inflammation of the vagus. Mental disturbances such as disorders of memorv', abnormalities of intel- lection and a mental condition known as Korsakoff's disease characterized by a tendency to "pseudo-reminiscence" and to tell of imaginary adventures or experiences, may occur. Alcoholic neuritis is usually rapid in onset and may be accompanied by mental symptoms such as dehrium or delusions; the pain and anaesthesia are very marked and the paralysis may be total. In other cases the symp- toms may be almost identical with those of locomotor ataxia (pseudo-tabes) but there is no pupillary distiirbance and rectal and vesical control remain normal. Lead neuritis may be ushered in by intestinal colic; there may be a lack of disturbance of sensation while the usual motor symptoms are present. Arsenic neuritis is characterized by gastro-intestinal disturbances followed by paralysis, ataxia, numbness and atrophy and but slight pain. A brownish pigmentation of the skin chiefly on the extensor aspects of the limbs is typical. Carbon monoxide poisoning causes a neuritis evidenced chiefly by sensory symptoms; these are usually slight but last for a long time. Diphtheritic neuritis is accompanied by marked paralysis with slight sensory 772 DISEASES OF THE NERVOUS SYSTEM. disturbance; ataxia may be present and the cranial nerves are often involved as shown by ocular paresis and difficulty in articulation and deglutition. Death may occur as a result of involvement of the phrenic nerve. The prognosis. The usual course of the disease is slow but as a rule recovery finally takes place unless the nerves have been so profoundly affected that regeneration is impossible. In alcoholic neuritis the symptoms rapidly increase in severity for several weeks, remain stationary for two or three months and gradually subside, recovery ensuing usually within a year. In lead and arsenic neuritis the diiration of the condition depends upon the amount of the poison in the system and the rapidity with which it is elimin- ated; recovery usually takes place in from four to six months. Diphtheritic cases are dangerous only on account of the possibility of involvement of the nerve control of the vital functions; failing this deplorable condition, recov- ery occurs in three or four months although at times the symptoms extend over a much longer period. Either the sensory or the motor symptoms may begin to disappear first but even if there are long periods during which there is no improvement one should not despair; recovery is possible even after two years or more. An unpleasant consequence of the disease is a tendency to contracture and deformity due to the unopposed action of unaffected muscles. Treatment. This in certain measure depends upon the cause of the neuritis. In alcoholic cases the use of this substance should be stopped; in cases due to plumbism or arsenical poisoning a change of occupation may be necessary, although much may be accomplished in the way of prophylaxis of the former type by insisting upon thorough washing of the hands before eating, by the drinking of sulphuric acid lemonade made by adding five drops of aromatic sulphiiric acid to a wineglass of water, and by keeping the bowels freely open with Epsom salts. The elimination of these poisons may be aided by the administration of potassium iodide, 15 to 30 grains (1.0-2.0) two or three times a day. During the acute stage of the disease the patient should be kept at rest in bed and his food should be nutritious and easily digestible, the bowels should be kept open and the skin and kidneys active. The salicylates may be useful in mild cases and the pain may be controlled by the use of the various agents mentioned under the treatment of neuritis in general (p. 769). Contractures and their resulting deformities should be prevented by keeping the limbs in proper position by the employment of bandages, splints or sand bags and the pressure of the bed clothing should not be allowed to increase any tendency to foot drop. Gouty or purinsmic conditions should receive appropriate treatment and in angemic states iron, arsenic, codliver oil and other tonics are useful. In pol}meuritis following the infectious diseases it is important that the SCIATICA. 773 patient should be kept in bed until all heart weakness is past and if there are manifest signs of cardiac disorder he must be warned against any sudden movement, sitting up in bed or excitement, since undue strain may result fatally, death being due to heart failure. Here cardiac stimulants are often indicated as well as the ordinary treatment of the condition. After the acute stage is past phosphorus and strychnine are indicated; it is often wise to alternate the latter drug with arsenic giving the strychnine in doses of -^ of a grain (0.0015) three times a day for a week, then the arsenic — arsenic trioxide gr. 2V (o-oo3) — for ^ week, and so on. The nutri- tion of the affected muscles and nerves now should be improved by the employment of faradism, a rapidly interrupted current being used upon the nerves and one slowly interrupted upon the muscles. Galvanism is also useful and warm baths at body temperatiu^e for a half hour several times daily, as well as massage and passive movements, in moderation, should be employed. Contractures and deformities resulting from multiple neuritis may necessi- tate the employment of orthopaedic apparatus or of surgical measures such as tenotomy or tendon transplantation. SCIATICA. This condition is the result either of a neuralgia or more usually an inflam- mation of the sciatic nerve or its sheath. .Etiology. Sciatica occurs as a rule only in adults and is most often observed between the ages of thirty and fifty years, although it appears at times in the third decade of life as well as in individuals over fifty. It affects men much more often than women. The poisons of chronic rheumatism, gout and more rarely of syphilis, seem to predispose to the disease, while as exciting causes exposure to cold and wet and to draughts, particularly after exertion, may be mentioned. Mechanical pressure upon the nerve by intrapelvic tumors and accumulations of faeces, and inflammatory foci either within or outside the pelvis may cause sciatica. Pathology. The morbid anatomy of this condition is identical with that described in connection with other forms of neuritis. Symptoms. Of these pain in the posterior part of the thigh is the most frequent. This pain may extend upward as far as the sciatic notch through which the nerve emerges from the pelvis, and along the coiu'se of the nerve through the popliteal space, down the leg behind the internal malleolus and upon the dorsum of the foot. The pain may be more or less distinctly local- ized in the course of the nerve and throughout this extent tenderness may be present; pressure over the sciatic notch is almost pathognomonic. Positions of the leg which stretch the nerve, particularly flexion of the thigh on the 774 DISEASES OF THE NERVOUS SYSTEM. pelvis while the leg is extended at the knee, increase the pain. In character the pain is like that of inflammations of other nerves and the onset of this symptom may be gradual or sudden. The reaction of degeneration is seldom observed but the patellar reflex may be absent. Vaso-motor and trophic manifestations are rare. The prognosis. The course of the disease is chronic and often obstinate, yet recovery is the rule. Life is not endangered. Treatment. Rectal and pelvic examination often throw light upon the causation of the condition and in such cases removal of the cause is of course indicated. Defects of the spinal column are often responsible also and here relief may be obtained by orthopaedic treatment. Gouty, rheumatic and syphilitic cases should receive treatment appropriate to these conditions. The acuity of the attack should be treated by rest in bed and the application of a Thomas splint extending from the axilla to the heel. Numerous local applications are recommended most of them counterirritant. Of these per- haps the best is the thermo- or electric cautery; it should be applied very lightly so that a minute after its use the skin shall show no trace; every two days is often enough to employ this agent. Other counterirritants have a field of usefulness; of these leeches, flaxseed poultices, collodium cantharidatum or a mixture containing i6 parts of strong spirit of ammonia, spirit of rose- mary 12 parts, spirit of camphor 4 parts, may be employed as a vesicant over the painful points; cold applications, the aether or ethyl chloride spray, bandaging with a mixture of sulphur and menthol, and ichthyol may be prescribed. The injection of various substances into the painful area or into the sheath of the nerve is often efficacious. Strychnine sulphate or nitrate, gr. -g^Q- - 2V (o.ooi to 0.003) injected into the buttocks twice a day is an excellent treatment. The dose may be gradually increased to gr. yV (0.006) but the patient must be carefully watched for increased muscular excitability. In injecting drugs into the nerve it is best to induce anaesthesia by a cocaine injec- tion (gr. |-| — 0.008-0.016) before the procedure. The intraneural injec- tion may consist of sterile water or chloroform. Acupuncture is a drastic method of treatment but may afford relief. Its technique consists in plunging several needles into the painful area for a depth of about two inches and allowing them to remain for about a quarter of an hour. Of internal analgesics, antipyrine, acetphenetidine, salipyrine, and ace- tanilide in the usual doses may be tried. If there is tendency to heart weakness it is always wise to add to each dose of these drugs 2 or 3 grains (0.13-0.2) - of caffeine sodiobenzoate. Codeine may also be employed and at times the pains may be so severe that the hypodermatic administration of morphine becomes absolutely necessary; it should, however, be given only DISEASES OF THE CRANIAL NERVES, 775 as a last resort on account of the ease with which patients become habituated to its use. For the disease itself aconitine, gr. -^jfQ (0.00015) with g-^Q- of a grain (o.ooi) of strychnine may prove effectual. It should be given every six hours at first, but the intervals should be gradually shortened until by the fifth day of the treatment the patient is receiving it every two hours. He must be carefully watched for signs of heart weakness and should be told to warn the phys- ician when tingling and numbness of the pharynx are noticed. Gelsemium to the physiological limit may also be employed. Oil of turpentine in doses of 15 drops (i.o) three times a day with oil of wintergreen has been considered a specific, but is of rather doubtful value. In rheumatic cases sodium or potassium salicylate should be given to the physiological limit; colchicum may act favorably also and should likewise be administered to the limit of tolerance. Ichthyol internally in small doses may prove beneficial, and blue mass in doses of i grain (0.065) twice a day has been recommended in cases where the inflammation is acute. If all the other drugs are without effect potassium iodide may be given. Massage and electricity may prove useful in chronic cases especially if atrophy is present. The galvanic current should be used, one electrode being applied at the point of emergence of the nerve from the pelvis and the other moved along the course of the nerve. Spa treatment with warm or mud baths often acts well but is by no means certain to do so. Nerve stretching may be employed as a last resort. The technique consists in laying the patient upon his back and fixing him in this position, the operator, with one hand upon the patient's knee so that this joint may remain extended, flexes the thigh upon the pelvis. Too much force should not be exerted. The operation of dissecting the sheath from the nerve for a distance of a few inches has been employed. These two last procedures are calculated to break adhesions between the nerve and its sheath. DISEASES OF THE CRANIAL NERVES. DISEASES OF THE FIRST PAIR: THE OLFACTORY NERVES. The functions of the olfactory nerves may be disordered at their points of origin, at any point in their course through the cerebral tissue, in their trunks, in the bulb or in their terminal distribution in the mucous membrane lining the nose. Pathology. The disturbances may be the result of brain tumors involving their course, of congenital abnormality or atrophy. Affections at the distri- 776 DISEASES OF THE NERVOUS SYSTEM. bution of the nerves in the nasal Hning occur as a result of chronic nasal inflam- mations or new growths. Hysterical disorders of smell are often observed and changes in the function of the nerves which have no apparent patholog- ical basis, are seen after head injuries and epilepsy. Symptoms. These consist of disorders of the sense of smell: a. Anosmia or loss of the sense of smell. This condition is caused most frequently by affections of the nerves in the nasal mucous membrane due to nasal catarrh or polypi; it occurs also in lesions of the olfactory bulbs or tracts such as may result from injuries, tumors, inflammations, or atrophy of the nerves such as may occur in tabes; it is also seen in lesions or congenital defects of the olfac- tory centers. h. Hyperosmia or increased acuity of smell. This is chiefly a hysterical manifestation occurring more often in nervous women. Patients have been observed who could recognize persons by their odor alone. c. Parosmia or hallucinations of smell. These are seen in the insane and in epileptics, the epileptic aura in which a distinctive odor is perceived being an example. This disturbance may occur also as a result of cerebral tumor or injury. The patient may have so perverted a sense of smell as to consider two totally different odors as alike or attribute an odor to a certain substance entirely different from its actual odor. In testing the sense of smell the essential oils such as those of peppermint, anise, cloves, etc., are used, and in the further diagnosis of the condition thorough rhinological examination should never be omitted. Treatment consists in the proper management of the intranasal lesion if such is present; otherwise little can be done and the normal sense of smell is seldom restored. DISEASES OF THE SECOND PAIR: THE OPTIC NERVES. The disease may occur in the optic tract, in the chiasm, in the optic nerve itself or in the retina. Lesions of the optic nerves may be caused by new growths, haemorrhages, meningitis, abscesses, syphilitic disease, etc. Dis- orders of the optic tract may exist independently of retinal change but when of long standing, atrophy of the retina may occur as a consequence. Chias- mal lesions may be caused by tumors of the base, hydrocephalus, basilar meningitis and acromegaly. Such lesions usually involve that part of the chiasm through which the decussating fibres pass and result in blindness of the nasal halves of the retinae. Lesions affecting the direct fibres of one side produce blindness in one eye and of the nasal half of the retina of the other. Involvement of the entire chiasm causes total loss of vision. Lesions of one tract, for instance, the left, cause blindness of the temporal half of the left retina and of the nasal half of the risht, a condition termed DISEASES OF THE SECOND PAIR: THE OPTIC NERVES. 777 homonymous hemianopsia. The hemianopsia may be partial or entire, depend- ing upon the extent of the lesion, and the vision of the other halves of each retina may or may not be impaired. Disturbances of the tract anterior to the anterior corpora quadrigemina often involve other cranial nerves and result in optic paralyses, sensory disorders in the face or affect the special senses. In determining the site of the lesion in hemianopia Wernicke's test is of much value. This is based upon the assumption that the pupillary reflex centers are situated in or anterior to the anterior corpora quadrigemina. If the lesion is behind this situation the pupil will contract when light is thrown upon the blind portion of the retina. If the pupil does respond to light it is probable that the lesion is a central one. In affections of the optic thalamus or internal capsule hemiplegia or hemianaesthesia are likely to accompany the ocular disturbance; lesions of the right motor tract, for instance with left hemiplegia, being associated with, when there is involvement of the optic tract in the internal capsule, disturbance of sight characterized by inability to see objects in the left field of vision. Conditions of mind blindness — ability to see objects but failure to recognize them — and of aphasia may also occur. There are two principal lesions of the optic nerve, these are optic neuritis and optic atrophy. Optic neuritis, papillitis or choked disk begins as a blurring of the edges and congestion and sweUing of the optic disk, later the margin of the disk becomes indistinguishable, the change taking place first upon its nasal side. Indirect examination reveals a disk red or reddish gray in color, while direct inspection shows a striated appearance, the striae radiating from the center outward. The veins are dilated while the arteries remain normal in size or are diminished. The retina also may become affected, a neuro-retinitis resulting. Haemorrhages may take place. The condition is most usually the result of some intracranial lesion, partic- ularly tumor. It also occurs in abscess, meningitis, nephritis, anaemia, multiple sclerosis and plumbism and idiopathically. The milder types of the disease may cause no disturbance of sight, in severer cases the visual function is impaired and may be wholly lost. If the inflam- mation subsides the symptoms usually become less marked, but the condi- tion may result in permanent blindness. Optic atrophy occurs primarily in the hereditary type, appearing in the males of a family after puberty; it occurs also in spinal diseases, particularly locomotor ataxia, in diabetic disease, plumbism and alcoholism, after exposure, and in the acute infectious diseases. It develops secondarily in multiple sclerosis and other brain diseases and as a consequence of optic neuritis. In the primary type ophthalmoscopic examination reveals a grayish disk of well-defined outline and a practically normal condition of the arteries, while 778 DISEASES OF THE NERVOUS SYSTEM. in the secondary form the disk is whitish and opaque, its margin is irregular and the arteries are shrunken. The vision is disturbed in a degree varying with the severity of the lesion^ it becomes less acute, the field of vision is diminished and color sense is changed. In the primary type blindness usually resiilts; in mild cases of the secondary variety recovery may occur but more often the sight is permanently impaired. The !reatment is that of the cause of the condition. Lesions of the retina may be either organic or functional. Of the former type two varieties should be described. Hemorrhage into the retina occurs in nephritis, in chronic gouty condi- tions, syphilis, septicaemia, anaemia, leucaemia and purpura haemorrhagica. The extravasations of blood take place in the nerve fibre layer and are of greater or less extent and pial haemorrhages may co-exist. The haemorrhagic spot is at first bright red, then darker, and finally, as the blood pigment becomes absorbed, light in color; white areas may be visible due to exudates, spots of fatty degeneration or consequent sclerosis and in the haemorrhages of septic- aemia, to collections of white blood cells. Retinitis occurs in malarial states, plumbism and in the same conditions as does retinal haemorrhage. The most important type is that occurring in chronic nephritis. The ophthalmoscopic appearance is characterized by white areas differing in size and distribution. These are the result of haemor- rhages and sclerotic processes. Arteriosclerosis is always seen in patients exhibiting this affection. According to Gowers three forms are distinguishable. a. The degenerative with retinal changes but with little alteration of the disk. This is the most common type. h. The inflammatory with marked swelling of the retina and obscuration of the disk. c. The hasmorrhagic with numerous hemorrhages and only slight inflam- mation. At times the inflammatory changes in the optic nerve are more marked than those in the retina which may cause doubt as to w^hether the lesion is the result of renal or intracranial disease. Syphilitic retinitis is rare; when congenital it usually occurs in pigmentary form (retinitis pigmentosa). Anaemic retinitis occurs especially in the pernicious t^'pe of the disease. Sudden blindness in one or both eyes may take place after profuse haemor- rhage or the process may take several days for its completion. The loss of sight may prove permanent. Neuro-retinitis may also occur. Chronic malaria with consequent anaemia may be complicated by retinitis. Leucaemic retinitis is characterized by an enlarged and distended condition of the retinal veins, there may be haemorrhage and yellowish or white spots. Functional retinal disturbance or amaurosis occurs as a result of a variety DISEASES OF THE MOTOR NERVES OF THE EYEBALL. 779 of causes. Of these urcemic poisoning is the most frequent. It may appear independently of other ursemic symptoms or before or after convulsions due to the same cause. Its onset is usually sudden and the blindness lasts but a few days. The ophthalmoscopic appearance is unchanged. Analogous to uraemic amaurosis are the types of this condition due to quinine, plumbism and alcoholism. Tobacco amaurosis affects the center of the visual field particularly and is usually of gradual development. The fundus may remain normal in appear- ance or there may be congestion of the disks. Unless the use of the drug is discontinued organic changes and atrophy of the disk may result. A central scotoma for red and green is always present. Hysterical amaurosis may occm- but there is more often impairment of vision only; the blindness may affect one eye only. In night blindness ornyc- talopia vision is clear by day or strong artificial light while the reverse is true in the shade or in twilight. In hemeralopia, the opposite condition obtains. These are rare states and may occur epidemically. Retinal hyperesthesia is not often observed in retinal lesions but may occur in hysterical patients. DISEASES OF THE MOTOR NERVES OF THE EYEBALL: THE THIRD, FOURTH AND SIXTH PAIRS. The third nerve, the oculomotor, supplies the levator palpebrae superioris, the superior and inferior recti, the internal rectus, the inferior oblique, the sphincter of the iris and the ciliary muscle; the fourth nerve, the trochlear, the superior oblique, and the sixth nerve, the abducens, the external rectus. Paralyses or spasms of the third nerve occur as a result of inflammation of the nerve, as a result of pressure from the products of neighboring inflammation — as in meningitis — from tumors, syphilitic and otherwise, and due to lesions at the origin of the nerve upon the floor of the aqueduct of Sylvius. In the latter case there is accompanying disturbance of the other motor nerves of the eye. Paralysis of this nerve occurs also in rheumatic conditions, secondary to the infectious diseases, especially diphtheria, after exposure to cold, in hysteric conditions and in locomotor ataxia. Its symp- toms are ptosis, pupillary dilatation and entire loss of accommodation, double vision and divergent strabismus. Cycloplegia is a result of paralysis of the ciliary muscle and gives rise to loss of the power of accommodation. Objects at a distance are seen clearly while those nearby are indistinct. When in both eyes it is usually due to lesion at the origin of the nerve. It is seen early in diphtheritic paralysis and occurs also in locomotor ataxia. It may be corrected by glasses. Iridoplegia or paralysis of the iris occurs in locomotor ataxia, brain tumors, 780 DISEASES or THE NERVOUS SYSTEM. etc. In the accommodative form the pupil does not alter in size during accom- modation. In the reflex variety — the "Argyll-Robertson pupil" — the loss of accommodation to light may be tested by directing the patient to look at a distant object, then a bright light is suddenly flashed into the eye. If this affection is present the pupil will fail to contract. In skin iridoplegia the cutaneous reflex is lost and a reflex dilatation of the pupil takes place if the skin of the neck vi^hich is supplied by the cervical sympathetic nerve is irri- tated mechanically or electrically. The condition of anisocoria, unequal pupils, may be observed in health and also as a symptom of locomotor ataxia and paresis. Spasmodic contraction of the muscles supplied by the third nerve may occur in migraine, hysteria, meningitis, congenital and other cerebral lesions and in albinos. The spasm usually is in the form of a rhythmic movement of the eyeball from side to side — nystagmus — more rarely is the motion rotary or vertical. The fourth nerve, the trochlear, is subject to abnormal conditions analogous to those described above and under the same conditions. Paralysis of this structure is manifested by loss of power in the superior oblique muscle and consequent convergent strabismus. Here there is impairment of ability to move the eyeball downward and inward. This defect is frequently not noticeable. The head is inclined forward and toward the unaffected side and diplopia is present when the vision is directed downward. The sixth nerve, the abducens, may be paralyzed as a result of lesions similar to those affecting the third and fourth nerves. It produces internal strabismus since the only muscle supplied by it is the external rectus. The eyeball cannot be turned so as to look outward. Double vision may be present when the patient looks toward the paralyzed side. In affections of the nucleus of origin of this nerve, conjugate deviation of both eyes away from the side of the lesion, is observed due to the fact that the nucleus of the third nerve is connected with that of the sixth, consequently in lesions of the latter the internal rectus is paralyzed in associated movements, although the nucleus of the third nerve which supplies this muscle is not affected; there is no dis- turbance of the power of convergence. General paralysis of all the motor nerves of the eye or ophthalmoplegia may be caused by disease of the nuclei of origin of the third, fourth, and fifth nerves, by tumors and the pressure of inflammatory exudates, and may occur in general paresis, locomotor ataxia and progressive muscular atrophy. It occurs in two forms, ophthalmoplegia externa and ophthalmoplegia interna. The two types may co-exist — total ophthalmoplegia. In the external type the eyeball is immobile, ptosis is present and there may be slight exophthal- mos; with it there may be optic nerve atrophy and involvement of other cranial nerves. DISEASES OF THE FIFTH PAIR: THE TRIGEMINAL NERVES. 78 1 In the internal type power of accommodation and pupillary reaction are lost. Ophthalmoplegia is usually a chronic condition but rarely an acute form is observed, the onset of which may be rapid; accompanying this type are cerebral disturbance and haemorrhagic degeneration of the nuclei of origin of the motor nerves of the eyeball. Treatment of the ocular palsies. This, to a great extent, depends upon the cause. In acute cases the pain may be relieved by hot compresses, mild counterirritation and the application of leeches to the temples. Syphilitic cases and those occurring in the course of locomotor ataxia should receive mercury and potassium iodide in large doses. Strychnine, hypodermatically in considerable doses, -g-^ to -^V of a grain (0.002-0.003), arsenic and iron are also useful; the three may be given in combination. In the chronic type the use of electricity is recommended. If galvanism is employed the anode is applied to the forehead and the cathode is moved along the margin of the orbit over the affected muscles; if the faradic current is used the cathode is not moved. For the ptosis the current is applied over the third nerve. Double vision may be relieved by the use of prisms, or if it is impossible of correction, both it and the dizziness may be obviated by wearing an opaque glass over the affected eye. DISEASES OF THE FIFTH PAIR: THE TRIGEMINAL NERVES. Lesions of the fifth nerve result from disease of the pons, especially haemor- rhage or sclerosis; injiury or disease at the base of the cranium, such as bone caries, meningitis, syphilitic or other new growths; pressure upon the branches of the nerve from tumors or aneiu"ysms in the cavernous sinus or from lesions in the spheno-maxillary fossa. Primary inflammation of the nerve is rare. Sensory symptoms may be caused by hysteria and disturbances of taste by the influence of disturbances of the facial nerve upon the chorda tympani. Motor disturbances. These consist of paralysis and spasm. The former involves the temporal, masseter and pterygoid muscles and is characterized by difl&culty in mastication; if both sides are involved this act is impossible and the lower jaw hangs down. If only one side is affected the jaw is displaced toward the affected side when open. Spasm occiurs with muscular cramp, in tetanus (lockjaw or trismus), in tetany, and meningitis. It is seen also in hysteria and as a restdt of diseases of the mouth, jaw or teeth. The jaws are tightly shut and the contraction of the muscles of chewing may be painful. Clonic spasm (chattering teeth) may occvir in chorea, hysteria and without assignable cause. Disturbances 0} taste resulting from lesions of the fifth nerve consist in the partial or complete loss of this sense over the anterior two-thirds of the tongue 782 DISEASES OF THE NERVOUS SYSTEM. as stated by some, although it would seem from the fact that many trigeminal neurectomies do not result in gustatory disturbance that the nerve fibres from this part of the tongue may reach the brain by more than one route. Sensory disorders are characterized by loss of sensation of half the face, conjunctiva, cornea, mucous membrane of the lips, tongue, hard palate and nose of the same side. Smell is rendered less acute as a result of drying of the nasal mucous membrane; taste may be disturbed. Painful tingling may precede the anaesthesia. Trophic disturbances occur such as diminution of the saliva, the lachrymal, buccal and nasal secretions and the teeth may become loose. Herpes with pain may develop over the course of the nerve and there may be facial oedema. The diagnosis is simple. Taste may be tested by touching the tongue on either side with a weak acid solution and comparing the effect, motility by directing the patient to bite a piece of soft wood, and sensation by the usual methods. Treatment should be directed to the removal of the causative factor. Syphil- itic cases should receive appropriate treatment. The teeth should be put in proper order, nasal and aural examinations should be made and any existing abnormality corrected. Anaesthetic parts shoiild be protected against injury and irritation. The pain may be relieved by the means described under the section on the treatment of neuritis (p. 769) and the local applications there mentioned are also useful. Morphine should be employed as a last resort only. The use of the faradic current and of massage is indicated in order to restore the muscular tone, and attention should be given to the general health of the patient. DISEASES OF THE SEVENTH PAIR: THE FACIAL NERVES. Disease of the facial nerve may result in paralysis or spasm. Paralysis (Bell's palsy, monoplegia facialis or mimetic facial paralysis) may be caused by lesions in the cortex, in the brain between the cortex and the nucleus of origin of the nerve, in this nucleus and in the nerve itself. The cortial lesions occur with hemiplegia due to cerebral haemorrhage, inflam- mations and tumors; those of the nucleus result from like causes and from the toxins of infectious diseases, especially diphtheria, and lesions of the nerve itself may be caused by exposure, extension of middle ear or temporal bone disease, new growths, injury at the base of the brain, meningitis or syphilitic infiltration in the same situation. The nerve may be affected in lesions of the medulla oblongata, and as a result of traumatism during birth. Symptoms. These differ with the site of the lesion causing the paralysis. The onset of the condition is usually sudden but at times prodromal symp- toms such as disorders of taste, facial and aural pain and tinnitus, are noticed. DISEASES OF THE SEVENTH PAIR: THE FACIAL NERVES. 783 As a rule the paralysis is one-sided, rarely is it bilateral. The face is drawn toward the sound side, except after contracture, in cases of long standing. The affected side of the face is immobile and smooth, the forehead loses its wrinkles, the power of facial expression is lost, the eye remains open even during sleep, the corner of the mouth drops and there is dribbling of saliva, whistling is impossible and the labials are pronounced with difl&culty; the tongue is not deviated and during mastication the food collects in the paralyzed cheek. The corneal reflexes are lost, the eye waters and conjunctivitis is frequently observed. Winking is impossible if the paralysis is complete. Drinking is difl&cult on account of the inability of the patient to approximate his lips to the glass. In lesions of the nerve between its union with the chorda tympani and the geniculate ganglion, taste is lost in the anterior two-thirds of the tongue on the affected side. The saliva is diminished and the tactile sense of the tongue may be impaired. Auditory disturbance may occur due to concurrent aural lesions but the hearing, especially for low notes, may be rendered more acute by paralysis of the stapedius muscle. Herpes may be present. The electric reaction in mild cases may remain normal in the paralyzed muscles, and here recovery within a few weeks is usual. In more severe cases the electric reaction in the nerves is diminished while in the nerves, after a few weeks, the reaction to direct galvanic stimulation is increased, the anodal closure contraction exceeding the cathodal, and the response to stimulation is delayed. Here recovery is less rapid but is likely to be complete in a month or two. In very marked cases complete reaction of degeneration is present, the course of the disease is much more protracted and may last for a year or more. Relapses may occur. When brain tumor or necrosis of the petrous portion of the temporal bone are aetiological factors the paralysis may be permanent. Treatment should be directed at the cause of the condition. In syphilitic cases the administration of the iodides in gradually increasing doses is indi- cated. If the paralysis is due to lesions of the middle ear these should receive appropriate treatment. When pressure is responsible its cause should be removed if possible. When the disease is the result of exposure the salicylates in large doses should be given and warm compresses, wet or dry, should be applied to the face; later counterirritation by means of the thermo-cautery or vesicants is useful. The hypodermatic exhibition of strychnine sulphate in doses of 3^ to 2V of a grain (0.002-0.003) daily or every two days may prove useful and salicin, 20 to 30 grains (1.3-2.0) three times a day or sodium salicylate in similar dosage may be prescribed with benefit. In the later stages electricity should be employed; galvanism is to be preferred; the current should not be strong and it may be applied over the affected muscles and also administered by placing the poles alternately below and in front of the ear. 784 DISEASES OF THE NERVOUS SYSTEM. and interrupting the current about every fifteen or twenty seconds. Massage of the facial muscles may also be employed. Nerve anastomosis is indicated in cases in which the continuity of the nerve has been destroyed by injury or by disease, after electricity has been faithfully used for several months without sign of return of function. The anastomosis is made with the hypoglossal or the spinal accessory nerve and while complete recovery may not take place, the operation is likely to restore the power of the affected muscles to a considerable extent and to greatly mitigate the deformity. Spasm. Facial spasm, mimic spasm or convulsive tic may be unilateral or bilateral and consists of a clonic contraction of one or more of the muscles innervated by the seventh nerve. Habit spasm is an analogous affection, occurring usually in children as a result of "making faces." The cause is indefinite, but the condition has been considered as due to exposure, to pressure at the base of the brain from tumor or aneiu^ysm or to a lesion of the facial center in the cerebral cortex. Reflex cases also occur, due to decayed teeth, intestinal worms or sexual disorders. The condition usually involves only one or two branches of the nerve, especially those supply- ing the orbicularis muscle (blepharospasm) and the neighboring muscles. Here there is twitching of the eyelid often with accompanying spasm of the muscles of the side of the face. The angle of the mouth may be twitched downward and the contractions may also involve the muscles of mastication, the tongue and the platysma. The spasms occur spontaneously, are not painful, and last for shorter or longer periods. They may be so continuous that, while the patient is awake, his face exhibits constant twitchings. The contractions are increased by physical or mental fatigue and by undue emotion. Pressure over various points along the course of the nerve may elicit pain. A tonic form of the disorder may occur with paralysis or from cold or, more often reflexly, from some disturbance of the eye. The prognosis of facial spasm is not favorable although intermissions may be observed. Treatment consists in removing all possible causes of reflex irritation, especially in the eyes and teeth. Counterirritation may be applied along the course of the nerve and especially over the points which are tender upon pressure. Here the Paquelin cautery and vesicants may be useful. Freez- ing of the affected cheek with the ethyl chloride, rhigolene or aether spray for a few moments daily may prove beneficial, temporarily at least. Hypo- dermatic injections of strychnine have been recommended and such drugs as potassium iodide, arsenic, iron, atropine and curare may be employed but it is doubtful if they will cause improvement. Nerve sedatives, the bromides, hyoscyamus or codeine may be given. Electricity in the form of galvanism may be employed, the anode being DISEASES OF THE EIGHTH PAIR: THE AUDITORY NERVES. 785 placed over the tender points or along the nerve trunk. Reflex cases may be benefited by applying the positive pole to the nuchal region while the nega- tive pole is held in the hand. Surgical interference consisting of division of the nerve and making an anastomosis between it and the eleventh nerve, has been advocated. Nerve stretching may afford relief although this may be but transient, the spasm recurring when the paralytic effect of the stretching has passed. DISEASES OF THE EIGHTH PAIR: THE AUDITORY NERVES. Affections of the eighth nerve may result from lesions in any part of its course. Disease at its nucleus of origin is rare; in its course it is subject to involvement in fractures, tumors, inflammations or haemorrhages and in- flammation of the nerve itself occurs as a complication of the infectious diseases, locomotor ataxia and cerebrospinal meningitis. The two branches of the nerve should be considered separately since the cochlear is concerned in audition and the vestibvflar in coordination. The Cochlear Nerve. Lesions such as tumor at the cortical auditory center in the temporo-sphenoidal lobe, when on the left side, cause word deafness; those involving the course of the cochlear nerve from the auditory center to its origin result in true deafness. Pressure upon the nerve at the base of the brain from tumors, aneurysms, inflammatory exudates, haemorrhage, or injuries, and degeneration of the nerve such as occurs in locomotor ataxia, may produce lesions of the nerve in its course. Deafness also may be caused by the effects of epidemic cerebrospinal meningitis upon the nerve. Affections of the internal ear, primary or as a result of middle ear lesions, are the most frequent causes of disorders of the auditory nerve. The symptoms produced by lesions of the cochlear branch are a, auditory hyperassthesia; h, irritation of the auditory nerve; c, nervous deafness. Auditory hyperesthesia (hyperacusis) is a condition in which sounds inaud- ible to the normal individual become audible and ordinary sounds are heard with an increased intensity. Dysasthesia (dysacusis) is a condition charac- terized by discomfort upon hearing ordinary sounds, as in headache when a sound, such as would have no effect under normal conditions, increases the pain. These affections may occur in hysterical conditions and in cere- bral disease. Treatment should be directed at the cause of the condition and the unpleasant symptoms may be controlled by sedatives such as the bromides and valerian. Auditory Irritation (tinnitus aurium). Under the general term tinnitus are classified all forms of abnormal subjective sensation to which the ear is subject, including ringing, buzzing, hissing, roaring sounds, etc. Even 50 JQO DISEASES OF THE NERVOUS SYSTEM. the sound of voices may be heard. The sounds vary from those hardly noticeable to those that cause profound discomfort. Bruits may be heard synchronous with the cardiac systole and may be audible through the stetho- scope applied behind the ear, clicking sounds, at times perceptible to the patient's companions may be caused by spasm of the palate muscles. The auditory aura, occurring sometimes in epilepsy, is a form of this trouble. The mfsery induced by such conditions has been known to result in suicide. The aetiology may be diiScult to discover. The ear should always be examined for accumulations of cerumen and for middle ear disease. Gouty, anaemic and neurasthenic conditions are often responsible for tinnitus, as is the administration of quinine and salicylic acid in large doses. Treatment consists in measures calculated to relieve any existing aural lesion, such as the removal of impacted cerumen, the exhibition of the salic- ylates, the iodides and colchicium in rheumatic and gouty cases and of iron and arsenic when anaemia seems responsible. Neurasthenia should receive appropriate treatment and the patient's nutrition and general hygiene should be considered. The application of vesicants or even of the actual cautery behind the ear, and the bromides, either alone or in connection with small doses of belladonna are said to be useful. Glyceryl nitrate in ascending doses until the physiolog- ical effect, as evidenced by feeling of fulness in the head and dizziness is noted, is also recommended. Nervous deafness is evidenced by diminution of the ability to hear sounds when conducted by the air, while sounds conducted through the temporal bone are audible. The test consists in holding the tuning fork near the ear, then placing it in contact with the temporal bone. If it is not heard in the latter case the loss of the power of hearing is not due to nerve deafness. Treatment is likely to be of little avail. The otologist should be consulted and a careful examination of the organ made, and the management of the condition belongs rather to the domain of the specialist than to that of the physician. Antisyphilitic treatment should be given when indicated and electricity and mild counter irritation have a field of usefulness. The Vestibular Nerve. Disturbances of this structure are evidenced by vertigo, nystagmus and disorders in the function of coordination in the head, neck, and eyes. Meniere's disease or aural vertigo is a condition resulting from a lesion of the lab}T:inth. Its pathology is indefinite; it occurs much more frequently in m.en than in women and is most often observed between the ages of thirty and sixty years. Exposure, syphilis and gout have been considered setiological factors and the degeneration occurring in such affections as locomotor ataxia and that of senility, as well as vaso-motor disturbances of the lab)Tinthine vessels, seem to have influence in its causation. THE GLOSSOPHARYNGEAL NERVES. 707 Symptoms. The onset of a paroxysm is usually sudden and may occur without assignable cause or be induced by coughing or sneezing. Between the attacks the patient may suffer from slight dizziness. The paroxysm is characterized by sudden buzzing noises in the ears and marked vertigo, in which the patient feels as if he were staggering or falling, the surrounding objects may seem to be turning about and he may grasp at stationary objects to prevent himself from falling or may lose consciousness for a few seconds. After a moment or two the dizziness passes, the patient being left faint, pale and nauseated with the face bathed in clammy perspiration. Aural symptoms such as tinnitus and deafness in one or both ears may occur and double vision or nystagmus may be coincident. The deafness is never complete, is of nervous type and the tinnitus is throbbing or roaring in character. The paroxysms appear at intervals varying from a few days to a few weeks or even months. The prognosis depends upon the cause. If this can be eliminated recovery is possible and at any rate improvement may be expected. In less favorable cases deafness results, which when complete is unaccompanied by dizziness. The disease should not be confounded with epidemic paralytic vertigo (Gerlier's disease or kubisagari) — see p. 207 — or with gastric vertigo, which is not accompanied with deafness. Treatment consists in relieving the cause of the condition in so far as pos- sible. The eyes should always be examined for errors of refraction, correction of which may afford relief. Gouty patients should receive the salicylates, colchi- cum and the iodides; the first of these should not be given in sufficient dosage to induce tinnitus. Syphilitic cases should receive appropriate medication. When contraction of the general arterial system is present glyceryl nitrate or potassium iodide is indicated. Potassium bromide in doses of 15 to 30 grains (1.0-2.0) three times a day may be employed and Charcot has recommended the administration of quinine beginning with moderate doses and gradually in- creasing them until cinchonism is produced. Counterirritation behind the ears in the form of blisters may prove temporar- ily beneficial. DISEASES OF THE NINTH PAIR: THE GLOSSOPHARYNGEAL NERVES. Branches from this pair of nerves supply sensory fibres to the upper part of the pharynx, the tonsils and soft palate, innervate the stylophar- yngeus and middle constrictor of the pharynx and send taste fibres to the palate and posterior third of the tongue. Lesions of the glossopharyngeal nerve result from tumors, meningitis and 788 DISEASES OF THE NERVOUS SYSTEM. degenerative processes; the nerve is seldom affected separately because of its communications with others of the cranial nerves. The symptoms of disturbance of the functions of this nerve are ansesthesia of the parts supplied by its sensory fibres, paralysis of the stylophar^'ngeus and middle pharv^ngeal constrictor, as evidenced by difiiculty in swallowing, and gustatory disorders of the posterior third of the tongue and the palate. Loss of taste sense — ageusia — results from disorder of the end organs in the mucous membrane of the tongue caused by the habitual use of strong con- diments such as pepper or of irritating substances such as tobacco; it also occurs in the dr}^ tongue of febrile disease and the coated tongue observed in alimentar}^ disturbances. Ageusia is a symptom of affections of the lingual branch of the fifth nerve, of the trunk of the fifth before it leaves the skull, of the seventh nerve between its union with the chorda tympani and the gen- iculate ganglion, and of certain cerebral lesions. Perversion of taste sense (parageusia) is met but rarely and then as a symptom of hysteria or insanity. Subjective sensations of taste also occur in the insane and as an epileptic aura. The sense of taste is tested by causing the patient to close his eyes and applying such substances as quinine, sugar solution, salt solution and vinegar to the anterior and posterior parts of the tongue. A feeble galvanic current gives a metallic taste and is a useful test. It is important that the test should be decided while the tongue is protruded. DISEASES OF THE TENTH PAIR: THE PNEUMOGASTRIC OR VAGUS NERVES. The extensive distribution of this pair of nerves renders them liable to a variety of disturbances. Their nuclei of origin in the floor of the fourth ven- tricle may be involved in bulbar palsy, they may be subjected to pressure in meningitis, syphilitic or other new growths, abscess, aneur^'sms or haemor- rhages. Their branches inside the skull are subject to pressure from var- ious intracranial lesions; extracranial branches are subject to traumatism, to pressure from inflammatory processes, tumors and aneurysm, and may be involved in true neuritis. The pharyngeal branches may be paralyzed in bulbar paralysis or in neuritis, especially that resulting from diphtheria. If but one side is affected the disturbance of swallowing is but slight; in involvement of both sides degluti- tion is attended with difficulty and liquids may regurgitate from the nostrils. Spasm of the muscles of deglutition occurs in hysteria and in true and pseudo- hydrophobia. The laryngeal branches. The laryngeal paralyses occurring in vagus lesions are of several tj-pes: Unilateral abductor paralysis is most frequently THE PNEtJMOGASTRIC OR VAGUS NERVES. 789 caused by aneurysm, particularly of the arch of the aorta, since the recurrent laryngeal nerve of the left side passes around this structure. The nerve of the right side may be pressed upon by pleural thickenings. In this condition the voice is hoarse or brassy and there may be slight dys- pnoea. The paralyzed cord is seen immovable near the mid-line of the larynx. Bilateral abductor paralysis is met in bulbar paralysis and locomotor ataxia, in hysteria, as a result of intralaryngeal inflammations and degenerations, as well as of pressure upon both recurrent laryngeal nerves. The symptoms are inspiratory stridor and dyspnoea. The voice is unaffected and cough is absent. The dyspnoea is due to the close approximation of the vocal cords during inspiration and may necessitate intubation or tracheotomy. Laryn- goscopic examination reveals the vocal cords in close proximity to one another. Adductor, phonic or hysterical paralysis is seen in hysteria, in catarrhal laryngitis and as a result of over-use of the voice and is an affection of the crico-arytenoid and arytenoid muscles themselves. Examination reveals an inability to approximate the vocal cords on attempt at phonation. The table given below (Gowers) will be found useful in differentiating the various types of laryngeal paralysis. SYMPTOMS. SIGNS. LESION. No voice; no cough; stridor \ Both cords moderately ab- only on deep inspiration. ducted and motionless. Total bilateral palsy. Voice low-pitched and hoarse; no cough; stridor absent or slight on deep breathing. One cord moderately ab- ducted and motionless, the other moving freely, and even beyond the middle line in phonation. Total unilateral palsy. Voice little changed; cough normal; inspiration difficult and long, with loud stridor. Both cords near together, and during inspiration not separated, but even drawm nearer together. Total abductor palsy. Symptoms inconclusive; little affection of voice or cough. One cord near the middle line not moving during inspiration, the other nor- mal. Unilateral abductor palsy. No voice; peifect cough; no stridor or dyspnoea. Cords normal in position and moving normally in respiration, but not brought together on an attempt at phonation. Adductor palsy. Spasm of the laryngeal muscles affects the adductors only; is seen in children as laryngismus stridulus and rarely in the adult; it is characterized by very 790 DISEASES OF THE NERVOUS SYSTEM. marked dyspnoea, so persistent at times as to cause cyanosis. The attacks usually come on at night. The laryngeal crisis of locomotor ataxia is a laryn- geal spasm. Spastic aphonia is a condition in which phonation is prevented by spasm. Laryngeal ancesthesia is met in bulbar paralysis, in the neuritis of diphtheria and in hysteria. It is important that it should be recognized since particles of food may block the trachea or be drawn into the lungs. Dysphagia is a common symptom of this affection. The cardiac branches. The nerve supply of the heart is derived from the vagus and sympathetic nerves. The vagus supplies motor, sensory and probably trophic fibres. The motor fibres of the vagus inhibit, control and regulate the action of the heart. Irritation of these has an inhibitory influence upon the cardiac rate which results in retardation of the pulse (bradycardia). Entire vagus paralysis results in loss of this inhibitory influence, consequently the cardiac accelerator action is uncontrolled and the heart rate becomes rapid (tachy- cardia). It is an interesting point that total paralysis of one pneumogastric may be without symptoms. Disorders of the motor functions of the vagus may result from the pressure of new growths, accidental ligation or injury of the nerve, neuritis or irritation at its nuclei of origin. Individuals are on record who seemed to have voluntary control over the heart's action, and it is possible in some instances to slow the pulse rate by pressure over the nerve in the neck. Sensory disorders of the vagus are rare and obscure, but the sensations accompanying palpitation, pain or irregularity are transmitted through this nerve. The theory that the vagus exercises a trophic influence is based upon the fact that fatty degeneration of the heart has occurred after injury to this structure. The gastric and CESophageal branches. The vagus sends motor and sensory fibres to the stomach. Through the former both central and reflex excitation cause vomiting. The peristalsis of the stomach is presided over by the vagus but that other influence is also at work here is evidenced by the fact that section of this nerve is not followed by the subsidence of all gastric motion. CEsophageal spasm and deglutition are controlled by these fibres. The sensory impulses conveyed through the pneumogastric nerve are believed to be those of hunger and thirst since these have been lost in lesions affecting its root; however, in some cases of disease of the nerve the appetite has remained normal or has been abnormally increased. The gastric crises of locomotor ataxia are the result of central irritation of the nuclei of origin of this nerve. The puhnonary branches. Of the function of these little is known. It THE SPINAL ACCESSORY NERVES. 79 1 is supposed that they supply the bronchial musculature and asthma has been considered a neurosis of these fibres. The changes in the rate of respiration are believed to be due rather to the respiratory center than to vagus in- fluence. Hiccough may result from lesion of this nerve. The course and prognosis of disorders of the pneumogastric nerve vary with the cause of the condition in question. In those due to central lesion or intrathoracic neoplasms or aneurysms it is not encouraging, while those resulting from local affections and hysteria may be favorably affected by proper treatment. Treatment depends altogether upon the aetiology of the condition under consideration. Central disease of syphilitic nature should be amenable to the influence of potassium iodide in ascending doses or to the S}Tupof hydriodic acid, one drachm (4.0) three times a day. Laryngeal paralyses due to recurrent nerve pressure from tumor or aneurysm are hopeless unless the tumor is specific in nature or removable by operation. In patients of rheu- matic tendency the possibility of this element in the causation of laryngeal muscular disorders must be considered. Here the salicylates, alkalies and iodides may prove beneficial. Wlien the affection is a part of a general neuritis the treatment is that of this condition (see p. 769). Paralyses of inflammatory origin should receive local treatment (see p. 769), in those due to hysteria the electric current is indicated and the daily hypo- dermatic administration of strychnine nitrate in doses of -g-^j- to -jV of a grain (0.001-0.003) is useftfl. Laryngeal exercises and massage performed by grasping the upper and back part of the thyroid cartilage between thumb and forefinger and phonating at the same time, may also be employed. \ The inhibitory fibres of the vagus may be stimulated in tachycardial states by digitalis and in bradycardia due to hyperirritation of the cardiodepressory apparatus atropine may be found usefiil. The general condition of the patient may require general hygienic and tonic treatment. DISEASES OF THE ELEVENTH PAIR : THE SPINAL ACCESSORY NERVES. Paralysis or spasm of this pair of nerves may occur as a result of involve- ment of their nuclei in bulbar paralysis; its external nuclei in the cervical region of the cord may be afl'ected in degenerative processes of the motor nuclei of the cord; within the cranium the nerve is subject to pressure from tumors and meningeal exudates, and outside the skull it is subject to injury and to in- volvement in tumors, vertebral necrosis and cervical abscesses. The internal or smaller division of this nerve joins the vagus and supplies through it the muscles of the larynx. Paralysis of this portion has been 792 DISEASES or THE NERVOUS SYSTEM. discussed under laryngeal paralyses. The external or spinal division inner- vates the sternomastoid and trapezius muscles. Paralysis of the external portion of the nerve is evidenced, when unilateral, by interference with the rotation of the head toward the sound side; torticollis is absent but the head may be held in an oblique position. The trapezius, receiving, as it does, innervation from other sources is only partially paral- yzed; that part, however, which extends from the acromion process to the occiput is useless and the middle portion of the muscle is weakened, conse- quently the shoulder is slightly lower than normal and is rotated inward by the unopposed action of the rhomboids and the levator anguli scapuli. In respiration and shrugging of the shoulders the disorder is plainly evidenced and there is imperfect ability to lift the arm since the trapezius fails to fix the scapula and to give the deltoid a point from which to work; atrophy and the reaction of degeneration are usual. Bilateral paralysis is evidenced by loss of power to hold the head upright. If the sternomastoids are involved the head is prone to faU backward; if the trapezii are affected it droops forward, a characteristic of progressive muccu- lar atrophy and also a symptom of meningitis in the neighborhood of the foramen magnum and of cervical meningitis following caries of the spine. Injury of the spinal accessory nerves during childbirth may cause a falling forward of the child's head lasting usually not beyond the first year. The treatment of these conditions should strike at the aetiological factor. If the disease is central the condition is hopeless. Pressure paralyses may be relieved by surgical or orthopaedic measures; this done the wasted muscles should be treated by massage and the electric current. Faradism is more effectual than galvanism. Accessory spasm, torticollis or wry neck is caused principally, although not entirely, by spasm of the muscles supplied by the eleventh nerve; two types are described. a. Congenital or Fixed Torticollis. This condition affects the right side more usually and may result from injury to the sternomastoid during labor or occur as a congenital developmental defect. Injury of the muscle followed by cicatricial contraction may produce a like condition later in life. The muscle is shortened, tense, firm and usually atrophic, and associated with the congenital type is an asymmetry of the face which may be, together with the wTy neck, the result of some central cause analogous to that producing talipes. The treatment of this condition is wholly surgical or orthopaedic, and often is quite satisfactory although the facial asymmetry sometimes persists or be- comes more marked. The operations applicable to the condition are those of section of the muscle or tenotomy. THE SPINAL ACCESSORY NERVES. 793 b. Spasmodic Torticollis. This affection occurs in both a tonic and a clonic form. Both varieties may occur in the same case or, what is more usual, the condition assumes at its outset one type and does not change. It is observed most often in adults and in America seems more frequent in males, although the opposite seems to be the case in England. Exposiu-e and trauma are factors in its aetiology; it may be due to hysteria and is prone to occur in individuals of neurotic heredity. The tonic type is evidenced by approximation of the occiput to the shoulder on the affected side, elevation of the chin and turning of the face toward the sound side. This position is due to contraction of the sternomastoid. Involve- ment of the trapezius draws the occiput still further downward and toward the side affected. The affected muscles are tense and prominent and their continued rigidity may produce, in long-standing cases, a spinal curvature (scoliosis) with its convexity toward the unaffected side. Involvement of the scaleni and the platysma and rarely of some of the deep muscles of the neck may co-exist. Bilateral spasm (retrocoUic spasm) draws the head backward, even so far that the face is directed upward in marked cases. In the clonic form attacks of twitching of the head, sometimes of severe type, may appear without previous symptoms or they may be preceded by pain or stiffness. In unilateral spasm of the sternomastoid each contraction turns the head toward the unaffected side and raises the chin; when the trapezius is involved the head is drawn back and toward the shoulder of the same side. In bilateral spasm of both sides there is paroxysmal retrocollic spasm at times combined with nodding movements; the movements may occur every moment or two and the head cannot be kept still. Enlargement of the muscles induced by their continued exercise results. Other muscles of the neck may be affected and at times even those of the arms. During sleep the contractions cease; after fatigue, excitement or emotion they are accentuated. Pain may accom- pany the spasms. The condition is an obstinate one. Treatment may have little effect and, at best, recurrences are frequent. Treatment consists in the removal of the cause of the condition if this can be ascertained. Acute attacks necessitate confinement to bed and the appli- cation of heat, moist or dry. Large doses of the bromides may lessen the spasms and other sedatives may be employed. The fluidextract of cannabis indica in increasing doses has been given but little benefit is to be expected from its use. Morphine hypodermatically will relax the spasm but the danger of producing the habit should never be forgotten. Recoveries have been reported due to this drug given for several months in doses increased to i grain (0.065) daily but it is likely that when the patient is cured of his spasm that the physician wiU have induced the morphine habit and will then have this condition to deal with. 794 DISEASES OF THE NERVOUS SYSTEM. The hypodermatic injection of atropine into the muscles involved has been advocated. Electricity may prove beneficial. Both galvanism and faradism may be employed; if the former, the ciirrent should be weak, the positive pole being applied to the occipital insertions of the sternomastoid and trapezius, and the negative to each affected muscle in turn for ten or fifteen minutes. Farad- ism should be applied by brushing the involved muscles, the current being gradually increased in strength. Surgical treatment consisting of stretching, section, or excision of the nerve, may give temporary relief and the more radical procedure of dividing the spinal accessory nerve together with resection of the posterior branches of the upper two or three cervical nerves may diminish the spasm. DISEASES OF THE TWELFTH PAIR: THE HYPOGLOSSAL NERVES. Paralysis of this, the motor nerve of the tongue and of the depressors of the hyoid bone and of the hyoglossus and geniohyoid muscles, takes place in cortical lesions such as apoplexy, cerebral compression, thrombosis, embolism and softening, and in nuclear and injranuclear disease. In the latter lesions the disturbance of the h}-poglossal nerve results rather from slow degener- ation such as usually occurs in bulbar paralysis and locomotor ataxia, than from acute softening. Tumors, basilar meningitis, and lesions of the cranial bones may involve the nerve, and outside the skuU it is subject to injury, involvement in a cicatrix and pressure by tumors. Neuritis of the twelfth nerve may occur as part of a polyneuritis. Paralysis of the hypoglossal nerve is characterized by loss of motility of the tongue. In unilateral paralysis only half the organ is involved and it is protruded toward the affected side; in bilateral palsy the organ remains without motion in the floor of the mouth; speech is diflacult, mastication and swallowing are interfered with. There is partial or complete atrophy of the tongue as the case may be and its mucous membrane is thrown into folds. In disease above the nuclei the atrophy is absent and the electrical reaction remains normal. If the causative lesion is below the nuclei there may be fibrillary twitching and the reaction of degeneration is present. Spasm is rare unaccompanied by other manifestations and may be unilateral or bilateral. Usually it is associated with some other convulsive disttu-bance such as chorea, epilepsy or spasm of the muscles of the face; in some instances of stammering, spasm of the tongue precedes the utterance of the words; it may be obser^'ed in hysteria or result from irritation of the fifth nerve. It is more often bilateral and may occur paroxysmally; in severe cases the FUNCTIONAL DISEASES OE THE NERVOUS SYSTEM. 795 tongue may be quickly thrust in and out many times a minute and this may persist diu-ing sleep. Treatment should be directed at the causative lesion and should this prove incurable, the condition is likely to prove permanent. In paralysis, electricity may be employed, the electrode applied to the tongue being in the form of a tongue depressor. Electricity may be used in spasm also and here good results may attend the administration of the bromides and other sedatives. Potassium iodide is also recommended. FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM. ACUTE CHOREA. Synonyms. Sydenham's Chorea; Chorea Minor; St. Vitus' Dance. Definition. A disease characterized by irregular involuntary contractions of the muscles, sometimes accompanied by mental disorder and frequently associated with endocarditis and rheumatism. It is most often seen in children. -Etiology. Chorea occurs chiefly between the ages of five and fifteen and seems to aft'ect females more often than males. It is more common in the lower walks of life and heredity may have some influence in its causation. It is rare in negroes and has never been observed among the American aborigenes. The nervous temperament is a predisposing cause; emotional excitement, fright and grief, as well as over-study, may excite the disease. Imitation is considered, at present, to have little influence as an astiologic factor, and the same is true of reflex irritation, digestive and otherwise, as well as of evr- strain. Chorea has been considered closely associated with acute articular rheu- matism by English and French authorities for many years, German observers however, do not regard their connection as so intimate. The chorea may succeed the joint manifestations after considerable periods of time, while in other cases the arthritis may be closely followed or be accompanied by this disease. It is probable that the joint symptoms are often overlooked, since rheumatism in children may be manifested by any slight swelling of a single joint or by vague pains. "WTiile the so-called growing pains of children may be rheumatic in character it is well to keep in mind the fact that this is not always the case. Endocarditis has been held to be a cause of the disease and is often asso- ciated with it. Chorea has foUowed the acute infectious diseases, such as pyaemia, gonorrhceal and syphilitic constitutional infection, puerperal septic- aemia, diphtheria, scarlatina, measles, tA'phoid fever, etc., but it is probable that 796 DISEASES or THE XERVOUS SYSTEM. the relationship between chorea and these affections is not close. Anaemia may act as a predisposing cause and often results from this disease and it may occur during pregnancy. Poisoning by iodoform, carbon dioxide and other substances have seemed to cause short attacks. Pathology. There are no definitely recognized post mortem changes characteristic of chorea; the numerous lesions which have been found are due to comphcations or are coincident. The accepted theon^ of the disease is that it is a functional affection of the nerve centers presiding over the motor apparatus. Associated vdth chorea have been found endocarditis in a large majority of cases, pericarditis and other miscellaneous diseases. The embolic theor}' of chorea based upon the finding of emboli in the cere- bral vessels, will not account for all cases; for while such lesions have been made out in a number of instances, there are others in which such lesions were wholly absent even when distinct endocarditis existed. With regard to the consideration of chorea as an infectious disease nothing has as yet been definitely proven. Symptoms. The onset of the disease is usuahy gradual, the first manifes- tations being those of excessive nervousness, with restlessness and mental irritability. The condition occurs in three t}-pes which diff'er mainly in degree. a. The mild variety with only slight involvement of the muscles and only slight disorder of speech and general health. h. The severe form with generalized choreic movements, inability to talk and to perform the or dinar}' duties of life. c. The maniacal t}-pe. After the restlessness and irritability, the motor s}Tnptoms are first to appear. These usually involve the upper extremities, later the face and still later the legs, although rarely the legs may be first affected or the movements may be general from the outset. The patient drops objects and is unable to dress or feed himself, the gait is disturbed and there may be spasms of the facial muscles. The spasmodic movements may finally extend to all parts of the body or be limited to one side (hemichorea), they are irregular, jerking, arrh}i:hmical and voxy from an almost unnoticeable contraction of the muscles to constant twitchings. They are wholly involuntary and efforts at control often increase them. They are augmented by fatigue or excitement but seldom persist during sleep. Speech is involved in many cases and the disturbance of this function varies from mere hesitance to entire incoherence. Muscular weakness appears as the disease progresses and in consequence the patient's gait may be limping and his ,grip weakened. Sensor}' manifestations are not marked although there may be pain and tenderness in the limbs. Pain may be elicited by pressure over the points of ACUTE CHOREA. 797 emergence of the spinal nerves and sensations of numbness or tingling may- occur. The reflexes remain normal usually but may be exaggerated or lost. Trophic manifestations are very seldom observed. Mental symptoms are, as a rule, not marked but melancholic states and hallucinations may occur. Chorea insaniens may develop from the milder types and is most common in women. Heart symptoms are very common and this organ should be most closely watched in all cases. Irregularity of the cardiac pulsations and particularly increased rapidity of its action are ver}^ common and in cases associated with anaemia, the haemic murmur, a soft systolic at the base or apex, is very frequently audible. True endocarditis in chorea is seldom evidenced by symptoms, but frequent physical examination of the heart in a great majority of cases will reveal the presence of organic cardiac lesion. Any of the valves may be attacked but those of the left heart are by far the most likely to be affected. The endocar- ditis is of the simple verrucous type as a rule and is likely in many cases to result, in after years, in permanent valvular disorder. Pericarditis not infre- quently complicates chorea, especially rheumatic cases. Rise of temperature in chorea is usually due to complicating conditions except in the maniacal type when a febrile movement even as high as 104° F. (40° C.) may occur. At times the surface temperature of the affected side in unilateral chorea may be slightly elevated. Skin affections are sometimes seen and are often due to the continued admin- istration of arsenic. This drug causes spots of pigmentation,. herpetic, papil- lar\^ and er}^thematous eruptions. Other cutaneous manifestations observed in chorea are usually rheumatic in character such as erythema nodosum, purpuric urticaria or the peliosis rheumatica of Schonlein. Sometimes the excessive motion may abrade the skin in exposed localities. The prognosis as regards recovery in chorea, except in the maniacal type, which is usually fatal, is good, two to three months being the usual duration of an ordinary case; recurrences are frequent, however, and while the com- plications involving the heart may not result in permanent affection of this organ, they are only too likely to become chronic and distressing. Cases of chorea in which the duration of the disease is unusually protracted should be examined for causes of peripheral irritation. The chorea of preg- nancy is of severe t}^e. Treatment. The prophylaxis of chorea is important and consists in care- fully watching all unusually bright children, especially if of neurotic heredity, and preventing any over-study or other mental over-activity. Competitions for school prizes should be heartily discouraged. The general hygienic treatment of this disease consists of removal from school and seclusion from all excitement. The patient should not be reproved 79^ DISEASES OF THE NERVOUS SYSTEM, or ridiculed because of his movements and his small faults and wrong doings should be condoned. In the milder cases the patient need not be confined to bed but in those of severer t^-pe it is best to advise this measure. When pos- sible a trained nurse should be procured and the patient should be separated as far as possible from exciting and disturbing influences. Oftentimes it is better to keep the child from his parents and relatives since sympathy and indulgence accentuate the condition. Patients who have done poorly at home often begin to improve at once in a hospital where they are properly restrained and encouraged toward self-control. The importance of rest in bed is par- ticularly to be emphasized in cases in which there is any suggestion of a heart lesion. Here massage and warm bathing are of great benefit. In mild cases which are allowed to be up, gymnastics may be employed but only in moderation and under intelligent supervision. In the severe cases they may do positive harm. Cold sponging is also of benefit in the mild type of the disease. The drug which seems to affect chorea most favorably is arsenic; it probably has no specific action, its beneficial effect being due to its improving influ- ence upon the general condition. Liquor potassii arsenitis (Fowler's solution) is the preparation to be preferred. Often it seems to fail because of insuffi- cient dosage. The beginning dose for a child of eight to ten years is from four to five drops (0.26-0.33) three times a day and increased by one drop (0.065) daily until the physiological effect is manifest as evidenced by disturbance of the alimentary tract and oedema under the eyes. When this occurs the drug should be stopped, to be resumed after several days in the same dosage as when left off and continually increased until from fifteen to twenty-five drops (1.0-T.66) are taken at each dose. The solution should be given after meals and weU diluted. When the movements cease the drug should be stopped. Arsenical poisoning seldom occurs but in very rare cases a neuritis has been induced. In rheumatic cases, where other drugs have no influence, sodium salicylate in fiill dosage should be administered and may effect permanent cure. Opium or morphine should not be employed, exceptions in cases marked by insomnia and restlessness; the bromides are useful and in very severe and obstinate cases hydrated chloral may be given. In mild cases good results have followed the administration of an infusion of cimicifuga racemosa (black snakeroot) in doses of i or 2 ounces (30.0- 60.0) two or three times a day. The zinc salts, silver nitrate and copper sulphate are little used at present. The use of hyocsyamine hydrobromide given hypodermatically in doses of yrir of ^ grain (0.0006) three times a day has been recommended and hyoscyamus may be given in combination with zinc valerate as in the following formula: I^ zinci valeratis, extract! hyoscyami, bismuthi subnitratis aa gr. xv (i.o). Massa fiat et divide in pilulas CHOREIFORM AFFECTIONS. 799 no. XXV. Sig., three to six pills daily. Antipyrine may succeed in certain cases where other means fail and may be given in doses of from 7 to 10 grains (0.5-0.66) three times a day to a child of eight years. Strychnine may be useful in certain cases and from y-^-g- to -gV of a grain (0.0006-0.001) may be given three times a day. Aspirin is advocated in severe and persistent cases and should be particularly effective in those in which the rheumatic element is present. In children over seven the beginning dose is 10 grains (0.66) twice a day increased to 10 or 15 grains (0.66-1.0) four times a day. This drug may cause gastric irritation and tinnitus. Cerebrin is another drug which has been recently recommended. Very severe and otherwise uncontrollable movements may necessitate the intermittent administration of chloroform. For the anaemia which frequently is co-existent with chorea, iron should be given either in the form of the Blaud pill (pilula ferri carbonatis) one or two, three times a day, in mixture such as the following: I^ ferri citratis, 5ii (8.0); syrupi, oiv (16.0); aqu£e aurantii florum, giss (48.0). Misce et signa, one tea- spoonful (4.0) three times a day, or in the form of iron vitellin. The iron may often be advantageously combined with arsenic. Electricity may prove beneficial on account of its tonic effect. The eyes and nose should always be thoroughly examined for sources of reflex irritation and when present these should be corrected. The possibility of the presence of intestinal parasites should also be considered. The general nutrition should receive particular attention, the food should be easily digestible and nourishing; tea and coffee should be prohibited. The bowels should be kept open. Cases which go on for considerable periods resisting all forms of treatment often are greatly benefited by change of air and surroundings. The chorea of pregnancy should be treated by insisting upon rest and quiet, nutritious food and good nursing. As sedatives hydrated chloral and chloralamide are to be preferred to opium or the bromides and the arsenic prescribed should be combined with alcohol, the latter drug being, in the opinion of certain observers, the more important of the two. It is seldom necessary to induce labor on account of the severity of the chorea and spontan- eous abortion as a result of the affection is not very frequent. Chorea due to sepsis, puerperal or otherwise, has been successfully treated by intravenous injections of collargol. Two to five drachms (8.0-20.0) of a 2 percent, solution may be injected into one of the superficial veins of the arms. CHOREIFORM AFFECTIONS. These occur in several forms and may be described as convulsive contrac- tures. They are often spoken of as "tics" or "habit spasms." 8oO DISEASES OF THE NERVOUS SYSTEM. CONVULSIVE TIC. Synonyms. Habit Spasm; Habit Ciiorea. This condition is most often seen in children, girls particularly, from seven to fourteen years of age. The spasm usually affects the facial muscles, either a single one or a group. The milder types consist of rapid opening and shutting of the eyes, drawing the mouth to one side, jerking or shaking the head while the eye is winked at the same time, shrugging one shoulder or sniffing. The leg muscles are more rarely involved although the "string-half, tic in which one leg is suddenly lifted at intervals, may occur. These affections are rarely permanent although at times they may persist through life. They usually disappear gradually in a few months. Treatment consists in the removal of any cause of irritation. The eyes and nose should be examined, decayed teeth drawn, etc. General tonics and nerve sedatives are indicated. Otherwise the treatment is identical with that of spasm of the facial nerve (p. 784). IMPULSIVE TIC. Synonym. Gilles de la Tourette's Disease. This affection occiirs chiefly in children of neurotic heredity. More rarely it develops after the age of puberty. It is probably best considered as a psychosis akin to hysteria and is characterized by involuntary movements involving the muscles of the face or arms. In marked cases the spasms may be general. The particular characteristic of this affection is the tendency to the explosive utterance of words or sounds simultaneously with the movements. A sound heard may be repeated numberless times (echolalia) or the patient may repeat blasphemous or obscene words (coprolalia) to the great distress of his family and friends. Actions may be imitated (echo kinesis). There may be mental disorder characterized by fixed ideas; for instance the patient may repeat time after time names which he hears (onomatomania) or before performing a certain act may count a certain number of times (arithmomania). Another mani- festation is the fear of contact with certain objects (delire du toucher), still another is to require a reason for the most ordinary acts (Jolie pourquoi). Any of these symptoms may occur with the convulsive movements and the latter may vary from slight spasm of a facial muscle to contractions affecting all the muscles of the body. The condition is usually easy of diagnosis, the coprolalia being considered its most characteristic feature. The prognosis is uncertain but patients have been known to recover. The treatment is chiefly moral and occasionally hypnotic suggestion succeeds. SALTATORY SPASM. 8oi SALTATORY SPASM. Latah; Myriachit; Jumpers; Mali-mali. The saltatory spasm is a condition in which the patient is affected by vigor- ous contractions of the muscles of the legs which occur only when he is stand- ing. It is seen in individuals of neurotic habit, both men and women; the affection may be transitory or persistent, and seems closely akin to the latah of the Malays and mali-mali of the Filipinos. Amongst the Malay race it seems to chiefly attack women who, when affected, imitate the movements of those about them even though they make strong efforts to desist; echolalia may co-exist with this imitation of motion. Heredity seems to be a factor in its causation, and those affected by it are subject to attacks of " running amuck" (see p. 827). The myriachit of Russia and Siberia and the jumpers of the Maine woods and Canada are analogous conditions. Those subject to the latter disorder, when under any emotional influence, jump violently and cry out; they may obey a sharp command or imitate actions or sounds. CHRONIC CHOREA. Synonyms. Huntington's Chorea; Hereditary Chorea. Definition. A chronic disease characterized by irregular movements, speech disturbance and gradually increasing dementia. .Etiology. The most important role in the causation of this disease is played by heredity, the affection having been observed in certain families for generations; the family originally reported by Huntington in 1872 still exhibited the tendency to it as late as 1898. The family affected is usually of neurotic tendency and in marked instances over 50 percent, of the members are affected. The disease seldom begins earlier than the age of thirty and sex seems to have little influence in its causation. Idiopathic cases have been observed. Pathology. This affection exhibits no typical post mortem lesions, although the changes which are usually found in chronic dementia — atrophy of the cor- tex, meningo-encephalitis and changes in the cerebral vessels — are often present. It is probable that the disease is in no way akin to chorea minor. Symptoms. In the hereditary form of the affection the onset is usually sudden with irregular movements of the hands; the performance of fine volun- tary movements is difficult. Later the face becomes involved and the gait is disturbed. The movements differ from those of chorea minor in that they are slower, more irregular and lack coordination. The gait is swaying, the patient may seem about to fall and then by an effort recover just as an intoxi- cated person does. The movements are not present while the patient is at rest, may be to some extent controlled by the will and are increased by excite- 51 8o2 DISEASES OF THE NERVOUS SYSTEM. ment. The speech is slow, interrupted and indistinct; uniting is difficult at first and later impossible. Sensory disorders are absent, the special senses and muscular sense usually are not affected although the latter may be disturbed late in the disease. The disorder of mentality begins as a depression and irritability, passing to feeb^-mindedness and finally to complete dementia. Suicidal tendency occurs and the act may be committed. The disease is progressive and finally fatal. Treatment consists merely in the control of the symptoms as they arise. The patient's general health should be cared for by prescribing tonics, nourish- ing food and a life in the open air. Nothing can be done to arrest the progress of the disease. EPILEPSY. Synonyms. Falling Sickness; Morbus Divinus; Morbus Astralis; Morbus Sacer. Definition. Epilepsy is a chronic functional nervous disease characterized by paroxysmal seizures t}^ified by loss of consciousness and usually by con- vulsions. Jacksonian epilepsy is characterized by recurrent convulsions affecting particular groups of muscles and is frequently not accompanied by loss of consciousness. True or idiopathic epilepsy is of three forms: 1. The grand mat, the most severe, in which the convulsions are marked and the loss of consciousness is distinct. 2. The petit mat, in which the convulsions and unconsciousness are of trivial character. 3. Psychical epilepsy which is characterized by mental disorder or violent acts. .Etiology. As a predisposing cause heredity must be considered to exert the most definite influence, about 30 percent, of cases showing a history of mental disease or epilepsy in the family. Other predisposing causes are alcoholism, consanguineous marriages, syphilis, plumbism, mental disturb- ances during pregnancy and traumatisms during parturition. Sex seems to have no distinct influence. The disease usually develops between the ages of ten and twenty, although it may appear before the age of five. After twenty years of age the incidence of epilepsy is rare. Exciting causes are rickets in infancy, alcoholism, syphilis, head injiiries, the acute infectious diseases and masturbation. Reflex causes are disorders of the genital system and of the digestive tract, intestinal parasites and consti- pation, and ocular and aural irritations. EPILEPSY. 803 Pathology. The pathology of true idiopathic epilepsy is unknown. Lesions have been described as occurring in cases in which a syphilitic element is present or in which vascular anomalies exist, but* in epilepsy in which such conditions are wanting no constant alterations in the nervous system are found. In Jacksonian epilepsy distinct abnormalities are present such as tumors, localized meningeal thickenings and injuries to the cranial bones resulting from trauma. Physiology. The epileptic paroxysm is to be considered an explosion of nerve energy, the seat of this discharge being the large motor cells of the cortex; the same mechanism is responsible for paroxysms of psychical epilepsy. Symptoms. In discussing these, the four chief types of epilepsy will be taken separately. I. Grand mal. There are frequently prodromal symptoms for a day or for only an hour or two before the attack, such as vertigo, or irritability. In many cases the paroxysm is ushered in by a peculiar sensation known as the aura. This may be a wave-like sensation rising from the feet, involving the body and when it reaches the head the unconsciousness and convulsion occur. In other individuals is may be manifested by a sensation of epigastric dis- comfort; auditory aurae, such as the hearing of voices or musical sounds, visual aurae such as a flash of light or color or the appearance of objects or faces and oKactory or gustatory aurae causing sensations of smeU or taste are not uncommon. Accompanying the aura and the onset of the paroxysm many patients cry out. As this cry is uttered the patient falls and the first or tonic stage of the attack begins. In the tonic spasm, which lasts fifteen or twenty seconds, the head is drawn back or to the side, the limbs and body are rigid, the elbows and wrists are flexed, the hands clenched and the legs and feet extended, respiration ceases and the face becomes swollen and cyanotic, the neck may be twisted and the vertebral column curved. The clonic spasm now supervenes and is characterized by convulsive movements of the face and limbs, the latter being violently flexed and extended; the facial muscles are involved, the eyeballs roll and the lids open and shut; saliva collects in the mouth and is chiu-ned into froth by the contractions of the muscles of the jaw, the froth becoming bloody if the tongue is bitten. The urine and faeces may be passed involuntarily; the cyanosis becomes less; the temperature may rise ^ to 1° F. and the pulse, weak at first, becomes rapid and tense; later as the convulsions abate it becomes feeble once more. This stage lasts a minute or two, gradually subsides and the patient subsides into the stage of coma. In this condition the muscles are relaxed, the respiration is stertorous, the face suffused but not cyanotic. The coma passes into a slumber which may last several hours after which the patient awakes suffering perhaps from headache or confusion of mind, or on the other hand in normal condition save for stiff- ness and bruises. 804 DISEASES OF THE NERVOUS SYSTEM. The status epilepticus is a condition in which the unfortunate patient passes from convulsion to convulsion for hours or days, never regaining con- sciousness; later the convulsions are replaced by coma, or more rarely mania, and the patient dies of exhaustion. After an epileptic seizure the reflexes may be lost; at times they are exag- gerated; there may be slight temporary glycosuria or albuminuria; the red cells of the blood and the haemoglobin are diminished. 2. Petit mal. In this form there is rarely an aura or a cry, the attack lasts but a few seconds, the patient stops suddenly whatever he may be doing, the features become set, the eyes open widely and are set, the pupils dilate, there may be slight muscular twitchings and consciousness is lost for the moment and he may fall. The attack is over after a few seconds and the patient resumes his former occupation conscious merely that he has suffered from a "spell." At times he may turn about, take a few steps or perform forced movements — procursive epilepsy. Seizures of petit mal may alternate with those of grand mal and as the disease continues the attacks increase in intensity and they may become entirely of the grand type. 3. Jacksonian epilepsy. This type of the disease is not characterized by loss of consciousness. The convulsion affects a single group of muscles or a limb. It is, as a rule, the result of a focal lesion of the motor area of the cerebral cortex such as a tumor, disease or injiury. The attack begins with numbness or tingling sensation in the part to be attacked; the convulsions begin always in the same part, a finger, a toe or the face. The movements are tonic and clonic extending in regular order, for instance from a finger, to the hand and thence throughout the arm. After the attack the affected part may be numb or partly paralyzed and loss of tactile or temperature sense may be present. The situation in which the seizure begins is important in determining the localization of the brain lesion and in fixing the site for operative intervention. 4. Psychical epilepsy follows petit mal, more rarely grand mal or, occur- ring independently, is considered a "psychical epileptic equivalent." During the paroxysm the patient may exhibit mental violence, or perform extravagant acts, sometimes criminal in character. Accustomed acts may be performed during a somnambulistic condition which at times occurs in place of the ordinary seiziure; these are often complicated and include driving, walking, etc. Abortive attacks of psychical epilepsy lasting but a few seconds and consisting of a short tonic and a very mild clonic stage are sometimes seen. Grand mal is the type of the disease most frequently observed, next in order comes the mixed type while petit mal is still less common. Jacksonian and psychical epilepsy are rarest of all. During the developmental stage of the disease major attacks may occur only two or three times a year. Gradually, however, they increase in fre- EPILEPSY. 805 quency until they may take place even several times a month. In very severe cases there may be daily attacks. Frequent seizures of petit mal are the rule, their daily incidence is not at all uncommon. The most usual time of day for epileptic attacks is between 8 A.M. and 8 P.M. and a not infrequent time is early in the morning when the vital forces are at their lowest ebb. Nocturnal seizures are not rare. Between the attacks the patient feels well, indeed a nervous explosion may be followed b}'' a distinct improvement in his condition. The prognosis. This is best as regards recovery in cases with infrequent attacks. When the seizures are altogether during the day or at night the prognosis is better than in the mixed type. When the disease begins after twenty years of age the chances of recovery are better than in cases commencing earlier in life. While epileptic, patients seldom die of the disease, their lives seem to be shortened by it and recovery is rather rare; about 10 percent, of cases result in insanity or dementia. Of the different types of epilepsy the prognosis is worst in the psychical variety, better in petit mal and most favorable in grand mal. Treatment. Prophylaxis: Neurotic children who have convulsions in infancy should command our best efforts to learn the cause of this manifes- tation, to remove it and to advise such an education and training as will result in both physical and mental health. Such children when under the influence of a neurotic father or mother often do better when brought up away from home. Before beginning treatment a thorough investigation of the case should be made in order to ascertain whether the condition is or not due to peripheral irritation. The blood, the urine and the faeces should be examined, the eyes should be investigated for evidences of eye-strain, the ears, nose, and mouth for signs of reflex irritation, the genitals for evidence of phimosis or masturba- tion; the digestive tract should be rendered as normal in its action as possi- ble; gastric atony, intestinal fermentation and constipation deserve especial attention. Another most important consideration is to institute treatment as early after the incidence of the disease as possible and to carry it out vigorously. Particularly should children who have had convulsions in early life receive careful attention and should the seizures be recognized as epilepsy, treatment should be continued for at least three years after the last attack has been observed. Constitutional treatment with the view of absorbing or preventing sclerotic patches in the nervous system — such deposits having been observed in many cases — may be instituted. Here the alteratives, arsenic, mercury, sodium and gold chloride and potassium iodide, are indicated; if a syphilitic element is present appropriate treatment is necessary. Cases in which there are co-exist- 8o6 DISEASES OF THE NERVOUS SYSTEM. ent lithEemic or purinsemic conditions sometimes may be relieved by the use of saligenin tannate, gr. xv (i.o) three times daily with the alkahes and proper diet as adjuvants. Circulator}- and va so-motor disorders, which are not rare, may be combated by stnxhnine and other heart tonics and, in conditions of hypertension, by glyceryl nitrate. In tha specific treatment of epilepsy the bromides are the most useful remedies but are not without disadvantages. The most effectual of these are potassium bromide, sodium, strontium, rubidium and ammonium bro- mides and hydrobromic acid. WTiile the action of all these salts is similar the potassium salt seems to be most effectual; at times it may be of benefit to the stomach or otherwise of advantage to change from one to another or to administer a mixture of several of the salts. Sodium bromide is less unpleasant to the taste than potassium bromide and less disturbing to the digestion; ammonium bromide is slightly stimulating to the heart. Hydro- bromic acid may be given when the alkaline salts are disturbing to the alimen- tan' tract; the bromide eruption is less likely to follow its use than that of the other bromides. The dosage employed should be sufficient to control the paroxysms, begin- ning at about 15 grains (i.o) four times daily and gradually increased until effectual. As much as 2 drachms (8.0) fo\ir times a day has been given; this amount produces bromism but, when necessary to suppress the attacks, may be employed, always with care, however, as harm sometimes results. The seizures having ceased, the dosage should be lessened, but the treatment should be continued for a couple of years at least. Nocturnal epilepsy may sometimes be controlled by a single large dose given at bedtime but as a general rule the drug is best given on an empty stomach either a little while before meals or two or three hours after. The disadvantage of the bromide treatment is the likelihood of causing bromism which is manifested by drowsiness and hebetude, digestive disorders, cardiac distress and the t}'pical bromide acne. It is difficult to mitigate these unpleasant symptoms unless the drug is stopped; the most approved measures to prevent their occurrence are the employment of salt water baths, massage and regular exercise with the administration of the bitter tonics, iron, cod- liver oil and the mineral acids. The acne may be prevented by the adminis- tration of arsenic, the unpleasant bromide eructations by combining the bromide with an alkali, though this may disturb the bladder, this disturbance may be relieved by giving the bromide in hydrobromic acid. The best method of taking these salts is in carbonic or Vichy water in proportion of about ^ drachm (2.0) to a glass full. In some cases, especially those in which the drug causes digestive disturbance, the bromides are ineffectual; in these obstinate cases they may be combined with solanum carolinense (the fluidextract, J to 2 drachms — 2.0 to 8.0 — tliree EPILEPSY. 807 or four times daily) and for patients whose intolerance to the bromides neces- sitates their omission, this drug alone may be prescribed. It is said that if the sodium chloride of the diet is restricted or omitted entirely the bromides will prove more effectual and smaller doses may be employed. Hydrated chloral and chloralamide are useful adjuncts to the bromides but should be, especially the former, given with care. Five to ten grains (0.33- 0.66) of chloral may be combined with a diminished amount of bromide and given with good effect. Another combination which is deserving of trial is one of antip}Tine, 6 grains (0.40) and ammonium bromide, 10 grains (o.66j given three times a day. Acetanilide may prove useful as also may mono- bromated camphor in doses of 5 grains (0.33). Other drugs which have enjoyed vogue in the treatment of epilepsy and may be substituted for the bromides are the tincture of capparis coriacea, I drachm (4.0) four times a day, belladonna, zinc iodide and oxide, sodium borate, sulphonmethane and valerian. In petit mal glyceryl nitrate given to the physiological limit is of service. Its dosage varies mth the tolerance of the patient from y^-jj to 2t of a grain (0.0006-0.0024). The bromides also are useful and antip}Tine, belladonna, cannabis indica, ergot and general tonic treatment may be employed. The treatment of the seizure. The patient whom an aura warns of a coming attack is fortunate, for in amyl nitrite we have a fairly efficient means of preventing its onset. This drug may be carried in the pocket in the form of " pearls" or in a small bottle; the former may be broken at the appropriate time and the contents inhaled. Other methods of aborting a paroxysm are the inhalation of ammonia or chloroform, pressure over the carotid arteries, the internal administration of alcohol or aromatic ammonia spirit. Brower reports a patient whose aura began in the hand; about the wrist he wore a noose of thread which, when the warning appeared, he would tighten thus stopping the progress of the paroxysm. During the attack the patient should be prevented from doing himself injury and some such object as a spool, a bit of wood or a roUer bandage should be inserted between the teeth to prevent biting of the tongue. The status epilepticus should be combated by hydrated chloral given per rectum and the stomach and bowels should be emptied by lavage or by emetics and purges. Bleeding may be employed. The treatment of epileptics at special institutions or colonies is strongly to be advocated. Here the mode of life may be properly regulated, the mind of the patient may be kept congenially occupied and physical work within proper limits prescribed. Hydrotherapy. Systematic hydrotherapeutic measures are a useful adjunct to treatment; under their employment there is less likelihood of inducing brom- 8o8. ■ DISEASES OF THE NERVOUS SYSTEM. ism and causing acne. By increasing the eliminative process of the organism as well as by the stimulating and tonic effect the tolerance for the bromide is increased and its toxic power diminished. For a patient accustomed to a cold morning tub this measure may be prescribed, otherwise he may be given a dry or alcohol rub before rising; later the cold packs followed by a vigorous rubbing are admissible; when the patient's condition permits, a hip bath be- ginning a^ 90° F. (32.2° C.) for five to eight minutes may be given, the tempera- ture being reduced one degree per day, until 80° F. (26.1° C.) is reached. Another useful procedure is the douche. Both this and the hip bath should be followed by vigorous rubbing by an attendant. Other balneotherapeutic measures will undoubtedly suggest themselves as indications arise Jacksonian epilepsy may often be traced to head injuries and in cases of this type there is possibility of cure by removal of pressure upon the brain by surgical means. In other forms of epilepsy surgery can be of no benefit. Diet. The dietetics of this disease is most important and the fact that this element in the management of epilepsy can be properly regulated in institutions is a strong point in favor of the employment of this form of treat- ment. The restriction of salt is a distinct advance in the treatment of this condition. The patient soon learns to do without sodium chloride and equally readily accustoms himself to the use of sodium bromide in its stead, and even may prefer it. The diet itself should consist of plain, nourishing and easily digested foods. Starchy indigestion should be avoided by guard- ing against a too exclusively vegetable regimen. For breakfast the patient may have fruit, a cereal, eggs, toast, rolls or biscuit and milk, buttermilk, or cocoa; at dinner a puree or clear soup is allowable with fish, meat or fowl, vegetables and a simple salad, with fruit, plain puddings or ice cream as dessert. Supper may consist of bread or rolls, cold meat, oysters, sweet- breads or calf's brain and stewed fruit, with milk or cocoa. Alcohol, tobacco, tea and coffee, sweets, fried foods and rich made dishes should be avoided. MYOTONIA CONGENITA. Synonym. Thomsen's Disease. Definition. A disease characterized by hypertrophy of the muscles and by tonic cramp on attempting voluntary movement. .Etiology. Myotonia congenita is an hereditary affection appearing, in all typical cases, in early childhood and in certain families. It had appeared in the family of its first describer, Thomsen, for five generations. Males are much more frequently affected than females and the disease is more frequent in Scandinavia and Germany than in England or America. The cases of acquired myotonia seem to differ somewhat from Thomsen's disease. MYOTONIA CONGENITA, 809 Pathology. The muscles, especially those of the limbs, are larger than normal and may be the seat of a true h)rpertrophy; they are, however, much less powerful than their appearance would imply. Microscopically the muscle fibres are sometimes enlarged and their nuclei increased although the results of late research seem to show that this enlargement is not characteristic of the disease; the intramuscular connective tissue may be increased and degenerative and regenerative changes have been observed. The theory has been advanced that the condition is the result of an autointoxication of the muscular tissue due to disordered metabolism. Symptoms. The onset of the disease occurs in childhood and is first evi- denced by a muscular stiffness which causes a delay in voluntary movement. There is no paralysis and when a movement is begun it is carried out. Rapid and accurate movement is impossible and a contraction may persist after its end has been accomplished. The arms and legs are chiefly affected; the gait is disturbed, in that there is a hesitancy at the start, after a few steps there is no difficulty in continuing. The condition is accentuated by excitement or cold. Rarely the muscles of the face, eye or larynx may be affected. There is no abnormality of sensation or of the reflexes; the so-called myotonic reaction of Erb is present and characteristic of this condition, the galvanic and faradic irritability of the motor nerves being quantitatively normal and short contractions result from briefly acting stimuli. With continuous excita- tion by either current the contractions slowly reach their maximum and slowly relax, while vermicular, wave-like contractions pass from cathode to anode. There is no atrophy or considerable loss of power except in so far as the stiffness interferes with movement. The disease resists treatment but the patients are often able to educate themselves so that the disability is but slightly noticeable. Treatment consists merely in attention to the general health and the employ- ment of massage and gymnastic exercises. PARAMYOCLONUS MULTIPLEX. Definition. A disease characterized by clonic contractions of various groups of muscles, usually of the extremities, occurring either in paroxysms or constantly. etiology. Little is known of the causation of this condition. Heredity seems to be a factor in that many cases give a family history of various types of nervous disease. It is a disease of adult life and is more often observed in the male sex. It has been known to follow emotional disorders and fright. 8lO DISEASES OF THE NERVOUS SYSTEM. Pathology. The morbid anatomy of paramyoclonus multiplex is still undiscovered. Symptoms. The most marked symptom is the occurrence of clonic contractions involving chiefly the muscles of the limbs and trunk, rarely those of the face. They are bilateral, as a rule, sudden, and as many as 150 per minute jnay take place. Tonic spasms have also been observed. The con- tractions are increased by emotional states, are diminished by voluntary movement and are absent diiring sleep. At times the patient may emit a grunting sound which perhaps is due to involvement of the larynx and dia- phragm. Between paroxysms there may be muscular tremors. In marked types of the disease the movements may be vevy violent and the patient may be with difficulty kept in bed. There are no mental, sensory or trophic symp- toms and the electric reaction of the muscles is unchanged, though an electric stimulus may incite a paroxysm. The tendon reflexes are exaggerated. The prognosis with regard to complete recovery is poor, the condition, usually persisting for a number of years, although it may prove fatal within a few months. Treatment consists in the employment of measures calculated to improve the general health, tonics, out-of-door life, nourishing food, etc. All possible excitement must be avoided. Arsenic, iron and phosphorus may be given and a course of hydrotherapy at a suitable institution may prove beneficial. The marked paroxysms of the severe types of the disease may necessitate the hypodermatic administration of morphine. PARALYSIS AGITANS. Synonyms. Shaking Palsy; Parkinson's Disease. Definition. A chronic nervous affection characterized by muscular tremors,, weakness and rigidity. ^Etiology. The causation of this disease is obscure. It occurs most often in individuals belonging to families in which other nervous diseases have appeared, is usually seen after the age of forty and is more common in males than in females. It may follow malaria and other infectious diseases and is predisposed to by alcoholism and sexual excess. Of exciting causes, exposure to cold, injuries, worry and mental over-exertion may be mentioned. Pathology. There is no characteristic lesion but the disease is probably the result of some change in the cerebral cortex. The theory has been ad- vanced that it is due to prematiire senile changes in the brain. Dana suggests that in paralysis agitans there is destruction and degeneration of the dendrites of the cells of the anterior cornua of the cord interfering with the even progress of motor impulses, leading finally to motor weakness and rigidity, owing to- PARALYSIS AGITANS. 8ll severence of the connection between these ceils and the brain, these mani- festations having been preceded by a functional disturbance. According to Gordinier the primary change is in the blood-vessels, later spreads to the adjacent neuroglia and results in patches of perivascular sclerosis; the abnor- malities which have been observed in the anterior horn cells and in those of the motor cortex being due to diminished nutrition dependent upon the vascular changes. Symptoms. Of these tremor, either constant or intermittent, and usually first affecting the hands, is earliest noted. The onset of the disease is slow as a rule although it may develop suddenly after exposure, trauma or emotion. The tremor of the hands is characterized by movements of forefinger and thumb resembling those made in rolling a pill; rotation and tremor of the forearm is also present. The arm is seldom affected and the movements of the lower Hmbs are most marked at the ankle joints. There may be nodding movements of the head. The movements at first are absent during sleep but finally remain present at all times. By an effort of will the patient may check the tremor but it returns, often exaggerated in degree. It is increased by excitement or emotion but may cease in states of excessive rigidity. The accompanying muscular weakness is present in greater or less degree and is most apparent when the tremor is marked. Entire loss of muscular power is rare. The rigidity is evidenced by impairment of activity, movement is stiff and retarded. This symptom is progressive and results in the attitude typical of the disease. Here the head and body are bowed, the elbows are flexed and held away from the body; the knees may interfere in walking and the patient may seem about to fall forward. He walks with eyes upon the ground before him and takes quick, short steps, acting as if he were about to fall for- ward and were endeavoring to prevent this calamity by continually changing his center of gravity. If pushed backward he is likely to fall being unable to maintain his balance. The facial appearance is changed being expres- sionless and mask-like. Saliva may dribble from the partly open mouth or if this is kept closed, it may be found full of this secretion owing to delayed deglutition. The voice may be high-pitched and the speech slow, though if the lips and tongue are involved in the tremor, the patient may stammer. The reflexes remain unaltered or rarely are exaggerated. There may be altered temperature sense but otherwise there is no sensory abnormality. The skin may be thickened, particularly that of the forehead, it may flush easily or perspire excessively. The temperature, bowels and bladder are unaffected but there may be areas of heightened surface temperature. The prognosis. The course of the disease is slow and gradual and, while periods of intermission may occur, its progress is continually toward the worse, lasting for years, the patient usually dying from intercurrent disease. 8l2 DISEASES OF THE NERVOUS SYSTEM. Treatment directed to the arrest of the condition is unavailing, consequently we can do little except to care for the patient's general health by the adminis- tration of proper food and tonics. Fresh air, exercises, electricity, massage and warm bathing are indicated. With regard to drugs hyoscine hydrobromide in doses of gr. yj-g- to y^Q- (0.000570.0006) or atropine, grains y^g- to -g-V (0.0006-0.001) may be given hypodermatically two or three times a day, depending upon the severity of the symptoms, and opium, arsenic, potassium iodide and duboisine may be tried. Hot moist or dry compresses may be applied to the muscles if these are painful and if hyperexcitability of the nervous system is present, the bromides and hydrated chloral may be employed with benefit. ECLAMPSIA. This term is applied to reflex convulsions occurring in children and to the convulsions of the puerperal state in women. INFANTILE ECLAMPSIA. Synonyms. Infantile Convulsions; Epilepsia Acuta. Definition. Convulsions due to peripheral reflex irritation. Etiology. Convulsions in children may result from very slight causes usually reflex in character and due as a rule to digestive disorders, such as inflammations, intestinal parasites, foreign bodies, faecal accumulations, vesical calculi, rickets, nephritis, and the infectious fevers. Children of neuropathic heredity are prone to exhibit this manifestation and it is the result of a hyperexcitable state of the nerve centers permitting sudden, excessive and transient discharges of nerve force. Symptoms. The seizure may vary from mere twitching or clinching of the fingers to marked convulsive paroxysms closely resembling those of epilepsy (see p. 803). The attack may be single but often several convulsions may appear following one another at intervals of hours or days. Rarely does the seizure end in death. Frequently repeated convulsions may induce the "convulsive habit" and from this epilepsy may result. The attack may appear without prodromal symptoms or it may be pre- ceded by malaise and restlessness. The seizure is often accompanied by rise in temperature. The prognosis of infantile convulsions depends upon the causative factor and the age of the patient. Life is seldom endangered except in very young infants and rachitic cases. Permanent brain impairment is rare but may occur. Convulsions at the onset of an infectious disease are rarely fatal and may not augur a severe type of the infection. Nephritic convulsions are PUERPERAL ECLAMPSIA. 813 serious and in those of whooping cough and of asphyxia, the worst is to be anticipated. Treatment. The child suffering from convulsions should be kept perfectly quiet. The mustard bath is better omitted and a mustard pack substituted. The latter is made by adding to one quart of tepid water a tablespoonful of mustard; a towel is wet in this and while dripping is wrapped about the patient's body; outside this a blanket is wrapped and he is allowed to lie in it for ten to fifteen minutes. At the end of this time the skin should be well reddened. The pack may be repeated at intervals as indicated. Cold compresses should be applied to the head. If the convulsion is of severe type chloroform sufl&- cient to control it should be administered and at the same time an enema of hydrated chloral dissolved in an ounce (30.0) of warm milk should be given. A child of six months may receive 4 grains (0.26), a child of one year 6 grains (0.4). This should be injected through a soft catheter passed high into the rectum, the buttocks being held together to prevent its discharge. If neces- sary the dose may be repeated in an hour. When the convulsions persist when the chloroform is stopped and in spite of the hydrated chloral, morphine should be administered hypodermatically. To a child of six months ^^g- of a grain (0.0014) may be given; to one of one year ^V of ^ grain (0.0025), to be repeated in one-half to one hour if necessary. If the heart is weak chloroform may be contraindicated but morphine may be given. Oxygen inhalations may relieve the condition, especially in states of asphyxia when other treatment is of no avail. The convulsions being under control it remains to prevent their recurrence. This is accomplished by continuing the administration of chloral in gradu- ally diminished doses, with the addition of sodium bromide, or if the chloral is not well borne by stomach or rectum, antipyrine or acetphenetidine in small doses may be substituted. In addition to the above treatment the gastro- intestinal tract should be cleared of all possible irritant material by the adm.in- istration of J to ^ a grain (0.016-0.032) of calomel every half hour up to six doses and by thorough washing out of the colon by means of a soft catheter and warm normal saline solution. The further treatment consists in the regulation of the patient's food and mode of life, together with appropriate medication for the underlying condition. PUERPERAL ECLAMPSIA. The actual causation of this condition is not definitely known but it undoubt- edly is the result of a toxaemia due to faulty metabolism and elimination. It is often associated with the albuminuria of pregnancy although it is by no means certain that renal lesion is its causation. The convulsions are usually 8 14 DISEASES OF THE NERVOUS SYSTEM. preceded by a feeling of fulness in the head, dizziness and arterial hyperten- sion and may occur either before or after the uterus is emptied, usually, how- ever, before that event. The convulsions are both tonic and clonic and the condition is one which jeopardizes the life of the patient, consequently all possible measures should be taken toward its prevention by frequent urine examination during the later months of pregnancy and careful watching on the j^art of both patient and physician for premonitory symptoms. Treatment. This consists, if the con\Tilsions appear before the birth of the foetus, in emptying the uterus as rapidly as possible. The treatment for the compulsion itself is to be carried out by the administration of chloro- form and the employment of other means applicable to such conditions. If the arterial tension is excessive and cyanosis is present, venesection and the withdrawal of a considerable amount of blood should be practiced, the fluid withdra"wn being replaced by the injection of an equal or larger amount of normal saline solution either directly into the vein or into the muscular tissues of the thighs or buttocks. The drug most likely to be of service is veratrum and it is best given hypodermatically in the form of the tincture, 30 to 40 minims (2.0-2.66) and repeated until the arterial tension has been reduced to normal limits. The toxaemia should be treated by the administration of two to three copious (i gallon-4 litres) high rectal irrigations of normal saline solution at a tempera- ture of 105-110° F. (40.5-43.5° C), daily; moderate diuresis and other means calculated to assist elimination are indicated. While any symptoms persist the diet should be entirely of milk. TETANY. Synonyms. Intermittent Tetanus; Tetanilla. Definition. A nervous afl'ection characterized by bilateral intermittent or continuous tonic spasms of the extremities, seldom involving one limb only and rarely becoming general. ^Etiology. The condition affects both adults and children. In the former it occurs in a so-called epidemic or infectious form in certain parts of Europe among young workingmen, especially shoemakers and taUors; as a result of digestive disorders and the infectious diseases; as a complication of various nervous diseases, notably exophthalmic goitre, syringomyelia and brain tumors; follo^vdng morphine, ergot, chloroform, alcohol and lead poisoning; in urgemic states; in pregnant and nursing women; and as a result of removal of the th}Toid gland. In the last case it is probably due to the excision of the parath}Toid bodies which have been removed with the gland. In children tetany has been observed in digestive disorders, in the acute infectious diseases and in rickets. TETANY. 815 Pathology. This is not definitely known. It is supposed that the para- th}T:oid glands exercise a neutralizing effect upon some poisonous substance produced by metabolism. This theory would account for tetany following the removal of these bodies, and the production of this poison in such an amount that the parathyroids are unable to neutralize it may account for the disease in other cases. Symptoms. The spasm of tetany is usually limited to the limbs and ex- tremities. The thumbs are flexed into the palms; the fingers are adducted and flexed at the metacarpo-phalangeal joints, remaining straight at the pha- langeal articulations. There is flexion at the wrists and elbows and the arms are folded over the chest. In the lower limbs the hips, knees and ankles are extended and the toes adducted or there may be flexion of the knees and dorsal flexion of the feet. The skin over the extremities may be oedematous. The muscles of the face, neck and body are seldom affected, but rarely there may be trismus with drawing out of the angles of the mouth. Tenderness and pain accompany the spasm as a rule. The contractions in children usually last only a few hours; in adults they may be prolonged for several days or even weeks. When the condition is very acute there may be acceleration of the pulse and elevation of temperature. Other svmptoms characteristic of the disease are Chovostek's — a contraction of the muscles caused by light tapping along the course of a nerve; Trousseau's — the induction of spasm by pressure over the affected part, especially along a nerve trunk or over a blood-vessel; Erb's — exaggerated electrical irritability, especially to galvanism, and Hofmann's — the production of paraesthesia by pressure over a sensory nerve. Difficult urination or inability to perform this function may be observed. The reflexes are exaggerated. The prognosis of the disease is good, recovery usually taking place in a few days or more rarely after a month or two. Recurrences are common especially in the winter and early spring. Death may occur in cases due to severe gastric lesions or those due to- removal of the parath}T:oid glands. Treatment consists first in removal of the cause of the condition; any digestive disorder should receive appropriate treatment and the same is true of rickets. The spasm may be relieved by hot baths, an ice bag applied to the spine or if necessary chloroform may be given by inhalation; frictions, massage, passive movements and the electric current may be employed with benefit and a properly hygienic mode of life should be prescribed. Of drugs those which have a sedative action in spasmodic conditions should be employed. The bromides, hydrated chloral and antip}Tine are the most useful. In cases characterized by severe pain the h}-podermatic adminis- tration of morphine may be necessary. The extract of the th^Toid gland is said to relieve certain cases, even those 8l6 DISEASES OF THE NERVOUS SYSTEM. in which parathyroid excision has not been performed. The beginning dosage of this substance is 5 grains (0.33) three times a day. Thyroid transplantation has been suggested. In cases due to gastric dilatation, cure may result from one of the surgical operations adapted to the treatment of this condition, or if this mode of treat- ment is contraindicated or refused by the patient, frequent and thorough lavage slccording to the methods laid down under the treatment of gastric dilatation should prove beneficial. HYSTERIA. Definition. An abnormal condition of the nervous system characterized by morbid changes in the functions of the body resulting from lack of mental control over acts and emotions and by exaggeration of sensory impressions. iEtiology. Heredity has a direct influence upon the causation of this disease and even if true hysteric conditions have not occurred in the ancestry there is often a family history of other nervous conditions, such as epilepsy, insanity, mental degeneration, etc. Alcoholism and drug habits as well as consanguineous marriage are factors in its production. While hysteria is more common among females it is by no means seldom observed in males. The age at which the disease is most frequently met is from that of puberty to the thirtieth year. The Anglo-Saxon races are much less prone to the disease than are the Latin races and it is particularly frequent among the Hebrews. The hysterical temperament is likely to develop in pampered individuals who have been accustomed to excessive sympathy and to make much of every slight ailment. Hysteria is more frequently observed in the poor and wealthy than among the middle classes. It is predisposed to by poor, sordid and unhealthy sur- roundings, by lack of proper nourishment and life under severe mental strain or worry. As exciting causes may be mentioned sudden mental or traumatic shock, fear, joy, grief, business reversal, prolonged illness, sexual excess and mastur- bation. Pathology. Hysteria, being a purely functional disease, is characterized by no recognizable morbid change in the nervous system. Symptoms. These occur in number and variety equaled by no other disease and comprise the symptoms of any of the other nervous affections. In the earlier stages the hysterical patient is irritable, emotional or despon- dent, magnifies every ill and is anxious for sympathy; he may give himself over to mirth or may indulge in attacks of weeping without apparent reason. His mentality may be more than usually active, although hysteria may occur in the mentally deficient. The general health may be of the most robust. HYSTERIA. 817 The hysteric convulsion may be preceded by manifestations such as those described above or such prodromata as vertigo, neuralgic pains, localized cutaneous anaesthesia or ovarian tenderness may be present. At times an aura resembling that of the true epileptic convulsion may be observed; most frequently this occurs as the globus hystericus, which is characterized by a sensation of choking as if there were obstruction of the trachea or oesophagus. The most marked type of the convulsion {hystero-epilepsy or hysteria major) may be preceded by an aura, following which the patient may utter a cry, falls apparently unconscious and exhibits a tonic spasm, this is followed by the clonic stage and finally by relaxation and coma. The paroxysm is usually rather longer than that of epilepsy. The second stage of the attack is termed "clownism" by Charcot and is characterized by violent and exaggerated muscular contortions, emotional display or cataleptic poses. In the third period the patient assumes various attitudes expressive of ecstasy, happiness, terror or erotism. The fourth period or that of return to consciousness is characterized by delirious and hallucinatory manifestations in which the patient seems to see visions, hear voices and may converse with imaginary persons. These hallucinations may persist after the seizure is past. In the minor form of conviilsive seizure the prodromata may be similar to those described above; at the actual onset of the attack the patient falls, taking good care not to get hiirt; the spasms consist of clonic muscular contractions which may involve all four limbs and even the trunk. The contractions are irregular and although the patient seems unconscious he gives the impres- sion to the experienced observer that the condition is feigned. The convul- sion passes in a few minutes or the patient may be aroused by the use of a strong galvanic shock or by dashing a small amount of cold water in the face. The seizure does not leave the patient in a somnolent or torpid state as does that of epilepsy. During the non-convulsive stage the hysterical patient may exhibit symp- toms referable to almost any organ or tissue of the body; these may be divided as follows: Motor Symptoms. In addition to the convulsive movements of hysterical paroxysms the patient may simulate various forms of paralysis such as hemi- mono-, or paraplegia, tonic muscular spasms, contractures of the muscles of the extremities or of the neck, disorders of coordination or tremors. The paralysis is usually hemiplegic and more often on the left side, the face being seldom affected. Limbs apparently useless for locomotion may be moved while the patient lies in bed and if one leg is apparently paralyzed it is drag- ged shufiflingly along while the other limb is taking ordinary steps, and is not swung outward as in true hemiplegia. Ataxia may accompany the paralysis which may be either spastic or flaccid. Vocal cord paralysis with loss of voice is not rare and may be demonstrated by laryngoscopic examination 52 OI6 DISEASES OF THE NERVOUS SYSTEM. which is particularly easy in hysterical patients, because of the anaesthesia of the pharynx, one of the stigmata of hysteric conditions. The reflexes may be exaggerated, and the so-called hysterical joint may be observed. The latter is characterized by pain and swelling, of sudden onset, usually affecting the knee or hip. Motion is interfered with and in conse- quence muscular atrophy from disuse may ensue. Contracture of the abdominal muscles may result in the so-called "phantom tumor." This is most frequently seen in the umbilical region and at times very accurately simulates a firm and solid growth. It is considered to be due to a spasmodic contraction of the diaphragm, the recti abdominis being at the same time relaxed, the vertebral column curved forward and the intestines distended. Pseudocyesis or false pregnancy is a variety of this condition. Such spurious tumors disappear if the patient is subjected to general anaes- thesia. Sensory Symptoms. Of these the most common are areas of cutaneous hyperaesthesia, anaesthesia or paraesthesia, the latter consisting of sensations of numbness or tingling, formication or of heat and cold. Symptoms refer- able to the organs of special sense may occur such as mere lessened acuity of sight or diminution of the visual field. Other disorders are total blindness (never, however, hemianopsia) and loss of color sense. Deafness is not uncom- mon and loss of the senses of smell and taste is by no means rare. Vasomotor Symptoms. Paleness or blushing of the skin as well as localized areas of coldness or heat may be present. (Edema has been observed. Haemop- tyses and haematemesis may be alleged by the patient but in these cases the blood as a rule comes from the gums and then only in small amount. Hyster- ical haemorrhages into the skin have been reported but must be most unusual. Such secretory disorders as excessive or diminished perspiration, diminu- tion or increase of the saliva and lessened or increased urinary excretion are frequently met, pol}airia especially so, the urine being profuse in quantity, light in color and of low specific gravity. The urine in marked cases often undergoes further change, the urates and phosphates being diminished and the normal ratio (i to 3) of the earthy to the alkaline phosphates being changed to I to 2 even i to i ; at the same time the urine is diminished in quantity. This change is considered by the disciples of Charcot to be a differential diagnostic point between convulsive hysteria and true epilepsy. Digestive Symptoms. These are common and may consist of simple indi- gestion, gastralgia, perversions of appetite or flatulence. Vomiting is frequent and may be voluntarily induced and oesophageal spasm resulting in dysphagia may occur. Constipation is frequent while diarrhoea is seldom seen. Respiratory symptoms consist of the hysterical cough which occurs parox- ysmally, is harsh and is accompanied by little or no expectoration; of dyspnoea HYSTERIA. 819 which may disappear upon diversion of the patient's attention, and obstinate hiccough. Cardiac symptoms such as arrhythmia, tachycardia or bradycardia and attacks of syncope are not unusual. Mental symptoms are prominent and variable. The patient is emotional, easily worried and excitable; the temper is irritable and hallucinations are frequent. True insanity may develop and rarely cataleptic trances have been observed. Hysterical fever has been reported as reaching a temperature of 105 to 110° F. (40.5-43.5° C.) or even higher. Such a rise of temperature occurs irregularly and usually patients exhibiting this symptom are malingerers and in some way manipulate the thermometer; close watching usually results in their detection. The prognosis in hysteria as regards life is good, fatal cases being rarely if ever seen. As regards recovery the prognosis depends upon the type of the disease in hand. Mild cases may recover within a few weeks, while others may go on for a number of years exhibiting intermissions and variations of the symptoms. Treatment. Prophylaxis of the disease consists in combating all the influences mentioned in the section on aetiology as likely to be predisposing factors. Children, especially those of neurotic tendency or heredity should be most carefully trained, they should be kept from association with hysterical persons and should be subjected to a proper system of training and education, self-control and denial being insisted upon, while over-indulgence and the gratification of every whim should be discouraged. In the treatment of hysteria much depends upon the personality of the physician. He should be of firm character, insistent upon the proper fulfil- ment of his orders and at the same time sympathetic within proper limits. The milder hysterical manifestations seldom require much treatment other than that directed at the cause of the condition; this, in the mild type as well as in the more marked form of the disease, should be removed if possible. The patient's general physical condition should be carefully supervised and any abnormality corrected; at the same a regular and hygienic mode of life should be insisted upon, with the proper diet, sufficient exercise and fresh air, and particularly shoiild the patient be provided with some congenial occupation in which he is able and willing to engage. Tonics, especially arsenic and iron in moderate doses, are usually indicated. For the hyper- irritability of the nervous system various sedatives may be prescribed such as the bromides, including monobromated camphor, asafoetida, castoreum, musk, chloroform, acetphenetidine, exalgine and the preparations of valerian. Hydrated chloral and morphine if used at all should be employed with the utmost caution. 820 DISEASES OF THE NERVOUS SYSTEM. The pains should be treated by means of the thermo-cautery and the gal- vanic current. Paralyses and cojitractures necessitate the employment of massage, manipulation and forced movements in connection with the electric current. Laryngeal paralyses may respond to electric treatment and anaes- thesia to frequent applications of the faradic current. Paralyses and contrac- tures of the limbs may persist despite anything that can be done. Hysterical vomiting may necessitate the employment of Debove's method of forced feeding (see p. 6i6). The hysterical attack may be treated by sprinkling cold water in the patient's face or by flicking the face with a wet napkin, the flesh may be pinched vigor- ously, or it may be well, having seen that the patient is properly disposed of, to leave her, allowing her to emerge from the seizure and find herself alone, no one being present to offer sympathy. It has been suggested that pressure upon the epigastric region or over the ovaries will cause a cessation of the spasmodic manifestations. In spite of any rigidity of the abdominal parietes the pressure, if continuous and energetic, will often prove effectual. In the male pressure may be made over the same areas. A galvanic current of from five to ten milliamperes, one pole at the front of the body and the opposite behind, may be employed. Repeated sudden interruptious of the current increase its ef&cacy. Another method of treatment, which has the advantage of entire safety, consists in giving inhalations of amyl nitrite. This drug rarely fails to stop the seizure and has an excellent mental effect upon the patient, ^ther and ethyl bromide may also be administered by inhalation but chloroform is hardly disagreeable enough to be of use. Capsules of aether which explode in the stomach are sometimes effective. In marked types of hysteria no treatment excels that first advocated by Weir Mitchell. It is particularly indicated in those patients who are confined to bed. It consists in placing the patient entirely under the care of a compe- tent nurse and if possible removing her from association with her family and sympathizing friends, and, while the treatment should be varied to meet the exigencies of each case, its main details are as follows: The patient is kept absolutely quiet in bed, is not allowed to read or, at first, even to feed herself. Massage and electricity are employed for gradually lengthening periods, being omitted, however, during the menstrual epoch. A slowly interrupted faradic current is to be preferred to the galvanic. At first the diet is entirely of milk either skimmed or diluted with lime, barley or carbonated water in propor- tion of about 4 or 5 to i; 4 to 6 ounces (120.0 to 180.0) are given every two hours, this quantity to be gradually increased in accordance with the tolerance of the patient. If necessary the milk may be peptonized. After from seven to ten days, the milk being continued, solid food is allowed at mid- day. A chop or raw oysters with bread and butter or toast and a cup of cocoa or coffee make an acceptable luncheon and after some days a breakfast con- NEUEASTHENIA. 82 1 sisting of an egg and a roll or a few biscuit is added. The patient should be given a sponge bath daily. In from four to six weeks the patient is allowed to sit up, a few moments at first, but as time passes, for longer periods and still later she is allowed to drive out and to take short walks. The latter are lengthened little by little until the patient is able to take considerable amounts of exercise without fatigue. The treatment should be carried out with the utmost regard for system and regularity, a schedule being made for the day, the hours for feeding, massage, electricity, exercise, rest, etc., being fixed. It is important that the patient should be allowed to rest for an hour after massage and the latter and electricity should never be given in close conjunc- tion, an interval of two to four hours is not too great. Most excellent results have followed this method of treatment particularly in thin, poorly nourished individuals. Hydrotherapeutic measures are often of service in hysterical conditions, the nervous irritability responding particularly weU to hot and cold packs. Hypnotism has been employed in the treatment of hysteria, especially in France, but while remarkable results have in numerous cases been achieved, most American writers unite in asserting that it should be used with the utmost caution if at all. NEURASTHENIA. Synonyms. Nervous Exhaustion; Nervous Prostration; The American Disease. Definition. Neurasthenia is a functional disorder of the nervous system characterized by exhaustion of both the mental and physical energies of the patient. .Etiology. The influence of heredity in this disease is well recognized, neurasthenia often occurring in those whose parents have been of neurotic or hysterical type or have lived the rapid, worrisome life that has become too common during the past three decades. Neurasthenia is more common in men than in women and results from over-work, attended with excessive mental strain or worry, as well as from the abuse of alcohol and tobacco, and the use of morphine. It occurs secondary to syphilis and the acute infec- tious diseases, particularly influenza; it may be caused by sexual excesses and perversions and by traumatism. Pathology. No definite morbid change in the nervous system has been recognized as characteristic of neurasthenia. Symptoms. These in many cases are similar to those of hysteria of the mild type but are varied, depending upon the organ or organs chiefly affected by the state of nerve weakness. In the cardiac form there are rapid and irregular heart action perceptible to the patient, and pain referred to the pre- 82 2 DISEASES OF THE NERVOUS SYSTEM. cordium. In the gastric type there are epigastric pulsation and sensations of distress after eating with borborygmi. Vaso-motor manifestations such as sudden hot flushes or sweats may occur and the patient may suffer from vertigo or attacks of syncope. In another type of the disease the symptoms are referable chiefly to the nervous system and consist of muscular weakness, often scP marked as to interfere with locomotion and the performance of ordi- nary acts with the hands and fingers, hyperaesthesiae and parsesthesise and disorders of the special senses. The mentality may be affected and the patient suffers from low spirits, despondency or irritability of temper. Insom- nia and mental confusion are not rare and the suicidal tendency may occur. Sexual neurasthenia is not uncommon, the patient complaining of frequent nocturnal emissions, a dread of impotence which may result in inability to perform the sexual act and spermatorrhoea, the discharge of seminal fluid often accompanying mictiirition or defaecation. In males suffering from this type of the disease there are frequently pain and tenderness of the testicles; ovarian tenderness and menstrual disorders are frequently associated with neurasthenia in women. Polyuria is frequently present, the urine being of light color and low specific gravity, although cases in which the urine is diminished in quantity and dark in color may be met. Puringemic conditions are not infrequent complica- tions of neurasthenia and this fact should not be forgotten when treatment is taken under consideration. The prognosis is good in cases which are willing and financially able to undergo the treatment necessary. Treatment. Prophylaxis consists in the attempt to so train children of neurotic inheritance and tendency that both the mental and physical forces may be conserved and rendered as resistant as possible. Over-indulgence is to be avoided and the child's food, school work, exercise and hours of sleep shoifld be studiously regulated. Highly-strung and irritable children should be managed with great tact, the nurse or teacher should never lose her own temper while controlling the child and any excessive excitement or emotion is best managed by giving a warm bath followed by a sponge off with cool water. After this the child may be put to bed for a few hoiirs and will usually go to sleep. Prophylaxis in adults consists in the avoidance of excessive business worry and the leading of a regular life, particular attention being paid to exercise and sleep; frequent vacations may be advisable and it is often well, if the patient can arrange it, for him to take these under conditions totally different from those to which he is accustomed at home and away from sympathizing friends and relatives. The diet of the neurasthenic shoifld be simple and noiirishing and, if allowed at aU, tea, coffee, tobacco and alcohol should be used in moderation. NEURASTHENIA. 823 Just as in the treatment of hysteria the physician about to take in hand a case of neurasthenia should seek to gain the implicit confidence of his patient. Naturally the ability to accomplish this object depends to a great extent upon the personality of the physician. The latter's visits, while regular, should not be too frequent and should be made at definite intervals. Much discretion should be used in responding to unnecessary calls from the patient. It is, perhaps, better to have an understanding with the nurse in this regard and to suggest that she use her discretion in transmitting such calls. The selection of a nurse is an important item. She should be a vigorous and robust woman and of a temperament as little nervous and emotional as possible. The rest cure described in the section on the treatment of hysteria was first devised for neurasthenic patients and in many cases, especially obstinate and resistant ones in women or those complicated by drug habit, achieves excellent results. Hydrotherapy is an efficacious form of treatment and if about to employ it the patient should be studied in order to ascertain whether his state is one of nervous excitation or of depression. In the former case the patient may not possess sufl&cient resistance to undergo a rigid course of bath treatment but will need to be strengthened by means of a systematic rest and diet cure before the hydrotherapeutic measures are admissible. In the ordinary type of neurasthenia the preferable mode of hydrotherapeutic procedure is the cold douche given but a short time and under considerable pressure. The jet should be applied in turn to all parts of the body except the head. Very excitable and emotional patients are benefited by the cold wet pack or half bath, followed by vigorous friction and exercise in order to produce a satis- factory reaction. If the cold douches impress the patient unfavorably the Scotch douche may be substituted. The douches are usually given twice a day, the patient being allowed to lie down for an hour or two after each. Electric treatment is often useful in connection with hydrotherapeutic procedures. Galvanism or Franklinization associated with the high frequency current and general faradization may be employed. The Franklinic and faradic currents and the actual cautery may be employed in localized pain. Patients able to travel are often greatly benefited by a sea voyage or a sojourn at one of the various spas where baths may be taken and mineral waters drunk. The latter frequently have an excellent mental effect upon the patient and the regular mode of life insisted upon at such resorts is bene- ficial. With regard to medicinal treatment is may be said that while, as a rule, drugs should be avoided if possible, there are cases in which good results may result from their use. Tonics, especially if anaemia is present, are often indicated and of these those worthy of special mention are iron, strych- nine and the arsenic preparations. Sodium cacodylate or iron cacodylate 824 DISEASES OF THE NERVOUS SYSTEM. may be given hypodermatically if the stomach is intolerant, the former in doses of f of a grain (0.05) twice a day, the latter in doses of ^u of a grain (0.02). The glycerophosphates may often be employed with benefit as follows: I^ calcii glycerophosphatis, gr. ivss (0.30); sodii glycerophosphatis, potassii glycerophosphatis, magnesii glycerophosphatis, gr. iss (o.io); ferri glycero- phosphatis, gr. f (0.05). Fiat chartula no. i. Sig. Take two such powders daily; or I^ calcii glycerophosphatis, 3iss (6.0); sodii glycerophosphatis, potassii glycerophosphatis, magnesii glycerophosphatis, ferri glycerophosphatis, aa gr. XXX (2.0) tincturas kolae, 5iiss (10. o); syrupi am-antii corticis amari, q.s. ad 5vi (200.0). Misce et signa one tablespoonful during breakfast and dinner. The syrup of hypophosphites may also be prescribed or subcutaneous injections of sodium phosphate two parts, alcohol five parts, and distilled water 100 parts may be given. Of the latter 15 to 45 minims (1.0-3.0) should be injected daily. Another drug which has recently been much advocated is lecithin. It is given in pill form — 4J to 7^ grains (0.3-0.5) daily — or hypodermatically in oily solution, each injection containing y^po to 2^ grains (0.05-0.15) of lecithin. Injections of artificial sera have been recommended as a stimulant to the nervous system and to lower blood pressure. Such sera may be composed of phenol in crystal form i part, sodium chloride 2 parts, sodium phosphate 4 parts, sodium sulphate 8 parts, distilled water 100 parts, or sodium phosphate 10 parts, sodium sulphate 5 parts, sodium chloride 2 parts, crystalline phenol J part, distilled water 100 parts. Of the former solution 2J drachms (lo.o) may be injected daily; of the latter i J to 2J drachms (5.0-10.0) twice a week. The solutions should be sterilized immediately before administration. The treatment of cardiac symptoms: The application of cold wet compres- ses to the precordium or of the aether spray will relieve the palpitation or if this is a result of gastric disorder, treatment should be directed to the stomach. The bromides and the valerates may be indicated when this symptom is the result of nervous excitability. The systematic employment of hydro- therapeutic measures vsdll tend to diminish the cardiac irritability. Gastric symptoms should be treated according to the principles suggested in the sections on the treatment of neuroses of the stomach. The pains and excessive nervousness may be allayed by the bromides or occasional doses of salipyrine, acetphenetidine or exalgine. For the sleepless- ness a warm bath or a wet pack taken before retiring will often prove effectual. If drugs are necessary such mild h3^notics as sulphonethylmethane (gr. x — 0.66), sulphonmethane (gr. xx — 1.33) or veronal (gr. x to xv — 0.66 to i.o) may be prescribed at intervals. Morphine should never be allowed. In sexual neurasthenia with nocturnal emissions and spermatorrhoea general treatment with attention to exercise and mode of life, together with the admin- THE NEURASTHENIA OF THE MENOPAUSE. 825 istration of hyoscyamus and the bromides, is to be advised. The loins should be sponged off with cold water or a cool sitz bath taken before retiring; no food should be eaten just before going to bed and the rectum should be kept .empty to avoid pressure upon the prostate and seminal vesicles. The pa- tient's mind should be kept occupied and off from thoughts upon sexual mat- ters and he should be assured that he has greatly magnified his trouble and the possible consequences thereof. The recent work done upon eye-strain renders it of paramount importance that any defect of vision should be properly corrected by the ophthalmologist. THE NEURASTHENIA OF THE MENOPAUSE. The incidence of the menopause (climacteric or change of life) is character- ized in many instances by the appearance of numerous manifestations analo- gous to those of ordinary neurasthenia. The anatomical basis of these is undoubtedly a disturbance of the sympathetic nervous system. On no other ground can the symptoms be satisfactorily accounted for and on no other theory can the triad of pallor, flush and sweating, in whatever sequence they may appear, the tachycardia, the dyspnoeas, the neuralgias, the vertigo, faintness, tinnitus aurium, headache, pruritus, the serous diarrhoeas, the veritable downpour of urine and the varying mental moods be explained. At the menopause, the slowly increasing blood pressure of the intermenstrual period which reaches its maximum at the onset of the flow, falls rapidly to its minimum at the termination of the period, going on in rhythmical cycle for about thirty years, is now disturbed; vaso-dilatation and vaso-constriction succeed and precede one another in irregular waves. Pathologically there is an actual insanity of vaso-motor function. The majority of the patients who suffer from symptoms due to the meno- pause consult the specialist in internal medicine or the family physician, It is equally true that both these fully realize the importance of gynaecological operations and treatment and insist that their patients shall receive them should such be necessary; consequently it behooves the physician to be able to make a proper diagnosis of the condition. In accomplishing this object malaria, purinaemia and other general maladies, as well as diseases of the circulatory, alimentary and nervous systems must be intelligently sought and excluded. Next, all local pathological conditions as determined by the gyne- cologist must be remedied. Having concluded that the symptoms are due to the menopause we have immediate necessity for a working hypothesis which shall at once explain the manifestations of the condition and serve as a basis for a successful treatment. Such a one has been discussed above and as has been previously stated the patient's state can best be accounted for by holding the sympathetic nervous system responsible. 826 DISEASES OF THE NERVOUS SYSTEM. Treatment. Disturbed balance of the sympathetic nervous system is most rapidly benefited by the use of the bromides. If the pulse is of good volume, tension and rate, sodium bromide in 15 grain (i.o) doses four times daily should be prescribed. If left ventricular hypertrophy exists the potassium salt, in the same dosage should be given. If cardiac dilatation has supervened or arterial pension is lowered, the ammonium salt, the dose also being of the same size, is preferred. In the presence of dyspeptic symptoms or if prolonged administration seems likely to be necessary, strontium bromide is advisable. What the bromides accomplish with rapidity arsenic will achieve more slowly but with greater permanence, consequently as the condition responds to the former the doses are diminished and arsenic is added, the solution of potas- sium arsenite (Fowler's solution) in 3 minim doses (0.2) after meals, being the most useful preparation. The dosage should be gradually increased until slight untoward symptoms arise, when the initial dose is resumed. Since most of the patients are ansemic, iron, as iron and ammonium citrate, in dose of 4 grains (0.25) three times daily is advisable. The following combination of these remedies is suggested: Strontium bromide i ounce (30.0); solution of potassium arsenite 2 drachms (8.0); iron and ammo- nium citrate 2^ drachms (lo.o); cinnamon water to 4 ounces (120.0). Of this mixture i teaspoonful (4.0) in a wineglass (60.0) of water is taken after each meal and at bed time. As the patient progresses toward recovery the amount of bromide is to be diminished while that of the arsenic is increased. In some instances when cessation of the menstruation is speedily established, and particularly after surgical removal of the ovaries in young subjects, the administration of ovarian extract, 5 grains (0.33) thrice daily for one or two months is necessary; the dose should be gradually lessened. In other instances the vaso-motor disturbance may be more readily controlled by smaller — 3 grain (0.2) — doses in connection with the bromides and arsenic. Such em- ployment of ovarian extract is only exceptionally advisable. For special indications further medication may be prescribed: (i) Menor- rhagia: This may be controlled by absolute quiet in bed with ice bags over the hypogastrium. The fluidextract of hydrastis 30 drops (2.0) twice daily, or better, cotarnine hydrochloride, either by the mouth in 5 grain (0.33) doses in capsule, or hypodermatically in the same dose in a 10 percent, aqueous solution, is useful. A formula which is often effective consists of fluidextract of hydrastis 2 ounces (60.0); ergotine 2^ drachms (lo.o); syrup to 5 ounces (150.0). Of this the dose is a teaspoonful (4.0) in a wineglass of water every hour or two. In rare cases tamponade of the uterus under thorough aseptic precautions may be necessary; more seldom it may be ad- visable to add 10 percent, of gelatin to the gauze, the latter being plain or impregnated with iodoform. 2. Neuralgia. This is best relieved by pills of monobromated camphor. AMOK OR AMUCK. 827 2 grains (0.13); quinine valerate i grain (0.065); extract of gelsemium (B.P.) 2 grains (0.13); extract of belladonna leaves i of a grain (0.012) given four or five times daily. As an alternative pills of extract of belladonna leaves i of a grain (0.012); extract of gelsemium (B.P.) 2 grains (0.13) and zinc valerate 3 grains (0.2) may be administered twice daily. 3. Psychic Disturbance. Sulphonethylmethane (trional) 15 grains (i.o) combined with heroine, ^^ of a grain (0.005) given at bedtime wiU tend to insure sleep during the night and quiet during the following day; or a suppository of dionine, ^ grain (0.03), in cocoa butter may accomplish the same result. These prescriptions shoiild be used only occasionally. 4. Palpitation. The tinctiire of veratrum in 15 minim (i.o) doses thrice daily to which may be added tincture of gelsemium 8 minims (0.5), is usually effectual. 5. Constipation is best remedied by the use of saline laxatives as Rochelle salt or such waters as Hunyadi Janos, Apenta, Rubinat Condal and the like. The other symptoms referable to the digestive tract are also benefited by the judicious use of salines. 6. Diarrhoea is usually of the nervous type and wiU yield readily to the bromides. In the daily life of the patient, fatigue, wakefidness, sexual excitation, cold baths and especially sea bathing, spiced and highly seasoned food, tea, coffee and alcohol in all forms are to be avoided. In other words a quiet life from which all extraneous sources of irritation are removed is advisable. When it is remembered that at the menopause the mind of the patient is in a state of unstable equilibrium the importance of this last injunction is apparent. Rest, therefore, both physical and mental, is doubly essential. For exercise and to secure the necessary fresh air daily walks in the open, but not to the point of fatigue, are suggested. AMOK OR AMUCK. This is a maniacal condition, seen amongst the Malay race, in which the individual affected runs through the streets in frenzy and with sword or other lethal weapon in hand slays or maims every one he meets until he meets death at his own hand or that of another. The disease as a rule attacks males and occurs in young adult life. According to the most recent studies the condition of Amok includes several states in which the affected individual commits violent, unthinking, unpremeditated and impulsive acts while mentality is blurred. Certain cases are classed as the insanity of adolescence, others as epilepsy, others under the rather indefinite term malarial psychosis, while still others are inexplicable. Before the onset of the attack proper the patient for a number of days is 828 DISEASES OF THE NERVOUS SYSTEM. lethargic, stuporous or morose and sometimes amnesic. The exciting cause of the seizure is usually resentment at a real or imagined injury, loss of money, anticipation of disgrace or punishment on account of some misdeed, the sight or odor of blood or a marital grievance or infelicity. During the attack there is entire absence of memory which is an important point in the differ- entiatioriof this condition from that of latah. The disease has been attributed to alcoholism, opium smoking and relig- ious mania but while there is indubitably a religious element in some of the cases, the two former factors may be excluded. It is the opinion of authorities that the individual who is " running amok " is not responsible for the acts committed during the frenzy. ASTASIA-ABASIA. Definition. A morbid condition in which the patient is unable to stand or to walk while the sensation, muscular power and coordination of the limbs remain normal. The affection is an hysterical functional neurosis and has an setiology similar to that of hysteria. It has been observed as a sequela of the acute infectious diseases and may result from nervous shock due to trau- matism. Symptoms. The symptoms typical of this condition are total or incomplete inability to stand or walk, while the limbs may be used in swimming and the patient is able to move them as he lies in bed. There is, in most cases, no disorder of sensation, no spasticity, no rigidity, the power or coordination is normal, and the muscles retain their normal strength. In some instances the patient may be able to walk but the gait is some- what spastic or ataxic, while in others the limbs may undergo sudden flexions or the patient may manifest a saltatory spasm. The prognosis is that of hysteria of the ordinary type and the treatment is that of this latter disease, the rest cure and electricity being particularly indicated. TRAUMATIC NEUROSIS. Synonyms. Traumatic Hysteria; Erichsen's Disease; Railway Spine; Railway Brain. Definition. An hysterical or neurasthenic condition following nervous shock, particularly that due to sudden severe traumatism. .etiology. This affection may be the result of severe mental shock resulting from participation in or even witnessing railroad accidents, explosions, ship- wrecks or other accidents. Even slight traumatisms, such as may result from a slip upon the pavement or stairs, may cause it. OCCUPATION NEUROSES. 829 Pathology. The morbid changes occurring in this disease are indefinite. Fatal cases are few but degeneration of the p}T:amidal tracts has been found after spinal concussion, and punctiform haemorrhages in the brain and cord, sclerotic patches in the white matter and sclerosis of the cerebral vessels have been described. Symptoms. In certain cases these are not markedly different from those of hysteria or neurasthenia due to other factors. Those referable to sensation are headache and backache, spinal tenderness, numbness and tingling in the extremities; hemiansesthesia with achromatopsia on the anaesthetic side or contraction of the visual field may occur. Motor symptoms of various degrees, tremor and even paralysis may be present. The reflexes may be exaggerated in degree differing from time to time. In severe cases with actual spinal concussion symptoms suggestive of organic disease of the nervous system may develop. These may appear early or may be gradual in their evolution and the accountable lesion has been found post mortem in certain cases in the shape of a pachymeningitis. The symptoms of such cases consist of pain in the head, back and other parts of the body, hemianesthesia and areas of diminished cutaneous sensation and of tenderness, loss of temperatiure sense and of muscular sense, the latter being bilaterally symmetrical or irregular in distribution, disorders of smeU and taste and diminution of the visual field with inequality of the pupils. Motor symptoms are of various t}'pes; monoplegia with or without consequent contracture, without atrophy and with persistence of normal electric irritability may occur vnth diminution of the cutaneous reflexes, the deep reflexes being increased. The mental symptoms are identical with those of marked hysteria. Rarely in cases which have been primarily regarded as hysterical or neuras- thenic, true organic changes evidenced by such symptoms as optic atrophy, bladder disturbances, increased reflexes, paresis and tremor, develop. Such cases may end in death, the organic changes being demonstrable upon autopsy. The prognosis as regards recovery is good, few cases, however, are relieved while litigation is in progress; even after the decision has been rendered in the patient's favor the symptoms may persist but usually after the suit is terminated gradual recover}^ begins. Rarely cases grow progressively worse and melancholic symptoms develop, followed by dementia or paresis. In the cases in which organic changes develop, the prognosis is unfavorable. Treatment consists in the employment of the methods and means suggested in the sections upon the treatment of hysteria and neurasthenia (pp. 819 and 822). OCCUPATION NEUROSES. Synonyms. Professional Spasm; Copodyscinesia. Definition. This term is employed to designate a variety of nervous condi- 830 DISEASES OF THE NERVOUS SYSTEM. tions characterized by involuntary spasm or cramp of the muscles employed in performing some frequently repeated movement. The affection is seen most frequently in writers and here is denominated writer's cramp or scrivener's palsy; similar conditions occur in telegraphers, piano-forte and violin players, typewriters, milkers, seamstresses, cigarmakers and other tradespeople who continually perform the same muscular act in carrying out their occupations. Etiology. While occupation neuroses occur in those of phlegmatic tem- perament they seem to be more frequent in those of neurotic tendency. Men seem to be more frequently afifiicted than women though this may be the case because the male sex is more likely to be employed in occupations in which the condition develops. Writer's cramp is the most common tj'pe of occupa- tion neiirosis and according to Gowers it is seen more often in those who employ imperfect methods in writing, using the little finger or wrist as fixed points, whereas the elbow or forearm should properly remain stationary. Injury may precede the onset of the affection. Pathology. No morbid changes t}^ical of this disease have ever been described. Various theories, however, have been advanced to account for its occurrence. Of these the most probable is that the affection is a central one and due to a disordered action of the nerve centers which control the muscular movements employed in writing. Atrophy involving the affected muscles is sometimes observed. Symptoms. The first of these to appear is usually a cramp or spasm, chiefly involving the thumb and forefinger. The pen may be grasped too forcibly while the forefinger tends to slip off the pen, or the thumb may be flexed and adducted. A "lock spasm" may occur in which the pen can be removed from the grasp of the fingers only with difficulty. The hand feels weary and aching; pain sometimes affecting the arm as weU as the hand may be present. The patient's grasp of the pen may be weak while the hand-grip remains normal. Tremor, most frequently of the index finger, may occur, sometimes as a precursor of atrophy. Numbness and tingling of the hand and forearm may be observed and if a true neuritis is present there is tender- ness along the course of the affected nerve. Marked cases may manifest such vaso-motor symptoms as glossy skin, a condition resembling that of chilblains or hypersesthesia, while on an attempt to write the skin may become hot and cyanosed. Electric reaction in the early stages remains unchanged but late in the disease the response of the motor nerve endings to faradism is diminished while that to galvanism may be increased. The prognosis in marked types of the disease is hardly favorable as regards complete recovery although rarely this may take place. Patients exhibiting sensory symptoms are more likely to recover than others in whom these are lacking. Relapses are not uncommon. OCCUPATION NEUROSES. 83 1 Treatment. Prophylaxis consists in the acquirement of a proper technique in writing, as it is probable that if writing from the shoulder were in general use, cases of writer's cramp would be rare. The various appHances calculated to lessen the fatigue of writing are of little use, and invention of the typewriter has rendered all such unnecessary. Fortunately the affection does not inter- fere with the patient's ability to use this instrument. Learning to write with both hands is a way out of the difi&culty unless both become affected with the disease; this unfortunate circumstance may occur. Rest of the affected part is essential to a cure and as an adjunct, attention should be given to the patient's general hygienic condition. Fresh ah and good food are necessities and, when indicated, the tonics, iron, arsenic, strychnine and codliver oil should be employed. Electricity may be prescribed with benefit, most authorities preferring the galvanic current; its use should be continued for months, a current of four milliamperes being sufficiently strong. The current may be applied every day or two for from five to ten minutes. Various methods of using the current have been advocated; the positive pole may be applied to the neck while the negative is placed in the supraclavicular fossa being at intervals moved to the skin over the affected muscles and nerves. The current may also be applied to the spinal column, or it may be passed through the head. If marked tre- mor is present the negative pole may be appHed to the spinal region while the positive is placed over the nerves and muscles involved. An ascending current through the affected arm, the negative pole being on the forearm or ball of the thumb and the positive upon the neck, may be used. So many variations in the technique of the electric treatment are employed by different authorities that it seems safe to suggest that it is the fact that galvanism is used that achieves benefit rather than that a special method is effectual beyond any other. A weak faradic current is indicated when paralysis and anaesthesia are present. Hydrotherapeutic measures, massage and g}'mnastic exercises are useful, particularly the last. The most efficacious are those employed by Wolff. These consist of active and passive movements, the former are performed .as follows: The fingers, hands, forearms, and upper arms are moved in every direction possible, effort being made to contract forcibly each muscle from six to twelve times. The exercise should last about half an hour, the patient pausing after the completion of each movement. The passive movements are performed in the same manner and as each is made the operator offers opposition. Both active and passive movements should be repeated two or three times a day. Massage, consisting especially of percussion of the affected muscles, is given in connection with this treat- ment. Re-education similar to that advocated in the treatment of locomotor 832 DISEASES OF THE NERVOUS SYSTEM. ataxia produces good results. The patient is given systematic instruction in holding the pen and writing. VASO-MOTOR AND TROPHIC DISORDERS. "» RAYNAUD'S DISEASE. Synonyms. Symmetrical Gangrene of the Extremities; Local Asphyxia. Definition. A vascular disease due to a disorder of the vaso-motor system and characterized by three stages: (i) local syncope; (2) local asphyxia; (3) local gangrene. -Etiology. The causation of this condition is indefinite and obscure. The disease occurs less frequently in men than in women and is more com- mon in indi^dduals in early adult life. Children may be affected. Pathology. This also is not yet definitely determined. Raynaud suggested that vascular spasm is responsible. The asphyxia occurs as a result of dila- tation of the capillaries and minute veins with spasm of the small arteries as an additional influence. Symptoms. Of these the first remarked is a paleness of the affected part followed by loss of sensation and a marble-like whiteness. The condition simulates closely that due to exposure to cold and affects chiefly the fingers or toes, and is known as local syncope. It lasts var}dng lengths of time but usually but for an hour or so and may occur following a chilling of the extremities or emotional disturbance. As the reaction sets in the affected parts become hot, reddened and painful. This is the stage of asphyxia and may not affect all the fingers at the same time, one or more of the extremities may be purple and livid while the whiteness of the others persists. The ears and the tip of the nose may be involved in this state of asphyxia and more rarely the limbs, the skin over them assuming a characteristic mottled appear- ance. With the pain there may be swelling and itching. Chilblains may occur as a complication of this stage. The attacks may recur from time to time, being induced by exposure to cold or mental disturbances, disappear- ing under the influence of warmth; the parts involved, may, after successive attacks, become shrunken and indurated. Few patients go on to the third stage, that of symmetrical gangrene. In such this manifestation succeeds the stage of asph}'xia, one or more of the fingers or toes becoming cold, dry and black in color, just as in dry gangrene. A line of demarcation is formed upon the skin beyond which gangrenous blebs may form and finally there may be sloughing away of the dead tissue, although usually the loss of substance is slight. In rare instances symmet- rical patches of gangrene make their appearance upon the limbs or body ERYTHROMELALGIA. 833 and progress rapidly. Here the outcome may be fatal within a few days, especially when the condition occurs in children. An associated symptom which may be met is hasmoglobinuria which may accompany the local manifestations or take their place; with this the urine may contain red blood cells and albumin. Other symptoms which have been observed are stupor and partial uncon- sciousness, delusions, dimness of sight, urticarial and erythematous eruptions, scleroderma, cutaneous oedema and joint swelling which may resiilt in enlarge- ment of the finger joints and anchylosis. Peripheral neuritis may occur as well as symptoms of disturbance of the digestive system. The prognosis as regards the preservation of life is usually good, weak and poorly nourished children, however, may succumb; those whose powers of resistance are good may outgrow the predisposition to the disease. Treatment. All individuals subject to this disease should receive treat- ment calculated to improve their general condition, in the shape of tonics, proper diet, etc., and should avoid exposure to cold and mental irritation. During the attack the patient should be kept in bed and warmly covered, the limbs should be elevated and the fingers and toes wrapped in cotton, artifi- cial heat being supplied in the shape of hot water bottles, if necessary. Rubbing the affected parts and the employment of galvanism and faradism are often beneficial. Placing the limb in warm salt water and applying one electrode to the spine while the other is put into the water has been recom- mended. Good results have been reported from the administration of glyceryl nitrate, gr. y^o ^^ sV (0.0006-0.0012) three times a day. The effect of this drug is to relax the vascular spasm and thus to improve the circulation of the part. Shutting off the supply of arterial blood of the limb by means of a tourniquet or an elastic bandage for a few minutes and then releasing the constriction wiU result in a reddening of the part owing to the relaxation of the vaso-motor tension and is said to be beneficial. This procedure, in severe types of the disease, must usually be frequently repeated in order to prove effectual. For the severe pain salipyrine, acetphenetidine and antipyrine may be admin- ' istered; this symptom, may, however, require the exhibition of codeine or morphine; the last must be given with caution. ERYTHROMELALGIA. Definition. A rare chronic disease characterized by pain, hypersemia and rise of temperature in the part affected, this usually being one or both of the lower extremities. More seldom is the upper limb involved. .Etiology. The causation of this affection is somewhat obscure. It S3 834 DISEASES OF THE NERVOUS SYSTEM. may occur with certain spinal cord lesions, and in diabetes mellitus. Arterio- sclerosis seems to exert a certain influence in its incidence. Pathology. The most constant morbid change is a chronic inflammation of the arteries of the affected part. Weir Mitchell, who first described the condition, suggests that it may be due to a neuritis of the nerve-endings while another ^theory that has been advanced is that the lesions may be due to irri- tation of the anterior horn cells of the cord. Symptoms. These are first noticed in the ball of the foot or the heel and consist of pain varying from vague discomfort and sense of weight to extremely severe pain; swelling may appear later, especially after walking or standing. The skin is reddened, the veins are dilated and there may be visible arterial pulsation. Rest and elevation relieve the symptoms to a considerable degree. The condition is usually relieved by cool weather, but not in every instance. The prognosis as to life is favorable but the patient may be subject to recur- rences at varying intervals. Treatment. An attack may be aborted by bathing the limb with ice water. The affected part should be kept elevated and compresses wet in cooling lotions should be applied. Intermittent hot and cold douches may be em- ployed and the use of the faradic current and of systematic massage may prove beneficial. The pain may necessitate the administration of analgesic drugs. The patient's general condition should be cared for and tonics should be prescribed if necessary. ANGIONEUROTIC (EDEMA. Synonym. Giant Urticaria. Definition. A disease characterized by the sudden occurrence of transient localized oedematous swelling. .Etiology. Heredity plays a definite part in the causation of this affection; it seems to be more common in females than in males in the United States, while the opposite is the case in Eiu-opean countries. It is more common in individuals of nervous temperament. Attacks may be induced by exposure to cold or any influence which reduces nervous tone. The giant urticaria which occurs in digestive disturbances and in certain persons after eating strawberries, crabs or lobsters is probably a variety of angioneurotic oedema. Pathology. This disease has been considered to be due to a neurosis of the vaso-motor system resulting in dilatation and an augmentation of the per- meability of the blood-vessels. Symptoms. The most frequently affected region is the face; more rarely are the hands and genitals involved; the condition may occur, however, in any portion of the body even in the throat and pharynx. In the last situa- tion symptoms of asphyxia result and death has been known to take place. MIGRAINE. 835 Digestive disturbances such as vomiting, colicky pains and diarrhoea, may be associated with the cutaneous manifestations. The area affected is small, as a rule being not over two or three inches in diameter, and varies in color from pallor to deep red; itching and burning sensations may be present but pain is rare. Periodicity has been noticed in the occiirrence of the attacks and such associated symptoms as cardiac pain and haemoglobinuria have been observed. The disease is not dangerous to life except when there is involvement of the air passages, but often is very resistant to treatment. Treatment. This consists in the employment of all measures which tend to improve the general condition of the patient such as tonics, especially those which affect the nervous system (phosphorus, the glycerophosphates, quinine and strychnine) ; in anaemic states arsenic and iron should be given and under all conditions the insistence upon proper diet and exercise in the open air is necessary. Hydrotherapeutic measures are often beneficial and hypnotism has been suggested. This last form of treatment should, however, be employed with caution. The local treatment consists in the application of a 10 percent, ointment of ichthyol upon compresses of gauze. The routine administration of glyceryl nitrate in doses of y-^-jj- to ^of a grain (0.0006-0.0012) three times a day often produces excellent results. If, as has been suggested, the oedematous condition is due to an increased permeability of the blood-vessels, the treatment by dechloridation (elimination of sodium chloride from the diet) may be tentatively prescribed. When gouty, rheumatic or purinaemic con- ditions are present these should be corrected by appropriate treatment. MIGRAINE. Synonyms. Sick Headache; Hemicrania; Bilious Headache; Megrim. Definition. A sensory neurosis characterized by headache, often unilateral, and sometimes by nausea and vomiting and visual disorders. iEtiology. Heredity seems to exert a definite influence upon the causation of this disease. It occurs more frequently in women, especially those of nervous temperament, and not seldom in those whose general physical condi- tion is excellent. Pinrinaemic states predispose to its incidence and the con- dition may be induced by eyestrain, menstrual abnormalities, mental and physical over-exertion and alimentary disorders. Predisposing causes are dental caries, and abnormal intranasal and nasopharyngeal conditions. In chronic nephritis recurrent migraine is not uncommon. Symptoms. The onset of the attack may be sudden or there may be pro- dromata such as dizziness, ringing in the ears, spots before the eyes and pecu- liar visions — the patient seeing imaginary animals, for instance. Temporary hemianopsia or scotoma may be observed. The pain soon makes its appear- 836 DISEASES OF THE NERVOUS SYSTEM. ance. It is usually frontal and on only one side although it may begin in the temple or occiput. From the original situation it extends to one-half or the entire head. In character it is continuous, sharp and boring. It is increased by noise and a bright light. The appetite is lost, there is marked nausea which may be followed by vomiting; the vomitus consists first of the contents of the stomach — partially digested food or mucus — and later of bile. If the vomiting takes place when the stomach is full the pain is often relieved. Vaso-motor manifestations such as paleness of one side of the face which may be followed by marked redness, may be noted. Arteriosclerosis of the temporal artery on the affected side is not infrequent. The rate of the pulse is usually not accelerated. The attacks tend to recur periodically and their duration is variable, last- ing from one to three days. The disease is an obstinate one, although the prognosis as regards life is favorable. In certain instances the attacks, after having persisted from youth, have disappeared after the age of fifty has been reached in males, and after the menopause in females. Treatment. This should depend upon the cause if this can be ascertained. The diet and mode of life should be' carefully regulated. Some patients do well upon an entirely vegetable regimen. The bowels should be kept regu- larly open and any digestive derangement corrected. The eyes should be examined by a competent ophthalmologist and proper lenses prescribed if necessary. Intranasal and pharjTigeal conditions should receive appropriate treatment. The urine should be examined for albumin and to ascertain if the excretion of uric acid is sufficient. Should the migraine be due to purin- asmic conditions these should be treated (see p. 252). In anaemia the admin- istration of iron and arsenic is indicated. In neurotic patients all emotional disturbance should be avoided. The treatment by means of the bromides, especially potassium bromide, may prove effectual. This drug should be given in doses of i to 2 drachms (4.0-8.0) per day and continued if necessary for eight to twelve months. The point of toleration should be ascertained and the maximum dose given for six months; for the succeeding two to four months the dosage should be gradually diminished and at the end of about one year the drug should be stopped. When arterial h}^ertension is present glyceryl nitrate may be given (tott to 5^ of a grain — 0.0006 to 0.0012). Here inhalation of amyl nitrite, 3 to 5 drops (0.2-0.33) may abort an attack. In patients in whom the paroxysm is attended by marked nausea and vomit- ing a thorough gastric lavage followed by a saline purge, if employed as soon as any prodromata are noticed, may succeed as a preventive measure. During the attack the patient should be kept in bed in a darkened room; the nausea may be relieved by a cup of strong coffee or by 20 to 30 drops (1.33-2.0) of chloroform. Hot or cold compresses should be applied FACIAL HEMIATROPHY. 837 to the head. The treatment of the attack otherwise consists in the admin- istration of various analgesics such as salipyrine, antipyrine, or acetphenetidine. The following formula may be recommended: I^ acetanilidi, gr. iii (0.2); camphorae monobromatse, gr. ii (0.13); caffeinae sodiobenzoatis, gr. i (0.065). One such powder may be taken every three or four hours. I^ acetphenetidini, gr. viiss (0.5); siilphonmethani, gr. xv (i.o); three such powders may be taken during twenty-foiu: hours. I^ acetanilidi, sodium bicarbonatis, aa gr. iiss (0.16); caffeinae citrate, gr. i (0.065); extract! aconiti, gr. 2V (p.oo^). One such tablet every three or four hours. Citrated caffeine alone in doses of 5 grains (0.33) or caffeine sahcylate in the same dose may prove beneficial. This drug may also be given hypodermatically — caffeine sodiobenzoate, 5 to 10 grains (0.33-0.66). Cannabis indica as the extract is considered by some to be the most effectual drug in the treatment of migraine. Its beginning dose is J grain (0.016). This dosage is gradually increased and the administration of the drug may be continued for a considerable period. Aconitine (Duquesnel) may be employed in doses of 4^ to 2^0 of a grain (0.00015-0.0003). When heart weakness is present strychnine should be given at the same time. This last drug is especially indicated in ophthalmic migraine. Tinc- ture of gelsemium 10 to 20 drops (0.66-1.33) either alone or with | to I grain (0.032-0.065) of extract of cannabis indica may relieve the severe pain of an attack. Other drugs which have been advocated in the treatment of this condition are ergot and guarana. When the attack is accompanied by emesis it is usually best to administer medication hypodermatically or per rectum. If the pain is conffned to the course of a certain nerve the over- lying skin may be painted with a mixture of menthol, chloral and camphor. When less drastic measures fail a tape seton may be passed through the skin of the nape of the neck and allowed to remain in place for two or three months. Electricity may be tried, preferably in the form of galvanism; one pole should be applied over the cervical sympathetic and the other to the nuchal region. The employment of hydrotherapeutic measures, particularly as carried out at one of the various spas, may benefit certain patients, perhaps rather because of the enforced regularity of life than because of the baths themselves. A sojourn at Vichy, Carlsbad, Evian or at some of the similar resorts in this country may induce favorable results. FACIAL HEMIATROPHY. Synonym. Unilateral Progressive Facial Atrophy. Definition. A rare affection characterized by a gradual wasting of the integument, fatty tissues, muscles and bones of one side of the face. .etiology. While this disease is obscure in its causation it is doubtless 838 DISEASES OE THE NERVOUS SYSTEM. due to a neurosis of the trophic functions. It is more common in females and may occur secondary to the infectious diseases and in s}Tingomyelia. Pathology. In the only autopsy in which the findings were such as to give evidence of the nature of the affection an interstitial neuritis of all the branches of the trifacial nerve in its terminal stage was found. Symptoms. The disease usually begins in childhood but in rare instances may not appear until adult life. The atrophy more frequently affects the left side of the face though bilateral involvement and patients who exhibited atrophic areas on the back and arm of the affected side have been observed. At its inception the wasting may aft'ect a definitely localized area upon the face or may be diffuse. The skin and subcutaneous tissues are first affected, then the bones, particularly those of the upper jaw, and finally the muscles, especially those of mastication. In the unilateral U^e the atrophy is dis- tinctly Hmited at the mid-line of the face and the facial appearance is remarkable, giving the impression that the countenance is composed of two halves from different individuals. There may be hemiatrophy of the tongue and soft palate and the teeth may fall out as a result of the wasting of the gums and alveolar processes; the skin often changes in color and the hair of the affected side falls. The orbital fat is involved in the wasting process and the eye is sunken. Motor and sensory symptoms are rare but spasm of the facial muscles and disordered sensation may be present. The disease is not dangerous to life but is of chronic course and little influ- enced by treatment. Treatment consists in the regulation of the patient's mode of life in ac- cordance with proper hygienic considerations and the systematic employment of electricit}^ and massage. MYASTHENIA GRAVIS. Synonym. Asthenic Bulbar Paralysis. Definition. A condition characterized by progressive muscular weakness, an increased susceptibility to fatigue and the presence of the myasthenic reaction of Jolly — a tendency on the part of the muscles to exhaustion when subjected to the faradic current. iEtiology. The cause of this disease is unknown, although the infectious diseases may exert an influence in its production. Pathology. No definite pathological changes have been described but in certain instances lymphoid infiltration of the muscular tissue and a prolif- eration of the essential elements of the thymus, together with an infiltration of lymphoid cells, have been found. Symptoms. The disease occurs chiefly in the young; the muscles of the eyes, face, and those of mastication and swallowing are first involved. Later PERIODICAL PARALYSIS. 839 the affection spreads to the other muscles of the body. Walking may become difl&cult and a characteristic feature is a rapidly developing fatigue following the continued use of the muscles. Their power is, however, recovered after resting. The myasthenic reaction is a pathognomonic symptom. Dyspnoea may be present. The course of the disease is marked by remissions and recoveries have been reported, although usually the patient dies from exhaus- tion or dyspnoea. Strangulation while attempting to swallow has caused death in some instances. There are no atrophic changes; spastic manifesta- tions and tremors are absent. Treatment is usually of slight avail. Rest, both mental and physical, is an essential. Electricity is contraindicated, massage, however, may be employed. Strychnine and antisyphilitic treatment may he administered but little benefit is to be expected. When disturbance of deglutition is present the patient may be fed by means of the nasal or stomach tube. PERIODICAL PARALYSIS. This is a rare and interesting condition which occurs in certain families or in isolated individuals. It is characterized by a suddenly appearing paralysis involving various groups of muscles. It is probably due to autointoxication and in a number of cases a dimin- ished excretion of kreatinine occurring shortly before and at the beginning of an attack, has been observed. Symptoms. The disease may appear suddenly and without assignable cause in otherwise healthy individuals or prodromata in the shape of malaise and weakness in the parts to be affected may be noticed. The limbs, especially the legs, are chiefly involved in the paralysis, although paralysis of the entire body has been observed. The cranial nerves and the special senses escape. The reflexes are diminished or lost and faradic irritability of both muscles and nerves is absent. There is usually no febrile movement nor acceleration of the pulse although symptoms of acute cardiac dilatation may be present in some instances. After a few hours or days the paralysis begins to disappear rapidly and the patient quickly and entirely recovers. Recurrences are frequent, occurring at intervals varying from a day or two to two or three weeks. Seizures are rare after fifty years of age. The paralysis is never permanent but patients sometimes die during an attack. Treatment. The administration of the alkaline diuretics, particularly potassium citrate in doses of 20 to 30 grains (1.33-2.0) three times a day is said to prevent or shorten the seizures. This fact is perhaps in favor of the theory that the condition is due to the retention of toxic substances which should be excreted in the urine. 840 DISEASES OF THE NERVOUS SYSTEM. ADIPOSIS DOLOROSA. Synonym. Dercum's Disease. Definition. A rare condition characterized by the deposition of masses of fat in the subcutaneous tissue of various parts of the body. These masses are tender and painful. etiology. The disease is one of women in the great majority of instances and has been considered to be the result of the early incidence of menopause and of atrophic changes in the thyroid gland. Its actual cause is unknown. Pathology. The fatty deposits are denser than normal fat tissue owing to the more abundant connective tissue supporting framework. Atrophy and sclerosis of the thyroid gland have been observed and in one instance a tumor of the pituitary body was found. There may be degeneration of the cutaneous nerves with interstitial neuritis and the fatty tissue may contain haemolymph glands. Symptoms. As adult life progresses and the patient's adipose tissue in- creases it is noticed that the fat is unevenly distributed and that burning, shoot- ing pains occur referred to the deposits of fat; these continue to increase in size and there is increasing weakness without signs of degeneration of the mus- cular system. Cerebration may become sluggish but there is no true mental disturbance. Irregular areas of h}rperaesthesia or of anaesthesia may be ob- served and there is frequently loss of the patellar reflex. The prognosis. The coiirse of the disease is chronic and recovery appears to be impossible. Death occurs from some intercurrent affection. Treatment. The administration of extract of the thyroid gland seems to lessen the severity of the symptoms in certain instances; it is given to the point of tolerance and may prove effectual. The pains should be controlled by the coal-tar analgesics, antipyrine, salip}Tine or acetphenetidine; codeine may also be employed and, in cases of absolute necessity, morphine. ACROMEGALY. Definition. A chronic disease characterized by abnormal growth, par- ticularly of the bones of the face and extremities. .Etiology. The affection is rather more common in women than in men and usually begins between the ages of twenty and thirty years. Syphilis, rheumatism and the infectious diseases have been considered as predisposing to the condition but their influence in its incidence is not proven. In the light of recent research it is deemed probable that acromegaly together with gigantism and dwarfism, occurs as a result of a disordered function of the pituitary body. Pathology. The bony hypertrophy is uniform and symmetrical; it affects both the shafts and extremities of the long bones; the maxillae appear ACROMEGALY. 84I increased in size due to enlargement of the antrum of Highmore; this with a true hypertrophy of the mandible causes the characteristic increase in the size of the face. In a very large percentage of the autopsies which have been made in this disease, involvement, usually hyperplasia, of the pituitary gland has been found which has led to the hypothesis that the affection is caused by a functional derangement of this structure and that the pituitary body presides in some way over skeletal growth and that the enlargement of the bones in acromegaly results from a hypersecretion of this organ. Persist- ence and enlargement of the thymus gland has been observed in certain instances as has also enlargement of the thyroid body as well as atrophy of this structure. Symptoms. The head and face are much increased in size, the latter especially so; it is much lengthened as a result of widening of the alveolar processes and there is noticeable separation of the teeth. The lower lip may protrude, the neck seems to be shortened, the ears are prominent and the alae of the nose together with the eyelids, are enlarged; the tongue may be thickened. The skin may be coarse, changed in color and moist but is not harsh, thickened and dry as in myxoedema. The bones of the limbs and especially of the hands and feet, are enlarged, the fingers and nails are broad and the hand possesses a spade-like appearance. The enlargement is symmetrical and there is no interference with function. The increase in size does not involve the legs and arms until late in the disease when there may be an augmentation of their circumference. The scapulae, ribs, sternum and vertebral column may be affected, kyphosis being a not unusual late symptom. Muscular atrophy is sometimes present; the genitals may be enlarged. Headache and pains in the bones may occm*, the patient is lethargic and cerebration is slow. The voice may be changed due to the lingual thickening and enlargement of the laryngeal cartilages and the special senses may be dulled. Ocular manifestations are frequent, a common early symptom being bitemporal hemianopsia. Optic nerve atrophy is frequent and neuritis may be noted. Menstrual disorders are not unusual and early menopause may occur. The patient may suffer from dyspnoea, palpitation and cardiac h3rpertrophy and there may be increased dulness over the manubrium sterni due to a persistent thymus gland. The diagnosis is usually easy, the bony enlargement being general, not of the extremities of the bones only as in arthritis deformans or of the shafts alone as in osteitis deformans. Congenital progressive hypertrophy or giant growth affects one extremity or one side of the body only. The prognosis is entirely unfavorable as to recovery but life is usually preserved for a long period unless terminated by intercurrent disease. Fatal instances of acromegaly have been observed which were probably due to pituitary neoplasm. 842 DISEASES OF THE NERVOUS SYSTEM. Treatment is unavailing. Thyroid extract gives no definite results and the same may be stated of extract of the pituitary gland. The headache and pain in the bones may be relieved by antip}Tine or acetphenetidine. LEONTIASIS OSSEA. -J This is a rare disease characterized by an enlargement of the cranial bones and in some instances, of those of the face. The condition is the result of an hyperostosis due to a development of multiple osteophytes in the bones af- fected. In addition to the increase in the size of the bones, osteomata may- appear upon the outer or inner surfaces of the cranial bones which some- times may press upon the subjacent structures and give rise to the symptoms of tumor. The onset of the disease may occur in early life, sometimes fol- lowing trauma. There is no known effective treatment. OSTEITIS DEFORMANS. Synonym. Paget's Disease. Definition. A rare disease characterized by enlargement and softening of the shafts of the long bones and sometimes of those of the spine and cra- nium, those of the face being unaffected. The changes in bony structure result in certain deformities such as a trian- gular shape of the head, the base being upward, and spinal curvature, more particularly a kyphosis in the dorsal or cervical region. The head is projected anteriorly and the legs may be bowed outward, anteriorly or posteriorly, the hips and lower thorax are widened and the abdomen becomes lozenge shaped. .Etiology. The causation of the disease is unknown but the condition has been considered to have a possible relationship to acromegaly or osteo- malacia. Pathology. Microscopic examination of the bone structure reveals the presence of a rarefying osteitis associated with the formation of new bony lamellae, some of the Haversian canals being wider than normal while others are contracted. The symptoms consist chiefly of the deformities resulting from the bony- enlargements. Treatment appears to be vauleless. HYPERTROPHIC PULMONARY OSTEOARTHROPATHY. Definition. A condition characterized by enlargement of the bones of the hands and feet especially in the neighborhood of joints. Occasionally the ends of the bones of the forearm and les;s are involved. The affection is usu- SCLERODERMA. 843 ally associated with some pulmonary lesion such as chronic bronchitis, emphy- sema, tuberculosis, empyasma, fibroid phthisis or neoplasm. Etiology. The causation of the affection is not definitely known. It is a disease of adults and has been attributed to the toxins of the pulmonary lesion which being taken into the circulation bring about an ossifying periostitis by their irritant action; other hypotheses are that it is due to circulatory obstruction and trophic nervous disorders or that the condition is a Henign tuberculous inflammation. Pathology and symptoms. The bones of the head and face are not involved. There is enlargement of the terminal phalanges and the nails are increased in size and curved over the finger ends causing the so-called clubbed fingers. There may be osteitis and thickening of the shafts of the long bones and joint effusions; spinal curvatures are rare but may result from direct extension of the pulmonary disease. Muscular atrophy from disuse may be present. The course of the affection is protracted and its development is slow although in occasional instances the evolution of the deformities is moderately rapid. Pain and tenderness are infrequently observed. Treatment. The deformities cannot be influenced by medication. The chief indication is to combat the go-existing pulmonary condition by ap- propriate means. SCLERODERMA. Synonym. Dermatosclerosis. Definition. A chronic condition characterized by local or generalized stiffening and induration of the skin. There are two types of the disease; the diffuse and the circumscribed, the latter being also known as morphcea. .etiology. The circumscribed type is the more common and may be of trophoneiirotic causation. The diffuse form is probably of similar origin and seems to be predisposed to by exposure and attacks of rheumatism. It may develop as a complication of exophthalmic goitre or in association with Raynaud's disease. Both forms occur more frequently in women and usually in middle adult life. Pathology. There is no change in the epidermis; there is an increase in the connective tissue of the corium and an hyperplasia of the subcutaneous connective tissue probably resulting from arterial changes. The glands of the skin are not altered but there may be atrophy of the thyroid gland. In the diffuse form of the disease the cutaneous changes are general while in morphcea they are localized. Symptoms. The diffuse type of scleroderma is rarer and more obstinate than the circumscribed. The skin of the extremities, of the face, of the chest 844 DISEASES OF THE NERVOUS SYSTEM. or of the neck is fia"st affected; the skin becomes firm and tense and upon movement a peculiar stiffness is observed; later it becomes brawny and indu- rated and, while sometimes its normal appearance persists, it is more often smooth and glossy. Ultimately the skin becomes so hard and inelastic that flexion of the joints which are covered by the affected tissue is difficult or impossible. When the face is involved the expression is lost and the lips may become immobile. Cyanosis of the extremities may occur due to vaso- motor disturbances and pigmentation resembling that of Addison's disease may be observed. When the condition is not general it tends to symmetry of distribution which the circumscribed type of the disease does not. The course of the affection is chronic, months often being required for its develop- ment. While it may persist in statu quo for years at times it gradually disap- pears leaving no trace. Sclerodactyly may be considered as related to scleroderma. Here the fingers become atrophied and their skin is thickened and glossy; the nails are dis- torted and pigment, ulcerations and excoriations may appear over the joints. The circumscribed form or morphoea is characterized by the appearance of brawny, waxy patches upon the skin, usually of the breasts or neck, some- times along the course of the nerves. Hj^eraemia with pruritus may be an initial symptom, later there may be deposition of pigment or entire loss of coloring matter (leucoderma). The patches often develop and spread with rapidity and there may be sensory distiirbances. While the cutaneous mani- festations may persist for only a few weeks, at other times they remain for years; iiltimately, however, they usually disappear. Treatment. The only medication that seems to exercise any effect over the condition is thyroid extract. Instances have been reported in which much benefit was derived from its administration. It may be necessary to continue its use for years. Tonics should be given, iron, codliver oil and especially arsenic. The salicylates and phenyl salicylate in doses of lo to 15 grains (0.66 to i.o) three times daily have been recommended and the use of the galvanic current upon the lesions has been advised. The patients should be kept warmly clothed and protected from exposure. Warm baths and massage of the affected parts with bland oils or, in protracted and obstinate instances, with oil of turpentine well diluted with olive oil should be employed to lessen the stiffness of the skin. AINHUM. Definition. A trophoneurosis characterized by the development of a furrow in the digito-plantar fold and finally resulting in amputation of the toe. .Etiology. This disease affects the dark skinned races almost exclusively. It is not infrequent in Brazil, India and Africa and has been observed in the AINHUM. 845 United States. Traumatism may act as a predisposing factor. No specific cause is known. Pathology. Microscopically a constricting band of fibrous tissue is seen about the base of the toe; this gradually becomes tighter, the member swells, becomes disintegrated without suppuration, and finally falls off. Symptoms. The little toe is most often involved. The furrow is first seen upon its inner aspect, increases laterally, becomes deeper, the toe swells and burning pain may extend to the foot or up the leg. Finally the swelling disappears and the toe is spontaneously amputated leaving a dry scab behind. Constitutional manifestations are wholly wanting. The prognosis is favorable as regards recovery although the process may persist for a number of years. Treatment is entirely surgical. Early in the affection the constricting band should be severed. After the toe has degenerated amputation will hasten recovery. 846 DISEASES OF THE MUSCULAR SYSTEM. CHAPTER XI. DISEASES OF THE MUSCULAR SYSTEM. MYOSITIS. INFECTIOUS MYOSITIS. Synonym. Suppurative Myositis. Definition. An acute or subacute inflammation of striped muscle due to an infectious agent. etiology. The disease has been observed most frequently in Japan and seems in most cases to be due to infection with the staphylococcus pyogenes aureus, while more rarely the albus is found co-existing or the streptococcus seems to be responsible for the condition. Pathology. The distinctive lesions seem to be firmness, brittleness and fatty degeneration of the muscles involved, serous infiltration and hyper- plasia of the intermuscular septa. Abscesses may be present in the substance of the affected muscles and an irregular erythematous rash is often seen. Symptoms. The muscles of the limbs are more usually affected but those of the body and the heart muscle may participate in the infection. The onset of the disease is usually sudden with marked febrile movement and prostra- tion. There is swelling of the muscles with slight oedema and an erythemat- ous rash upon the body and limbs. There is pain in the muscles, motion increases this symptom. Paraesthesiag may occur in lieu of the pain. Later abscesses with their ordinary symptoms may form in the substance of the mnscles and pyaemia may follow. Cases have been reported in which atrophy of the affected muscles occurred but these may have been instances of acute progressive muscvilar atrophy. The disease has been called pseudo-trichinosis from its resemblance to that affection. The coinse of infectious myositis lasts from one month to a year or more. Polymyositis Haemorrhagica is the name given to form of myositis differ- ing little from the preceding except for the fact that during its course haemor- rhages between the muscle fibres occur and circulatory symptoms resulting from involvement of the heart muscle are observed. OSSIFYING MYOSITIS. 847 OSSIFYING MYOSITIS. Synonym. Myositis Progressiva Ossificans. This is a rare disease characterized by a calcification of the muscles. It is seen most often in males and is likely to begin about the age of puberty. Its course is very protracted and finally most of the muscles may become involved. The process begins with fever and swelling and redness of the muscles affected; induration persists after the acuity of the condition has disappeared and the indurated areas are finally transformed into bony sub- stance. Entire muscles may become ossified. Theories advanced to account for the process are that the bone development originates from the periosteum or that the bone develops according to Cohnheim's law of foetal inclusion and is a true osteoma. Traumatism seems to be an exciting cause. Treatment. This consists in all varieties of myositis in relieving the symp- toms as they arise. The abscesses in the suppurative type should be opened and drained and the bony growths of the ossifying form may be excised if necessary. MUSCULAR DYSTROPHIES. PSEUDO-HYPERTROPHIC PARALYSIS. Synonyms. Lipomatosis Luxiirians Muscularis; Atrophia Muscularium Lipomatosa. Definition. A paralytic condition of the muscles associated with atrophy which is obscured by hyperplasia of the interstitial fatty tissue. .etiology. Heredity is the only recognized causal factor and is of consider- able influence. The disease is one which affects children chiefly and boys more than girls. It is usually transmitted through the mother although she may not have been herself afflicted. It is often seen in several successive generations and may occur in several individuals in the same generation. It usually develops before puberty but may appear as late as the twenty-fifth year or beyond that age. Pathology. The nervous system is seldom affected, the chief lesion being in the muscles themselves. The muscle fibres first are increased in size, their nuclei become more numerous and the connective tissue is increased. Later the muscle fibres atrophy and become fissured, the connective tissue becomes much hypertrophied and there is marked increase in the fatty tissue between the muscle fibres. Symptoms. The symptoms of the paralysis appear before the evidences of the pseudo-hypertrophy. The child is unsteady upon his legs, the movements are clumsy, especially so in jumping and in ascending stairs. Examination 848 DISEASES OF THE MUSCULAR SYSTEM. reveals what seems to be an enlargement of certain muscles; the pseudo-hy- pertrophy being especially evident in the calves and later in the extensors of the leg, the glutei and the lumbar muscles; those of the upper extremity are seldom affected save the deltoid and triceps. Walking becomes difl&cult, and the characteristic waddling gait with shoulders thrown back, abdomen protruded, and the lumbar lordosis accentuated, is evident; the nates are prominent and the feet far apart. As the legs are raised the feet drop because of weakness of the dorsal flexors of the foot. A very characteristic symptom is elicited by placing the child on the floor and bidding him to rise. He first gets on all fours, rises to his feet by drawing his arms along the floor and assumes an erect position by climbing his own legs by drawing the hands up the limbs until one knee is reached, then with this as a vantage point he raises the body, then grasping the other knee forces himself into the erect position. Palpation reveals the fact that while the size of the muscles is large their consistency, instead of being normally firm, is soft and flabby. True atrophy of some muscles, especially of those of the arm, without the replacement of their lost substance by fat, may be present. There is no sensory disturbance, the sphincters are not affected and the mentality is usually unimpaired. The electrical irritability of the muscles is less acute than normal because of the loss of muscle substance but the reaction of degeneration is absent; the knee jerk is sometimes lost and there may be mottling of the skin, especially over the legs. The prognosis is grave, the patient seldom living to grow up. JUVENILE MUSCULAR DYSTROPHY. This type of dystrophy is less frequent than the preceding affection and oc- curs in slightly older subjects although found as a rule before the age of twenty. Heredity plays the same part in its aetiology as it does in that of pseudo-hy- pertrophic paralysis. The disease begins usually in the arms and shoiilders and involves the pectorales, trapezius, latissimus dorsi and triceps; later the glutei, the quadriceps extensor, the peronei and tibialis anticus are affected. More rarely the latter muscles are first attacked; the muscles of the hands and feet are not affected although muscles of the limbs other than those men- tioned may finally participate in the disease, and certain groups are likely to be the subject of a true or pseudo-hypertrophy. When the serratus is involved there is a projection of the scapula which is quite typical. The gait is waddling and locomotion may finally become impossible. Bulbar symptoms are rarely seen; the atrophy, however, may involve the diaphragm and cause death. The course of the disease is protracted, Erb giving thirty-eight years as its longest limit, and the prognosis is distinctly unfavorable. MUSCULAR DYSTROPHY OF THE LANDOUZY-DEJERINE TYPE. 849 MUSCULAR DYSTROPHY OF THE LANDOUZY-DEJERINE TYPE. This affection is also termed Juvenile Palsy of the Facio-scapulo-humeral Type and is hereditary in the same sense as are the two preceding diseases. It may begin as late as the thirtieth year of life and is characterized by a muscular wasting involving primarily the facial muscles. The eyes cannot be entirely closed and phonation, whistling and laughing are difi&cult. The facial expression (Jades myopathique) is characteristic, the eyes being partly closed, the cheeks hollowed and the upper lip dependent (the tapir mouth). There are no fibrillary contractions and the electrical reaction is unchanged. The masseters and temporals, the internal muscles of the eye and those of the forearm and hand are not affected. MUSCULAR ATROPHY OF THE PERONEAL TYPE. This form of muscular atrophy begins late in childhood or even after puberty. Heredity is a factor in its causation and it is met more often in males. The muscles on the anterior surface of the leg, the extensor longus hallucis, exten- sor communis digitorum and the peronei are first involved; pes equinus or equino varus may result; the calf muscles may become affected later in the disease and after many years those of the hands and forearms. Fibrillary contractions are present and the reaction of degeneration and various sensory and vaso-motor disturbances may occur, the affection thus differing from the previously described types of muscular dystrophy. In this disease peripheral nerve degeneration and ascending degeneration of the posterior columns of the cord have been made out post-morten and in view of these findings the condition may be considered as the result of a neuritis. Its course is chronic and little can be done in the way of treatment other than to correct the deformities by means of apparatus or operations. The treatment of the various types of muscular dystropy is most unsatis- factory but the measures suitable in progressive spinal muscular atrophy (see p. 742) may be employed. The general health should be considered, exercise in moderation prescribed and massage of the affected muscles with oil is indicated. Electricity may be beneficial. After the patient becomes bedridden care should be taken to prevent contractures and bed sores. 54 850 PARASITIC DISEASES. CHAPTER XII. PARASITIC DISEASES. PSOROSPERMIASIS. The psorosperms, sporozoa or cytozoa, are classed among the lowest forms of the protozoa. These organisms are very common in the invertebrates and are not very rare in mammals. Of the psorosperms the coccidium ovijorme or cuniculi and the coccidium hominis are the most important. The former produces in the rabbit a condition characterized by the development of whitish nodules in the liver which vary in size and are due to circumscribed dilata- tions of the bile ducts. In man a similar condition (Internal Psorospermiasis) may result in which there may be hepatic tenderness with chills, fever, prostra- tion, stupor and finally coma; the nodules in the liver are sometimes palpable. After death whitish growths have been found in the peritonaeum, pericardium, liver, spleen and kidneys. The parasites have also been observed in the kidneys, ureters and intestine. In the former instance frequent urination of bloody urine has been noted and obstruction of the ureter with resulting hydronephrosis has been described. Intestinal psorospermiasis causes gastroenteric irritation with increasing prostration until the patient may lapse into the typhoid condition. External Psorospermiasis is said to occiir and is characterized by a hard, crusty, papular eruption upon the face, abdomen, lumbar region and groin; later the papules tend to become confluent. The sporozoa are found in the cutaneous lesions in this form of the condition as well as in those of cutaneous carcinoma and Paget's disease. Whether these organisms have any relation to the causation of these latter is undecided. In so-called dermatitis coccid- ioides bodies resembling psorosperms have been found to be blastomyces. Psorosperm infection reaches man upon such vegetables as spinach, lettuce, cabbage, etc., which are eaten uncooked and are liable to contamination by the excreta of lower animals in which the affection occurs, consequently the condition may be in great measure prevented by proper attention to the cleaning of green vegetables. Treatment. The injection of i to 1000 to i to 5000 solution of quinine has been suggested but it can hardly be effectual unless the medicament comes into contact with the parasite in the intestine. The treatment of psorospermiasis is otherwise symptomatic. DISTOMIASIS. 851 Other protozoa which cause disease in man are the amceba coli and the Plasmodium malarice. These have been considered in the section upon the infectious diseases. DISTOMIASIS. Synonym. Trematodiasis. Different forms of distomata or flukes are found in various situations in the human body. Distomiasis of the Liver is due to infection with one of the liver flukes (Dis- tomata). These organisms are of the family Fascolidce of which five species have been found in the human system. The most common is the liver fluke (Jasciola hepatica) which inhabits the bile passages of ruminants, and par- ticularly the horse, rabbit, sheep, goat and ass. The eggs of the fluke escape in the intestinal evacuations of these animals and under favorable conditions embryos extrude from these ova which are ingested by snails where they undergo further development and are finally cast off to attach themselves to certain water plants and, with these, are eaten by animals. Symptoms. When present in large number in the human bile ducts the flukes cause an irregular diarrhoea which at first may be bloody, the liver is enlarged and jaundice may be evidenced at intervals. The patient may com- plain of pain, there is seldom any marked febrile movement. The affection is a chronic one and finally anaemia and emaciation appear with ascites and general oedema. Temporary amelioration of the symptoms rnay take place but permanent recovery is very rare, the disease ultimately resulting fatally. An endemic type of hepatic distomiasis occurs in Japan from which children are the chief sufferers. The ova are easily demonstrated in the faeces. Treatment consists in combating the symptoms as they arise. Phenyl salicylate in large doses, male fern and naphthalene have been suggested. Pulmonary Distomiasis due to the distoma pulmonale or lung fluke is occa- sionally observed. This form of fluke has been found in the lungs of the pig, dog, cat, and tiger. It is believed to enter the human body with drinking water and is a parasite 8 to 16 mm. in length, 4 to 6 mm. in width and 2 to 4 mm. in thickness. The most typical symptom of its pres- ence is hagmoptysis which may be mistaken for a manifestation of pul- monary tuberculosis; there is also an intermittent cough with sputum resem- bling that of infectious pneumonia. Cerebral metastases may occur with paroxysms of Jacksonian epilepsy. The eggs, which may be found in the sputum, are dark brown, thick-shelled, operculated and are from 80 to 100 H long and from 40 to 60 n broad. The prognosis of the condition depends upon the general condition and 852 PAHASITIC DISEASES. age of the patient, the presence of compHcations, especially pulmonary tuber- culosis, and the number of the parasites in the lungs. Prevention of this condition may be accomplished by boiling drinking water and destroying the ova in the sputum by disinfection. Treatment is symptomatic. Distom|asis of the Blood or Bilharziosis is the result of infection with the blood fluke or Bilharzia hczmatobium (Schistosomum hczmatohium). This organism is a narrow worm, the male being from 4 to 15 mm. long, while the female, which is generally carried by the male in a gynsecophorous groove, is longer, being about 20 mm. in length. The blood fluke is common in Eg}'pt and other parts of Africa and is believed to effect entrance through the skin of persons who bathe in the rivers in which it is present in great num- bers, and upon drinking water or upon infected food such as edible water plants. The males with the females seek the bladder and rectum; the latter lay their eggs in the tissues but these travel to other parts, some being discharged with the urine and feeces while others which are retained produce irritation, and connective tissue changes and sometimes vesical and rectal papiUomata; in other instances they become the nuclei of calculi. Symptoms. The blood flukes may cause no serious distiurbance, at times being present for long periods without resulting harm; usually, however, their presence is associated with perineal discomfort, vesical irritability, pain on urination and bloody urine; when the parasites are harbored in the rectum there is tenesmus with stools containing mucus and blood; rectal ulcer- ations and papiUomata may result in marked infections. The ova may be found in the discharges from both bladder and rectum. Such complications as vesical and renal calculi, perinseal fistulse and peri- urethral abscesses may occur. The loss of blood may result in a moderate degree of anaemia. There is a distinct eosinophilia with a corresponding diminution in the number of polymorphonuclear leucocytes in the blood. The parasites may reach the portal and mesenteric veins but in these situa- tions cause no especial symptoms although a thickening of the tissues about the portal vessels (Glissonian cirrhosis) is said to occur at times. The affection is chronic in its course and as stated may not resiilt in serious damage. Upon the incidence of other infections, especially in children, the symptoms may disappear. Prevention of the entrance of the fluke into the body consists in avoiding possibly infected water and food and not bathing in the rivers of infected districts. Treatment. The employment of the extract of male fern has been sug- gested although there is no known method of destroying the parasites in the blood. The heematuria, rectal and vesical inflammations, should receive NEMATODES. 853 appropriate treatment and the other symptoms should be combated as they arise. Intestinal Distomiasis. A new variety of blood fluke, the schistosoma cattoi, has lately been described, the eggs of which are smaller than those of schis- tosoma hcematobium, brown in color and do not possess the typical spinous extremity. This parasite is said to inhabit the blood-vessels of the digestive tract and to cause intestinal ulceration. The ova are found in the stools of the infected individual. The fasciolopsis Buskii, the mesogonimus heterophyes and the gastro- discus hominis may be found in the small intestine. The first and the last occur in British India and the mesogonimus has been observed in Japan and Egypt. NEMATODES. ASCARIASIS. Ascaris Lumbricoides (the round or maw worm) is one of the most common human parasites and is found in all parts of the world. Its habitat is the small intestine. It is most frequently observed in the young but is not rare in adults. Usually not more than six or eight are found in one host but instances in which more than a himdred have occurred have been reported. Its body is round, tapering at either end and is marked with transverse stria- tions. It is yellowish or brownish in color; its diameter is about that of a common goosequill, the male being from four to eight inches (10 to 20 cm.) in length while the female is eight to twelve inches (20 to 30 cm.) long. At the oral extremity the worm possesses three lips, each supplied with fine denticulations, while the caudal end terminates conically, being curved ven- trally in the male and straight in the female. The eggs are ellipsoidal in shape 50 to 75 // by 40 to 58 pL, thick-shelled and covered with an albuminous envelope; when found in the stools they are stained yellowish from the faecal matter. When discharged in the intestinal evacuations the ovum slowly develops in water or moist earth and is taken into the body with food or drinking water; the embryo, which has up to this time been enclosed by the envelope of the egg, is now freed by the action of the juices of the alimentary tract and grows to the adult stage within four or five weeks. The parasites usually remain in the small intestine but may migrate. They have been found in the vomitus, in the faeces, in the bile ducts and in the pan- creatic duct. Collections of them may cause intestinal obstruction and they may wander to the mouth, nasal passages, into the air passages when they may cause asphyxia or. pulmonary gangrene, or into the eustachian tube and cause 854 PARASITIC DISEASES. perforation of the tympanic membrane. They frequently migrate into the rectum. Symptoms. The ascarides may give rise to no suspicious manifestations but their presence is usually associated with intestinal irritation and resulting colicky pain, dyspepsia, nausea, vomiting and diarrhoea; reflex symptoms such as restlessness, disturbed slumber, headache, vertigo and even epileptiform and choreic attacks may be observed. Salivation, itching of the skin, especi- ally at the nostrils, and anus, lachrymation, swelling of the lachrymal papillae, dilatation of the pupils and mental disturbances may occur. Complications referable to the presence of the parasite in imusual situations have been noted. Among these are jaundice, due to bile duct obstruction, intestinal obstruction and symptoms of asphyxia. The worms have been found in perforative appendiceal and perinaeal abscessess and in inflamed herniae. The diagnosis can be positively made only by demonstrating the presence of the worms themselves or by finding the ova in the faeces. The prognosis is wholly favorable unless complications arise. Treatment. Prevention consists in abstention from the use of possibly contaminated food or water. The most efficient anthelmintic in ascariasis is santonica which is preferably administered in the form of santonin. It may be given in divided doses either mixed with powered sugar or sprinkled upon bread and honey or jelly; for a child of five years three doses of i grain (0.065) ^^^h at intervals of four or five hours are usually sufficient. Lozenges containing santonin are not to be commended for they often fail to dissolve. The bowels should be freely evacuated by a saline cathartic or calomel shortly after the patient has taken the final dose of the vermifuge or the latter may be given with calomel, i grain (0.065) of santonin to i or 2 (0.065-0.13) of the mercurial. Untoward effects such as yellow discoloration of the urine or yellow vision (xanthopsia) may follow the use of santonin but they are neither permanent nor serious. Sodium santoninate should not be employed since most instances of san- tonin poisoning have been due to this salt. Spigelia is also a popular remedy for the round worm and is best employed in the form of the unofficial fluidextract of spigelia and senna, the dose for an adult being 2 to 4 drachms (8.0 to 15.0); for a child of two years ^ to i drachm (2.0 to 4.0) should be prescribed. Chenopodium is considered an excellent vermifuge in ascariasis and is particularly indicated in the presence of intestinal inflammation since it not only expels the worms but also appears to benefit the irritation in the alimen- tary tract. The ordinary dosage of the oil of chenopodium is 3 minims (0.2) which may be administered in capsules, emulsion or dropped upon lump ASCARIASIS. 855 sugar. The dose is usually repeated three times a day before meals, for two days, when a cathartic should be ordered. Oxyuris Vennicularis (the pin-, thread-, or seat-worm) is a very common parasite and one of almost universal distribution. It occurs most often in children but adults are sometimes infected; large numbers are usually present. The parasite very closely resembles a short bit of white thread, the male being about I of an inch (5 mm.) long and the female about twice this length. The oral extremity is supplied with a mouth possessing three retractile lips. The tail tapers to a point. In color the worm is white. The eggs are oval, flat upon one side, thin-sheUed and colorless and about 50 /i by 16 to 20 jj.. The oxyiuris inhabits the lower end of the ileum and the coecum. They wander freely, more usually downward to the rectum or even into the vagina but sometimes upward even as far as the stomach whence they may be vomited. When large numbers are present in the intestine they may form balls with the mucous secretion of the gut; they may be discharged with the faeces and the irritation which they cause often produces a chronic catarrh of the colon. Infection is believed to take place as follows : The ova with the developed embryos inside are passed in the fasces and become scattered over vegetables and fruit, which later are to be used as food, here they may remain for con- siderable periods without perishing. The eggs also attach themselves to the tissues and hairs about the anus and, being removed thence by the fingers of the patient, may be transferred to his mouth or contaminate substances which he may handle and thus infect other individuals. The possibility of the ova being transferred from faeces to food by flies has also been suggested. Water is said not to transmit the infection for the ova quickly perish in this medium. After the ingestion of the eggs the worm reaches the adult stage in about two ' weeks. Symptoms. The most characteristic and common of these is anal pruritus which generally appears soon after the patient retires at night; at this time the parasites migrate and often appear at the anal orifice. The itching is often extreme and the irritation caused by the presence of the worms in the intestine may result in the production of a catarrhal colitis with the exudation of a considerable amount of mucus. The rectal irritation also causes anal prolapse, frequency of urination, urinary incontinence, balanitis in the male and vulvovaginitis in the female; the latter may also be produced directly by the entrance of the parasites into the vagina. The genital irritation may induce the habit of masturbation. Nervous manifestations are more rare than with other species of intestinal parasites but chorea and convulsions have been observed. The diagnosis. The worms may be seen at the anus, to which attention has been directed by the complaint of itching; they may also be found in the faeces, in which the eggs are likewise present. 856 PAEASITIC DISEASES. The prognosis under proper treatment is entirely favorable although the condition is often obstinate. Treatment. The parasites in the intestine above the rectum may be destroyed by the means suggested for the round worm but the most effective method of treatment is that by rectal enemata. Preliminary to the medicated injection the rectum should be cleared of faecal matter and mucus by means of an ertema of lukewarm water containing i drachm (4.0) of borax to the pint (500.0). After the bowel has relieved itself of this solution an injection consisting of ^ a pint (250.0) of i to 10,000 mercury bichloride in warm water should be administered. The injection should be given through a soft catheter passed high into the bowel and it should be retained as long as possible. The procedure should be repeated every other night until the parasites and their eggs have disappeared, an enema of saline solution (0.9 percent.) being given upon the alternate evening. Cleanliness of the parts about the anus is an absolute essential, for no matter how much care is exercised the patient is likely to contaminate his lingers by scratching and despite our best endeavors will often reinfect himself by transferring ova to his mouth. After each defaecation or even oftener the anus and perinaeum should be sponged off vidth i to 10,000 mercury bichlo- ride solution, the anal folds being separated by means of the fingers to insure perfect contact of the solution to all parts. On retiring, the anus may be anointed with a little mercurial ointment or an ointment composed of ij drachms (6.0) of mercury bichloride to an ounce (30.0) of vaseline. Injections, the patient being in the knee-chest position, of solutions of other substances are often efficient; of these an infusion of quassia — ^ pint (250.0) of the preparation, i to 100 with cold water, to avoid extraction of too much of the bitter principle — is often employed. Infusion of asafcetida, aloes or garlic, as well as mixtures containing tannic acid, vinegar, oil of eucalyptus and camphor, may prove useful. An infusion of garlic, with large amounts of this substance taken by mouth, may destroy the parasites after the failure of the more ordinary means. Ascaris Alata {ascaris canis, ascaris mystax or round worm of dogs and cats) is a slender whitish or brownish parasite, the male from i to i^ inches (40.0 to 60.0 mm.) long, the female about three times this length. The tail is rolled into a spiral and upon either side of the head there is a wing-like projection. The mouth possesses three denticulated lips. The ova are nearly spherical and from 68 to 72 // in diameter. They are contained in a thin albuminous envelope. The life-history of this parasite is analogous to that of ascaris lumbricoides. The ascaris alata is only occasionally found in man. The symptoms and treatment are similar to those of the ordinary round worm. ASCARIASIS. 857 Trichocephalus Dispar (ascaris trichiura or whip- worm). This parasite is about 2^ inches (4 to 5 cm.) in length and possesses a body of rather remark- able form, the anterior two- thirds being extremely thin and hair-like, while the posterior one-third is thick and in the male obtuse and rolled into a spiral; in the female it is straight and terminates in a blunt conical point. The ova are oval and dark brown, their long diameter being about 0.05 mm. Great numbers of this worm are often found in the coecum and colon. It is quite common in Europe but is infrequent in the United States. The symptoms are not characteristic and even if the host harbors large numbers of the parasite he may exhibit no suspicious manifestations although anaemia and diarrhoea are sometimes associated with the presence of the worm. The diagnosis may be made by finding the eggs in the faeces. Eustrongylus Gigas (dicotophyme gigas) is one of the largest of the nemat- odes, the male being about i foot (30 to 40 cm.) in length while the female is about three times as long. Its color is reddish and the cephalic extremity possesses a six-lipped orifice bearing papillae. The ova are elliptical, thick- shelled and brown, their longer diameter being 64 to 68 fi. This parasite is found in the dog and other animals; it is rare in man. Its habitat is the pelvis of the kidney; as a result of its presence this structure becomes dilated and the kidney may become reduced to a hydronephrotic sac in which the parasites are found siirrounded by bloody urinous fluid. The presence of the worm is demonstrable only upon autopsy. The diagnosis rests upon the demon- stration of the eggs in the urine. The parasite can be removed by surgical operation only. Up to the present time only one kidney has been found in- volved in a single individual. Anguillula Acetici (the vinegar eel) is said to have been found in the urine but its presence is more probably due to the fact that a dirty bottle has been used to collect this secretion. The anguillulina prutrefaciens or onion anguillula, which lives in this vegetable, has been found in vomited fluid. Strongyloides Intestinalis. These are small nematodes which are com- monly found in the faeces of the epidemic diarrhoea of tropical countries. They probably have no especial influence in the causation of the affection but when present in large numbers may keep up the intestinal irritation of a dysentery due to other causes. The parasites infest all parts of the intestinal tract and may force their way into the bile and pancreatic ducts. The worm is frequently found in Indo-China, East India, Africa, Europe and South America; it has been observed in the United States in a number of instances. It causes no marked symptoms but, when present in large numbers, may produce anaemia. Stool-disinfection is necessary as a preventive measure and the worms may be destroyed by the administration of the extract of male fern. 858 PARASITIC DISEASES. Acanthocephala {thorn headed worm). One or two instances of human infection by the gigantorhynchus or echinorhynchus gigas have been reported as well as one of echinorhynchus moniliformis. In the intestine of the pig the gigantorhynchus is common, the intermediate host being the cockchafer or the June bug. ^ ANCHYLOSTOMIASIS. Synonyms. Uncinariasis; Hook-worm Disease; Brick-maker's Anaemia; Miner's Anaemia; Eg}'ptian Chlorosis. etiology. The train of symptoms to which the term hook-worm disease has been applied is the resiilt of infection -uath two tj^es of parasite, the anchylostomum duodenale of the old world and the uncinaria Americana of the western hemisphere. Hook-worm disease has been recognized since the time of the ancient Eg}'ptian writers but its connection with the anchy- lostomum diiodenale, which was discovered in Milan by Dubini in 1838, was not proven until within comparatively recent years. The hook-worm is generally distributed throughout tropical and subtropical coimtries, being very common in Eg^-pt and frequent in the Philippines, Porto Rico and in the mining regions of Germany, Austro-Himgar}' and England. In the United States no authentic instances of uncinariasis were recognized as such until 1893. In 1902, Stiles, to whom we owe great credit for his work upon this subject, showed that the disease was very frequent in many parts of the country and that to hook-worm infection most of the anaemia which was so common in the Southern States was due. An anchylostomum, the uncinaria Americatm, is the specific parasite. Both the anchylostomum duodenale and the uncinaria Americana possess the same general morphological characteristics. The male is about |- of an inch (i cm.) in length while the female is slightly larger," being about ^ an inch (12 to 15 mm.) long; the length of the foreign worm is slightly less than that of the native variety. The anchylostomum duodefiale is whitish in color or flecked with brown spots posteriorly if the intestine contains blood, there are transverse striae. The body tapers toward the head which is curved upon the dorsum in the form of a hook. The head is pro\ided with seven curved teeth. The tail of the male is abruptly pointed while that of the female is more tapering and finely pointed. The eggs are ovoid in shape, colorless and thin shelled, their long diameter being from 50 to 60 [x. The American hook-worm has no hook-like teeth upon the oral rim but is supplied with a large ventral and smaller dorsal chitinous lip upon either side, and a larger and more prominent dorsal conical tooth. The ova are similar to those of anchylostoma duodenale but are larger being from 68 to 70 (x in the longer diameter. ANCHYLOSTOMIASIS. 859 The parasite inhabits the duodenum and jejunum; the eggs are passed in the faeces and liberate their embryos in water or moist earth; these develop into larvae which may live for an indefinite length of time in the mud or water, to be iinally taken into the stomach upon drinking water, food which is con- taminated by the dirt under the nails or upon the hands or with earth which is deliberately eaten. In other instances the larvae may enter the body through the skin and iinally reach the intestine where they develop into the adult parasites, suck the blood from the intestinal wall, produce minute haemor- rhages, and, presumably, produce a substance which acts as a poison. The sucked blood provides nourishment for the worm and upon autopsy the parasite is found embedded in the mucous or submucous wall of the intestine and the intestinal lining shows ecchymoses open at the centre. The infection is most frequent in rural districts where sand abounds and in individuals who come into close contact with the damp earth, such as miners, excavators, brick-makers, etc. Whites seem to be more prone to severe infections than negroes and the most marked types of the disease occiir in women and young persons. Several cases in one family are often observed. Symptoms. These may be obscure in the mild type of the infection; in medium grades of the disease the anaemia is more or less marked and in the extreme cases the affection is characterized by extreme anemia and cedema. The period of incubation (the stage of the disease before the ova appear in the stools) is from four to ten weeks and may be characterized by irritation of the gastro-intestinal tract. In some regions where imcinariasis is common the faces of a considerable proportion of the comparatively healthy children contain ova. In the advanced stages of the infection there is more or less lack of bodily development; the skin is waxy white or yellowish; hair is present upon the scalp but is not abimdant upon other parts; the breasts and external genitals are poorly developed; the fades is anxious and sometimes oedematous; the conjunctiva are pale and lachrymal secretion is often diminished; the mucous membranes are of poor color and the tongue may be marked with purple or brownish spots. The cardiac apex beat is often visible and there may be cervical pulsation; the abdomen is prominent as a result of hepatic and splenic enlargement and the presence of ascites. The extremities may be oedematous and sluggish ulcers may be present. There is no characteristic febrile move- ment, in fact, the temperature may be subnormal. Dyspnoea is not rare, there may be palpitation and haemic murmurs are frequently audible. The appetite may be either diminished or increased and there is often a desire for unusual foods such as salt, pickles, coffee, sand or clay. Either constipation or diarrhoea may be noted. Such nervous manifestations as headache, vertigo, mental hebetude and stupidity are common. There is emaciation with marked 86o PARASITIC DISEASES. musciilar weakness. The urine often contains albumin; casts are rarely found. The blood shows a varying degree of anaemia, both the hemoglobin and the number of red corpuscles being diminished. The leucoc\i;es may be slightly increased or diminished. An important characteristic is the presence of eosinophile leucocytes. These are said to be found in over 90 percent, of the cases. The diagnosis is easily made by finding the ova in the faeces; if the micro- scope is not available a very simple and accurate test may be performed as follows: Place an ounce (30.0) of fresh faeces upon a piece of white blotting paper and allow it to stand for twenty to sixty minutes; remove the fasces and examine the color of the stained paper. In 80 percent, of the cases of uncinariasis of medium or severe grade the stain is reddish-brown and sug- gestive of blood. In making this test the presence of haemorrhoids should be excluded. The occurrence of eosinophilia is an important diagnostic sign. The prognosis is favorable save in advanced instances of the disease. With- out proper treatment the duration of a single infection has been, in one case, followed for six years and seven months (Stiles); how much longer it may last has not been shown. If the patient is subjected to reinfection the disease may continue for fifteen years or even longer. Fatalities are not very rare in severe and prolonged infections which have not received proper treat- ment. Treatment. Uncinariasis may be prevented to some extent by disinfection of faeces, by thorough washing of the hands, after having to do with earth or water which may contain the uncinaria, and by boiling all drinking water. The most efficient anthelmintic in uncinariasis is thymol; this drug is best administered as follows: After having placed the patient upon fluids (milk and soup) for three days, 30 grains (2.0) of thymol are given at 8 A. M.; at 10 A. M. the dose is repeated and two hours later a purge is given, preferably a saline; castor oil dissolves thymol and the solution of this agent within the body may cause toxic effects; for the same reason alcohol should not be given with the thymol as has been recommended. After a week the stools should be examined and if ova are still present the treatment shoiild be repeated until they disappear but it is better not to administer thymol oftener than once a week. It is very important to be certain that no eggs are to be found in the faeces before discharging the patient as cured. Thvmol carbonate has been suggested as a substitute for thymol but probably offers no advantages over the former drug; male fern is also advocated. The treatment of the anaemia is that of secondary anaemia from other causes (q. v.), iron and plenty of nourishing food in connection with other tonics being indicated. It is considered best to omit the iron upon the days when thymol is given (Stiles). TRICHINIASIS, 86 1 TRICHINIASIS. Synonym. Trichinosis. Trichinosis, the term applied to infection with the trichina spiralis is acquired by eating the meat of infected hogs. The parasite is cylindrical in shape, the length of the male being about -^ of an inch (from 1.4 to 1.6 mm.); the anterior extremity tapers to a point while the posterior extremity is thick- ened and bifid, each lateral appendage being somewhat conical. The length of the female is about three times that of the male and the tail is rounded. The larvEe when born are from 90 to 100 /i in length, blunt anteriorly and pointed at the caudal extremity. Muscle trichinae, the encysted larvae, are about I mm. long and 0.04 mm. in thickness, tapering anteriorly but obtuse posteriorly; they lie coiled in an ovoid capsule which is at first transparent but becomes opaque as a result of calcareous infiltration. In the adult sexual stage the trichina spiralis inhabits the intestine of man and other animals such as the hog, rat, mouse, guinea pig, rabbit, cow, sheep, horse, dog, cat, etc. The parasite is also found in the hen, duck and pigeon. In the intestine of its host the trichina gives origin to a great number of larvEe, after which the adults perish and the larvae migrate to the intermus- cular tissues and finally into the substance of the muscles where they develop in about fourteen days into the mature muscle form, setting up, during the process, an interstitial myositis and ultimately becoming encysted in an oval capsule which may contain from one to four of the coiled larvae. The cyst wall is transparent at first and about 0.4 mm. by 0.25 mm.; the capsule gradually thickens and becomes infiltrated with calcium salts, this process taking place in from five to eight months and sometimes involving the larva itself. The encysted larvae may live within the muscle of the hog for eleven years and in that of man for as long as forty years. The human being usually acquires trichiniasis by eating infected pork which has been cooked insufiaciently to destroy the parasite. In the intestine the capsules of the encysted larvae are dissolved by the digestive secretions and their contents is set free. In the intestine they develop into the adult worm in about three days. After fertilization has taken place the males perish while the females, adhering to the intestinal mucosa or penetrating the wall of the gut, migrate to the mesentery or the lymph glands of this structure. Each female is capable of giving birth to a great number of larvae which leave the intestinal tract in the lymph ciirrent and find their way to the muscles either in the blood stream or by direct migration. Trichiniasis is most common in Germany where the use of raw or imper- fectly cooked pork in the form of sausage is frequent. Pickling or smoking infected meat is not effective in destroying the parasite but thorough cooking will accomplish this object. In the United States the disease is somewhat 862 PARASITIC DISEASES. rare, Stiles, who has made a special study of the subject, stating that up to 1898 not more than 900 cases have been reported. It is probable that many instances of the affection are undetected for many of the reported cases were unsuspected, the parasite being revealed after autopsy, death having occurred from other causes. Patho]ogy. The morbid changes are chiefly in the striated muscle fibre and consist of a localized myositis characterized by granular degeneration and nuclear proliferation. The cysts are present in the muscles, appearing to the naked eye as small grayish oat-shaped bodies placed longitudinally in the muscular fibres, and the adult parasites may be found in the intestine. Enlargement of the mesenteric glands and fatty degeneration of the liver have been observed. Important blood changes occur and will be considered later. Symptoms. The presence of trichinae in the intestinal tract may not be followed by the disease, for the parasites may be passed off by the bowel before they have had time to mature and reproduce themselves; also the migration of only a few larvae may not be characterized by noticeable symptoms. Following the ingestion of numerous trichina larvae symptoms of gastro- intestinal irritation may appear within three or foiir days; there may be nausea, vomiting, abdominal distress and diarrhoea; general malaise with prostra- tion and pains in the bones and muscles may occur. These prodromal mani- festations may be wholly absent or, on the other hand, so severe as to be mis- taken for cholera morbus. The invasion of the disease takes place in from a week to ten or even fourteen days; it is usually characterized by a rise in temperature to 103° to 104° F. (39.6° to 40° C); the temperature curve is of remittent or intermittent type and is seldom associated with chills. In mild types of the infection there may be no fever. The migration of a large number of larvae in the muscular tissue, as stated above, causes a myositis which is evidenced by muscular pain, increased upon pressure and active and passive movement, and swelling, with cutaneous oedema, appearing first in the eyelids and later in the extremities and trunk. This symptom may last several days and disappear, to recur after a week or less. The involvement of the muscles of the jaws, throat and larynx, may result in painful and difficult mastication, deglutition and phonation, while the myositis of the diaphragm, thorax and abdomen is accompanied by dyspnoea and painful respiration. Sweating and cutaneous pruritus are not uncommon and urticarial and other eruptions have been observed. Nervous symptoms such as headache, sleep- lessness, pupiUary dilatation and transient loss of the tendon reflexes some- times occur. In prolonged instances of the disease emaciation and anaemia are noted. Increased urine and albuminuria have been common in certain epidemics. TRICHINIASIS. 863 The patient, in instances of very severe infection, may fall into the typhoid state, with its typical manifestations. The blood usually exhibits a varying degree of leucocytosis and, what is much more important and characteristic, a marked eosinophilia, the number of eosinophiles being in direct proportion to the severity of the case. The diagnosis of sporadic cases presents certain difl&culties on account of the resemblance of the disease to enteric fever and muscular rheumatism, but if a number of patients are stricken at once with characteristic symptoms, particularly after possible exposure such as an occasion where many persons have partaken of ham or sausage, suspicion should at once be excited. Differ- ential blood counts should be made immediately and the intestinal mucus, a mild laxative having previously been given, should be examined for the parasites which may be seen with a low power lens as small, glistening, thread- . like bodies. The dyspnoea, muscular pains, tenderness and swelling, and the oedema are important diagnostic signs. If the diagnosis is doubtful bits of muscle should be removed from the deltoid or pectoralis major, under cocaine or other local anaesthesia, and examined microscopically. A special instrument has been designed for the excision of the muscular tissue. The prognosis depends upon the number of larvse which have been eaten and upon the number of adult parasites which develop in the intestinal tract. In the milder infections recovery is usual within two weeks; marked gastro- intestinal irritation is considered to augur well for the patient. In severe instances of the disease the illness may be protracted for two months or more and is followed by a very slow convalescence. The death rate varies in differ- ent epidemics from i to 25 or more percent.; the fatal issue may occur as late as the sixth week. Treatment. The prevention of trichiniasis consists in the inspection of the carcasses of all hogs slaughtered for food and the destruction of those found infected. The importance of clean surroundings for their stock should be explained to those who raise swine for market and also the necessity of proper feeding. While it is not certainly known how hogs become infected it has been suggested that the infection may be transmitted from the rats which thrive about abattoirs, consequently the destruction of these animals in slaughter-houses and about pig styes is advisable. Finally complete prophylaxis may be achieved by the thorough cooking of all ham and sausage. If the patient is seen early in the disease free evacuations of the intestinal contents should be secured by means of large doses of calomel (followed by a sahne), rhubarb, senna, aloin or other pinrgative, with the object of freeing the bowel from the parasites there present. With the purges anthelmintic drugs such as santonin, male fern or thymol should be given. It is important that the bowels should be kept freely open for at least a week after infection has taken place. Glycerin in doses of a half ounce (15.0) every hour has been 864 PARASITIC DISEASES. recommended. We know of no means to destroy the larvae within the mus- cles, but the use of picric acid in doses of from 5 to 8 grains (0.33 to 0.5) has been suggested. The treatment otherwise consists in the employment of measures calculated to relieve the symptoms. The muscular pains may be relieved by means of hot baths or applications of anodyne liniments, equal parts of hydrated chloral, camphor and menthol, for instance, with hypodermatic injections of morphine should these become necessary. The restlessness and sleeplessness may be controlled by the bromides, sulphonmethane (sulphonal), sulphonethylmethane (trional) and similar drugs. During the febrile stage the diet should consist of nourishing fluids and upon the establishment of convalescence tonics, such as strychnine, quinine and iron, with massage and electricity to combat the excessive muscular weakness, are indicated. FILARIASIS. A number of different filariae claim man as their host. Of these the most common are the three species which are included under the term filaricB sanguinis hominis. 1. Filaria Bancrofti, the most frequently found blood filaria, occurs in most tropical regions. It has been observed in East India, China, Japan, the Malay Archipelago, the South Sea Islands, Australia, Africa, and the West Indies, as well as in the Southern United States. The male parasite is about ij inches (4 cm.) in length and 3-^-0 of an inch (o.i mm.) in thickness; the anterior extremity is slightly clubbed, the posterior extremity tapering and spirally twisted. The female is bro\\Tiish, about twice the length and thickness of the male and possesses rounded extremities; the ova are 38 /j. by 14 //. The embryos measure from 270 to 340 /i in length by 7 to 11 ju in breadth; their especial peculiarity is that they are found in the blood at night only, except in the case of individuals who sleep during the day, when they are present in the circulation during the hours which the host spends in sleep. 2. Filaria diurna is found in the blood during the waking hours only and is to be differentiated from /. Bancrofti by this fact and the absence of granules in the axis of the larva. Manson who first described this form of filaria suggests that it is the larval form of filaria loa. 3. Filaria perstans is also known only in its larval form and is found at all times, day or night. The embryos are smaller than those of the preceding varieties, being about 200 fx in length. It is actively motile and has an abruptly rounded and truncated posterior extremity; the anterior extremity is retractile and possesses a prominent spicule. This parasite is possibly the cause of craw-craw, an ulcerative skin eruption which occurs in west Africa. FILAEIASIS. 865 F. Bancrojti is the most important of the above described parasites and to its presence in the human body hcBmatochyluria and elephantiasis or lymph scrotum are attributed. The embryo filariae enter the blood stream by means of the lymphatics and being no larger in diameter than the thickness of a red blood cell are easily passed through the finest capillaries; although enclosed in their sheaths, they are actively motile and may be easily seen in specimens of fresh blood. During the day they are not found in the blood except in very exceptional instances or when the patient is accustomed to sleep in the daytime and work at night. At night they are present in the blood stream in great numbers. The life-history of the parasite is not very definitely known but it is supposed that they are withdrawn from the circulation by the mosquito. The larvse develop to some extent in the stomach of the insect and then migrate, finding their way into the thoracic muscles. Upon the death of the mosquito the larvae are set free in the water in which the insect has died, to be later drunk by human beings, according to the older theory, and entering the digestive tract bore through its walls into the lymphatic vessels. The larv^ have been found in the proboscis of the mosquito and the more probable method of transmission is by means of the bite of this insect and consequent direct infection. Symptoms. Large numbers of filariae may be present in the blood with- out giving rise to suggestive manifestations or prejudicing the health of the host; on the other hand certain pathological effects may be produced. HcBmatochyluria. If the parasites cause stoppage and obstruction of the lymph circulation a lymph fistula may open into the ureter or bladder and the urine becomes milky {chyluria) from the admixture of chyle and if, as a result of the development of this fistulous opening, there is a rupture of blood-vessels, blood also appears in the vocme {hcBmatochyluria). Without other symptoms or marked disturbance of health, the patient passes at intervals opaque milky urine which may show an admixture of blood. The urine is otherwise normal in its constituents but at times may be increased in amount. In the intervals of the chyluria the urine is of ordinary character. The passage of the chylous and bloody urine may be associated with lumbar pain. Under the microscope the milky urine is seen to contain fat globules, red blood cells, and sometimes motile filarite. Lymph Scrotum, Lymph Vulva and certain types of elephantiasis may result from the presence of the filariae. The affected parts are swollen and thickened and contain plainly visible and distended lymph vessels; these are found to contain a milky, turbid or blood-stained fluid which coagulates on standing. Filariae are sometimes present in the fluid. The inguinal and femoral glands may be swollen and soft. Erysipelas infection of the affected tissues may occiir and may be accompanied by chills, fever and sweating. 55 866 PARASITIC DISEASES. In connection with the conditions described above, blood changes, such as anaemia and eosinophilia, splenic enlargement and interference with general nutrition, have been observed. Treatment. The prevention of filariasis is, to some degree, possible by boiling the water used for drinking and in the preparation of food, by de- stroying mosquitoes and by preventing the access of these insects to human beings by means of bed screens, etc. There is no certain method of destroying the filarije in the body although good results have followed the administration of thymol in doses of i to 5 grains (0.065 ^^ °-33) given for a period of several weeks; benzoic acid, sodium benzoate and methylthionine hydrochloride (methylene blue) in 4 grain (0.25) doses have been recommended by certain observers. Chyluria necessitates temporary confinement to bed, an avoidance of fluids and fats, and the administration of saline purges to lessen the tension in the lymphatic system. Such treatment may result in the temporary disappearance of the chyle from the urine. If fats are omitted from the diet the urine may continue normal but the administration of a glass of milk is often followed by a recur- rence of the turbid urine, proving that the lymphoid fistula is still patent. The surgical removal of the adult parasites from the inguinal or other accessible glands is often of pronounced benefit and is unattended with danger. DRACONTIASIS. Synonym. Guinea-worm Disease. Filaria or Dranunculus Medinensis {The Guinea-worm) is a common parasite in the tropical and subtropical parts of Asia, Africa and America. The female only has been observed; it is whitish or yellowish in color, from 20 to 28 inches (50 to 80 cm.) in length and from ^ to -j an inch (0.5 to 1.7 cm.) in thickness. Its anterior extremity is rounded and supplied with a two- lipped oral orifice. The tail tapers to a blunt point bent into the form of a hook. The male is believed to be much smaller. The larvae are supposed to enter the alimentary tract of the host in drinking water, being enclosed in the bodies of certain small arthropods (cyclops) or free, having gone through several stages of development inside this latter organism. The theory that the parasites may enter the body by penetrating the skin has also been sug- gested. Probably the male and female are ingested but the former dies after having performed the function of impregnation, while the female, containing a very large number of embryos, penetrates the intestinal wall, and migrating to the subcutaneous tissues, still further develops. It may remain quiescent and is palpable under the skin; later the parasite finds its way downward through the tissues to the ankle or foot. This migration is probably in re- DRACONTIASIS. 867 sponse to a desire to allow the embryos to- escape. When the sought for situation has been reached the head is thrust through the skin, caus- ing a small vesicle which is surrounded by a more or less inflamed area. The vesicle ultimately bvirsts, leaving an ulceration, at the base of which the head of the parasite may be demonstrated. Having discharged the embryos the parasite leaves the body. Usually there is but a single worm in one host, although this is not always the case. Symptoms. These are those of a locaHzed inflammation at the site of exit of the parasite; there may be a slight febrile movement but this is only tran- sient if cleanliness is observed after removal of the parasite. If the worm is torn during its removal suppuration with the usually associated symp- toms is said to be a very probable resiflt. Treatment. Prevention consists in the thorough filtering and boiling of drinking water and in avoiding contact with muddy water in which the Cyclops may be present. The natives of the countries where the guinea-worm is common as a rule moisten the iflcerated bases of the ruptured vesicles and, when the head of the parasite is extruded, it is fastened round a bit of wood which is gradually twisted until after several days the entire worm is withdrawn. Injection of mercury bichloride solution (i to 1000) into the head will kill the parasite after which it may be readily pulled out. Injections of mercury into the tissue adjacent to the worm also kill it and it may be removed by excision. The wound should be dressed antiseptically; in this connection i to 15 phenol solution is recommended but should be carefully watched lest it cause gangrene of the part. The local application of the leaves of the "arma- pattee" plant is recommended by native physicians in India and large doses of asafoetida are said to be fatal to the parasite. Other filariae have been found in man but much less frequently than those pre\^ously described. Of these the following are worthy of brief mention. Filaria loa occurs in West Africa and exists in the subcutaneous tissues, especially those of the face, where it wanders about causing burning and itching. It is particularly frequent beneath the conjunctiva where it induces swelling and inflammation. This parasite has been found in the Western Hemisphere whither it has probably been brought by African slaves. Filaria immitis. This is a common parasite in the dog and has been found in the portal vein of man, the eggs being present in the walls of the ureters and bladder. Filaria Bentis has been observed in a cataract. Filaria trachealis and bronchialis has been observed in the trachea, bronchi and lungs. Filaria labialis has been demonstrated in labial pustule and Filaria hominis oris has been found in the mouth. 868 PARASITIC DISEASES. TRYPANOSOMIASIS. Trypanosoma hominis, the organism which is believed to be the cause of African sleeping-sickness, has been discussed in the section upon infectious diseases. ^ CESTODES. ECHINOCOCCUS DISEASE. Synonym. Hydatid Disease. The taenia echinococcus has been described in the section upon diseases of the liver. Echinococcus diseases of the lungs, spleen and other organs have been discussed in the sections devoted to the affections of the organs in question and to these the reader is referred. INTESTINAL CESTODES, T^NI^ OR TAPE-WORMS. Various types of taeniae are found in the human intestine as a result of the ingestion of the undeveloped larvae vT^hich occur in the muscular tissue or other organs of animals. The ova of the tape-worm pass from the intestine of the host in the dejections and are taken into the bodies of various animals where they become fixed in the muscles or other tissues, probably being trans- ferred thither by the blood or lymph currents. Within a few months after lodgment the ova develop into cysticerci or bladder -worms; these present the following characteristics. The cysticercus is inclosed in a thin connective tissue wall within which lies the bladder-worm, which really is the head of the future tape-worm and is termed the scolex. Behind the head there is a constricted neck consisting of undeveloped segments, the terminal one being distended into a bladder-like body. In some forms of taenia the ova may become encysted in the intestinal wall of the original host and subsequent development of the full-grown parasite in the intestine results in an auto- infection; more commonly, however, there is an intermediate host in the tissues of which the larvae develop and are finally eaten by a third host to whose intestinal wall the parasite, its cyst wall being removed by the action of the digestive fluids, becomes attached and gives origin to segment after segment, thus forming a new taenia. Taenia Mediocanellata, Tcenia Saginata or Beef Tape-worm is the most common variety of tape- worm in this country; it is also frequently found in other parts of the world, especially where beef is largely consumed. Its usual length is from 3 to 8 yards (3 to 8 meters); its head is four-sided and pear-shaped and possesses no hooklets or rostellum, but in place of INTESTINAL CESTODES, T^NI.E OR TAPE-WORMS. 869 these is provided with foiir cup-shaped sucking-discs placed at its corners. The head is about -^ of an inch (2 mm.) in diameter; the neck is slender and prolonged; the first segments are short, their transverse diameter exceeding their length. The segments gradually increase in length and near the pos- terior extremity of the parasite are about § of an inch (16 to 18 mm.) long and about one-half as broad. The genital pores in adjacent segments irregiilarly alternate upon the opposite margins and are placed sHghtly posterior to the middle of the margin of each. The embryophores are slightly ovoid, brownish in color and measure 30 to 40 {i by 20 to 30 (J.. The shell is thick and radially striated. The uterus is situated in the middle of each proglottis and consists of a median stem with eighteen to thirty lateral branches. The ripe seg- ments are passed in the stools and are eaten by cattle, in the muscles of which the cysticerci develop. The cysticercus of taenia mediocanellata has never been found in human muscle. Taenia Solium {The Pork Tape-worm) is more common in Eiirope than in America and is taken into the human intestine with raw or insufficiently cooked "measly" pork. But one worm is usually present in a single host but multiple infections have been observed. Taenia solium is about 6 to 12 feet (2 to 4 meters) in length. Its head is more spherical than that of taenia mediocanellata and somewhat tetragonal in shape due to the presence of four cup-like thick-lipped suckers; the head is supplied with a thick rostellum bear- ing a double row of booklets, about twenty-eight in number. The head is about the size of that of a pin; it is provided with a rather slender neck about J of an inch (i cm.) long and is succeeded by the segments or proglottides which, when mature, measure about -J of an inch (i.o to 1.2 cm.) in length and about \ of an inch (6 to 8 mm.) in width. The segments are bisexual, the uterus being situated in the middle of each and appearing as a median stem with from seven to ten coarsely dendritic branches on either side. The male organs are small vesicular bodies placed in the anterior part of each proglottis. There are thousands of embryophores in each segment, the former being nearly spherical, light brown in color and measuring about 35 j« in diameter. The shell is thick and radially striated. The tsenia solium reaches maturity and begins to give off ripe segments in about three to four months. The ova are taken into the intestinal tract of the hog or of man, and the embryos be- coming freed from the shell by the action of the digestive juices, migrate to various parts, the muscles, brain, liver or eye, and become cysticerci. Dibothriocephalus Latus, Tcsnia Lata or Bothriocephalus Latus {The Fish Tape-worm) is found in the human intestine and in that of the dog and cat. This parasite does not occur in the United States except in imported instances but is common in Switzerland, Italy, Southern Germany, along the shores of the Baltic Sea and in Japan. The larvae develop in the peritonaeal and muscular tissues of certain fresh- 870 PARASITIC DISEASES. water fish and are thus taken into the intestine of man. Dibothriocephalus latus is the longest of the tape-worms, the adult measuring from 10 to 30 feet (3 to 10 meters) in length; the head is elongated and almond-shaped, A to -^ inch (2 to 5 mm.) long and about ^^ of an inch (0.7 mm.) broad; it is supplied with two lateral groove-like suckers; there are no hooklets. The lengt^ of the neck varies according to the degree of contraction. The segments number from 3,000 to 4,000, the anterior links being not well marked; they increase slightly in length but markedly in width, the mature segments being -^2 to 3^2" i'^ch (2 to 4 mm.) long and ^ to § of an inch (i to 2 cm.) wide. The ova are ellipsoidal, 68 to 70 fx by 45 fi, and operculated. Ovu- lation takes place in the intestine and the eggs are discharged from the uterus, appearing in the dejections in large numbers. Further development takes place in water and the embryo is presumably swallowed by its intermediate host. Dibothriocephalus Cordatus is similar to the above and is commonly a parasite of seals. It has been observed in man in one instance. Bothriocephalus Mansoni has been observed in the larval stage only; this has been found in the subcutaneous tissue, in the pleural cavity and in the urine. The larva is thick, flat and about an inch (3 cm.) in length. Dipylidium Caninum, Tcsnia Canina, Tcsnia Elipiica or Tcenia Cucumerina is common in the dog and has been found in the human intestine, more especi- ally in children. The intermediate hosts are the dog flea (pulex serraticeps), dog louse (trichodedes canis) and the human flea {pulex irritans). These insects get the ova from faecal matter adherent to the hairs about the anus of the dog and the larvae are transferred to the human alimentary tract upon the fingers, these having been used to crush fleas, or having been licked by dogs. The parasite is 6 to 14 inches (15 to 35 cm.) long; its ova are spherical and from 43 to 50 /i in diameter. Hymenolopsis Nana {Tcznia Nana) is most -frequently observed in Italy and other parts of southern Europe. It is common among the children of the poorer classes; the parasite inhabits the lower portion of the ileum and as many as a thousand may be present in a single individual. Taenia nana is common in the rat and is conveyed to the human intestine upon water contaminated with the faecal matter of these animals or that of a human host, upon food to which rats have had access or upon fingers which have been soiled by contact with the anal tissues. The worm is from ^ to J an inch (i to 1.5 cm.) or more in length; the subglobular head is supplied with four suckers and a rostellum surrounded by a single row of hooklets. The neck is slender and is succeeded by about 150 short, broad segments. The ova are oval or spherical, about 40 /i in diameter and possess a double wall. Hymenolopsis Diminuta or Tcenia Flavopuncta occurs as a parasite of INTESTJINAL CESTODES, T^NI^ OR TAPE-WORMS. 87 1 rats and mice and has been observed in man. The larvae develop in beetles, earwigs and especially in meal moths in the larval stage. The worm is from ^ of an inch to 2 inches (10 to 60 mm.) long and possesses a small globular head with four suckers and a rostellum without hooklets; the neck is short and is succeeded by 800 to 1,200 or more segments which are short and broad. The ova are rounded, yellowish and double-walled, the external diameter being from 54 to 86 p.. Hymenolopsis Lanceolata or Tcenia Lanceolata is found as a parasite of geese and ducks in Europe and has occurred in the human subject in at least one instance. The adult worm measures from i to 5 inches (3 to 13 cm.) in length; the head is very small and is supplied with a rostellum which pos- sesses eight hooklets and four suckers. The neck is short and is followed by about 300 short broad segments. The ova are double-walled, spherical and from 60 to 100 u in diameter. The larvae of this parasite are believed to exist in certain crustaceans. Davainea Madagascariensis or Tcenia Madagascariensis has been found as a human parasite in Madagascar, Guiana, Mauritius and Eastern Asia. The larval form has not been observed. The adult worm is about an inch (3 cm.) long; the head is small with four suckers and a retractile rostellum fitted with a double row of about 90 hooklets. The segments number from 500 to 700 and are slightly longer than broad. The embryo is from 8 to 15 a long and is surrounded by a thin double wall. Taenia Confusa is a recently described species about which little is known but which may be a variety of taenia solium. The parasite has been observed in one instance in Nebraska. Taenia Africana and Taenia Marginata are rarely observed in the human subject. Tape-worms are found in patients of all ages, even young children may be affected. Symptoms. These are not definite nor diagnostic in any way, the existence of the parasite frequently being evidenced by no suspicious manifestations whatever. In other instances various symptoms of local irritation may be present and neurotic individuals, when aware of their disease, often complain of symptoms which have a purely imaginary basis. Local manifestations such as abdominal distress, sensations of weight and fulness in the region of the stomach, particularly after eating, capricious appetite, diarrhoea alter- nating with constipation, salivation, nausea and vomiting and emaciation with anaemia are sometimes observed. Reflex nervous phenomena are not unusual and may consist of irritability of temper, mental depression, lassitude, insomnia, vertigo, itching at the nose, ringing in the ears, visual disturbances and pupillary dilatation. Choreic movements and epileptiform convulsions are said to occur in rare instances 872 PARASITIC DISEASES. but their causation can generally be explained upon other basis than that of the presence of taeniae. Marked and even fatal anaemia has been brought about by the presence of the dibothriocephalus latus and may be due to some toxic substance produced by the worm. The diagnosis can be certainly made only by finding segments of the para- site or its eggs in the faeces or upon the underclothing and if tape-worm is suspected the administration of some simple purge will, unless the suspicion is groundless, bring to light conclusive proof. The prognosis of tape-worm disease is uniformly favorable. Treatment. Prophylaxis consists in using none but thoroughly cooked meat or fish for food, in boiling all drinking water, in destroying, by crema- tion, all faecal matter which may contain segments or ova, for if these are not so disposed of there is likelihood that they may be ingested by hogs or cattle. The institution of governmental inspection of the carcasses of animals used for food is most important in the prevention of tape-worm disease, although cold storage is said to destroy the cysticerci in three or four weeks. It is an interesting fact that the larvae are found chiefly in the muscles of the jaw in the case of the beef tape-worm. There are various effectual methods of ridding the intestine of tape-worms and numerous drugs have been employed with this object in view. The following formula will be found most certain. I^ corticis granati, Bss(i5.o); seminis peponis, oiii (90.0); ergotae, 3ss (2.0); contere et boulliat semi hora in aqua, Sviii (250.0); cola et adde extractum filicis aetheris, 3i (4.0); oleum tiglii, ni ii (0.13); pulverem acacias, oii (8.0). Misce et fiat emulsio. Signa — Take six teaspoonsful (24.0) of Rochelle salt on retiring and the remedy in the morning. Many clinicians advise the patient to subsist upon a light diet, consisting of bread, milk and soups, for two or three days preceding the administration of the anthelmintic in order that the parasite may be somewhat weakened and his hold upon the intestinal mucosa rendered less firm; the systematic administration of mild purges for a day or two before taking the taeniafuge is also advised in order that the bowel may be cleared of faecal matter which might otherwise in some degree protect the worm. In this connection it should be stated that castor oil should not be given in connection with any preparation of male fern for the former markedly increases the solution and absorption of filicic acid which sometimes causes toxic symptoms. Kousso flowers are an active anthelmintic but must be fresh in order to exert their best effect and have the disadvantage that they are likely to cause emesis and intestinal distress. An infusion of i ounce (30.0) of the flowers in 8 ounces (250.0) of water taken in the morning and preceded the night before by a saline cathartic will usually cause the death of the parasite. A INTESTINAL CESTODES, TiENLE OR TAPE-WORMS. 873 purge is seldom necessary after the administration of kousso but should the parasite not appear within six hours after it has been taken, a cathartic is indi- cated. Koussin, a resin obtained from kousso has been given with good results, the dose being 20 to 40 grains (1.33 to 2.66) in capsules. Pomegranate may be given alone as a taeniafuge as well as in the combina- tion suggested above. It is best administered in decoction (B. P., i to 5, dose i to 2 ounces — 15.0 to 60.0) and of this several doses may be taken, fasting at hour intervals. It should be preceded by a brisk cathartic and, if the remedy does not have a purgative effect, followed by another. In case the patient is unable to take the decoction on account of its exceeding unpalatable taste it is recommended that the proper quantity should be evaporated upon a water bath to a pilular consistency and administered in capsules. . PeUetierine tannate, a mixture of the active principles of pomegranate, is one of the most reliable taeniafuges and is decidedly preferable to pome- granate itself on account of the facility with which it can be taken and its freedom from nauseating properties. It is usually given in capsules, pre- ceded and followed by a purge. It should be administered with great cau- tion to children. The dose for an adult is 4 gr. (0.250). Pumpkin seed is considered less efl&cient than the previously mentioned anthelmintics; it is preferably given in emulsion which is prepared by pow- dering 2 ounces (60.0) of the seeds in a mortar with 8 ounces (250.0) of water until the husks are loosened and an emulsion is made, the mixture is then strained and the whole amount taken fasting; some observers consider that the effect is better if the husks are not strained off. The seeds may also- be beaten into a paste with milk and sugar. The resin in doses of 15 grains (i.o) and the expressed oil in doses of 4 drachms (15.0) have been used as substitutes for the seeds and are said to be equally efficient. Kamala in doses of i to 2 drachms (4.0 to 8.0) will kill the tcenia solium and may be given mixed with syrup to which a little hyoscyamus is added to prevent griping; the dead parasite will often appear at the third or fourth stool after the use of the drug. If a single dose is ineffective it may be repeated at three hour intervals until five or six doses have been taken. To be certain that the entire worm has been expelled by any given mode of treatment it is necessary to find the head of the parasite and this often entails a careful search, for, being very small, this part is easily lost in the discharges. Even though the head is not found, in many instances it may have been passed and overlooked. If it remains in the intestine in three to four months segments will again appear in the stools and treatment may be repeated. Obstinate cases may be due to the fact that the head is hidden beneath the valvulse conniventes and is thus protected from the action of the taeniafuge. 874 PARASITIC DISEASES. PARASITIC INSECTS. ARACHNIDS AND TICKS. Sarcoptes or Acarus Scabiei or the itch mite is not uncommon in persons of uncleanly habits. It is nearly circular in shape and hardly visible to the naked eye. The female burrows in the epidermis more especially where the skin is thin as between the fingers, upon the flexor surfaces of the knees, in the groins, etc. The eggs are deposited in this burrow and hatch in about one week and reach the adult stage about fourteen days later. The parasite is most frequently observed in persons of uncleanly habits and is transferred by bodily contact or upon clothing. Symptoms. These consist of intense pnu-itus; the burrows may be detected in the skin of the affected parts but are often obscured by scratch marks. Treatment. The body should be thoroughly cleansed with soft soap and hot water for the purpose of breaking open the burrows and exposing the parasite; next the surface should be rinsed with cold water and dried, after which sulphur ointment should be rubbed carefully into the skin. The ofl&cial ointment in full strength is often too irritating and it is usually wise to dilute it somewhat. The following application may also be employed: Oil of cade, i drachm (4.0); sulphur ointment, 2 drachms (8.0); lanolin, 5 drachms (20.0). After the inunction the patient should go to bed and the next morning should wash himself clean and put on clean clothing. One . such application is usually sufficient to effect a cure but it may be repeated once or twice. In order to prevent reinfection the bed linen and the clothing- previously worn should be burned or disinfected by boiling or exposure to steam under pressure. Sarcoptes Scabiei Hominis is a variety of the itch mite which infests the cat, dog, cow, horse, and other animals; it is sometimes transferred to man but dies spontaneously. Leptus Autumnalis ( The Harvest Bug) is a tiny red parasite possessing six legs, rows of bristles upon its dorsal and ventral surfaces and sharp mandib- les. It is common in summer on grass and other plants and attaches itself particularly to the skin of the ankles and legs into which it penetrates suffi- ciently far to obtain nourishment. It causes irritation and pruritus. Treatment consists in inunctions of sulphur, mercury or naphthol oint- ments or the employment of a lotion of i to 500 mercury bichloride solution. Demodex FoUiculonim {The Comedo Mite) is a minute parasite with a worm-like body and short legs. It is about -^^ of an inch (0.3 to 0.4 mm.) in length and infests the sebaceous follicles of the skin, particularly that of the face and nose, from which it can often be expressed. It causes no special symptoms but may incite inflammation of the follicles. PARASITIC FLIES. 875 Treatment. The insect may be expressed by means of a watch key or a comedone extractor. Prevention consists in frequently washing the face with a pure soap and a flesh brush; i to 500 mercury bichloride solution may be employed as a lotion. Pentastomata. These include the pentastomum tcznioides (lingulata rhin- aria) which inhabits the nasal fossae of the dog, horse and rarely, those of man. The female possesses a lancet-shaped body from 3 to 4 inches (9 to 12 cm.) long while the male is about a third of this size. The ova are ejected in sneezing and may be taken into the human body. The larvae have been found in the liver, lungs, and kidneys. Pentastomum Constrictum (Porocephalus constrictus) is a very rare para- site about i an inch (1.5 cm.) long which has been found in a few instances in the liver and lungs. In one case the parasites were expectorated in con- . siderable number. Ixodiasis (Tick fever) has been considered in the section upon infectious diseases. PARASITIC FLIES. Myiasis. This term is applied to the condition characterized by the pres- ence of the larvae of various species of flies (diptera). Several varieties of flies, notably the flesh or blue-bottle fly (sarcophila carnaria), the common house fly (musca domes tica), the blow-fly {calliphoria vomitoria) and the screw-worm fly {compsomyia macellaria) deposit their eggs upon wound surfaces, these hatch within twenty-four hours and the lesions become fQled with maggots or larvae, producing the condition known as myiasis vulnerum. The ova of the above mentioned flies may also be taken into the alimen- tary tract and cause intestinal myiasis; the larvae of these and of other species have been observed in vomitus and faeces. Usually intestinal myiasis is not attended by any serious results, sometimes ulcerations and fatal inflamma- tions of the colon result. Ova are sometimes deposited in the nostrils, ears, conjunctivae, urethra and vagina but, as a rule, not unless disease is present in these situations. Serious consequences may follow the presence of larvas in the ears and nose. Cutaneous myiasis is usually due to the larvae of bot-flies (estridae). These attack the skin of the horse, ox, sheep, and other animals and have been observed in man, in most instances in tropical regions. The parasites bore beneath the skin and cause lesions resembling boils; the parts most frequently attacked are the abdomen and scrotum. Myiasis of the skin, due to the presence of the larvae of musca vomitoria has been noted. In Russia, and more rarely elsewhere, cutaneous infection with the larva 876 PARASITIC DISEASES. of the horse bot-fly (gastrophilus equi) produces a migrating eruption con- sisting of a slightly raised pinkish line which traverses the skin with more or less rapidity. An epidemic urticaria is common in certain countries as a result of the presence of difierent species of caterpillars especially the cnethocampa. Actual contact, with these insects is said not to be necessary for the production of this eruption. OTHER PARASITIC INSECTS. PEDICULOSIS. Synonym. Phthiriasis. Three forms of pediculi are parasitic in man, the pediculus capitis, the pediculus corporis and the pediculus pubis. Pediculus Capitis {the head louse) infests the hair and scalp of uncleanly individuals. The male insect is about ^V of ^^ ^^^^h (i mm.) in length while the female is somewhat longer. The parasites multiply with great rapidity, the female laying 50 or more ova or nits. These are attached to the hairs, are hatched in about a week and within three weeks are able to reproduce themselves. Symptoms. These consist of itching and irritation of the scalp and if the insect bores beneath the skin an eczema or pustulous dermatitis may be excited, particularly in the occipital region, which results in the production of crusts and scabs which mat the hair into a filthy and disgusting mass known as the plica polonica from its frequence amongst the Polish Jews. The diagnosis is easily made by observing the insect itself or by detecting the nits, which are minute whitish bodies attached to the hairs. Treatment. To rid the scalp of the adult parasites is an easy matter but to destroy the ova is quite a different consideration. The lice themselves may be killed by thoroughly rubbing kerosene or turpentine into the hair. Staphisagria is a classical and effective parasiticide and a combination of the fluidextract with acetic acid and aether (i to 8) is recommended; the acid will dissolve the gum with which the nits are stuck to the hairs and permit their removal with a fine toothed comb. Such removal is usually necessary, espe- cially in women who object to clipping of the hair. Staphisagria should not be applied if the scalp is abraded for poisonous symptoms have been observed to follow its use. Phenol in 2 percent, solution and the tincture of cocculus indicus may also be employed. In using any of the remedies suggested it is wise to make the applications upon several successive evenings, the patient sleeping with the moistened hair wrapped in a turban made of a towel and taking a thorough shampoo on rising. Pediculus Corporis or Vestimentorum {the body louse) inhabits the seams PEDICULOSIS. 877 in the clothing of persons of filthy habits and derives its sustenance by sucking the blood through its proboscis which it inserts through the skin. These punctures are often evidenced by a minute heemorrhagic point and are most abundant upon the neck, back and abdomen. The parasite is twice or three times the size of the head louse and is whitish-gray in color. It deposits its eggs upon the underclothing, where they may be found after a prolonged search. Symptoms. These, as in the case of the head louse, consist of pruritus and irritation. Linear scratch marks may be observed and in long-standing instances a scaly and pigmented condition of the skin {vagabond's disease) results. Treatment. The infected clothing should be burned or subjected to steam or hot-air disinfection. The itching may be relieved by warm baths to which sodium carbonate or bicarbonate has been added and by the appli- cation of antipruritic lotions. Pediculus Pubis or Inguinalis {the crab louse) is about ^ of an inch (i mm.) in length, yellowish-gray in color and possesses six legs with strong claws. The parasite infests the hairy parts of the body such as the pubic region, the chest and axillae; it may also reach the beard and eyebrows. Like the preceding parasites is causes itching and irritation. Treatment consists in the application of mercurial ointment or the oint- ment of ammoniated merciiry. Beta naphthol, 15 grains (i.o) to the ounce (30.0) of vaseline is also effective. Shaving the hair may be necessary. Cimex Lectularius {the bed bug) is a flat brown insect from yV to i of an inch (2 to 5 mm.) in length and slightly less in breadth. It infests beds and the cushions of pubhc vehicles and possesses a characteristic and unpleasant odor. It subsists upon the blood which it sucks, and causes, in most persons, a troublesome itching and irritation of the skin. Certain individuals appear to be indifferent to or immune from its attacks. The female lays about 50 ova several times a year in the crevices of furniture and walls. Treatment. The irritation of the bite of cimex lectularius may be relieved by antipruritic lotions. To rid furniture and apartments of the pest fumiga- tion with sulphur, and painting of crevices in walls, floors and elsewhere with I to 500 mercury bichloride solution, kerosene, or a mixture of oil of cedar I part, spirit of turpentine or methyl alcohol 8 parts, are suggested. Pulex Irritans {the common pa) is found almost universally. The male is about -^ of an inch (2 mm.) in length while the female is twice this size; in color the insect is nearly black or, when filled with blood, brownish. It does not infest man naturally but may do so in districts where it is very abundant. The bite is very irritating to susceptible subjects, being evidenced by a slightly raised, circular red spot in the center of which the insect's proboscis has entered; other individuals may suffer no inconvenience. 878 PARASITIC DISEASES. Treatment. The irritation may be relieved by soothing applications. Where the insect is a common pest, rubbing the skin with one of the essential oils such as that of pennyroyal (hedeoma) may prevent its onslaughts. Pulex Penetrans (the sand-flea, jigger or chigce) is common in tropical countries and in the Southern United States. It is considerably . smaller than the common flea and brownish in color. The p&rasite bites all warm-blooded animals, including man, just as does the common flea. Impregnated females burrow into the tissues, particularly those of the feet, where they mature their eggs, the abdomen enlarging during this process to the size of a small pea. The mature ova are laid while the female is imbedded in the flesh of the host and escape thence into the dust of the ground or floor where they hatch into larvae. The shell of the parent when dead and empty of eggs usually causes no further trouble although at times irritation, abscesses and ulcers have been observed to result. If the parasite is removed from the host she extrudes her eggs and perishes and the eggs so laid do not hatch into larvae. The chigoe does not often produce serious lesions but infection, gangrene and even death may result indirectly from its presence. Prevention of the entry of the parasite may be accomplished by wearing high shoes and closely woven stockings. The insects may also be prevented from entering dwellings by sprinkling the floors with kerosene or naphthol. Treatment consists in the removal of the parasite by means of a dull knife or needle, strict asepsis being observed. The removal is also an important point in prophylaxis for the eggs are continually being dropped from the host who thus becomes dangerous to his associates. If infection of the lesion has taken place it should be treated by the usual surgical and antiseptic methods. INDEX. Abasia-astasia, 828 Abscess, mediastinal, 659 of the brain, 727 of the liver, 425 of the lung, 639 of the spleen, 513 paranephritic, 697 perinephric, 697 Acanthocephala, 858 Acarus scabiaei, 874 Achylia gastrica, 372 Acromegaly, 840 Actinomycosis, 127 course of, 127 diagnosis of, 128 of alimentary tract, 127 of brain, 128 of lungs, 127 of skin, 128 pathology, 127 symptoms of, 127 treatment of, 128 Active congestion of kidney, 666 Acute albuminuria, 664 alcoholism, 297 angioneurotic oedema, 834 anterior poliomyelitis, 739 arsenical poisoning, 290 articular rheumatism, 105 ascending paralysis, 753 atrophic spinal paralysis, 739 B right's disease, 671 bronchial catarrh, 617 bulbar palsy, 752 catarrhal dysentery, 62 gastritis, 334 nephritis, 671 desquamative nephritis, 671 dyspepsia, 334 febrile jaundice, 201 gastric catarrh, 334 hydrocephalus, 714 ileo-colitis, 381, 393 leptomeningitis, 712 miliary tuberculosis, 148 nasal catarrh, 607 nephritis, 671 phthisis, 150 poliomyelitis, 739 rheumatism, 105 softening of the brain, 710 Acute tonsillitis, 327 tracheo-bronchitis, 617 tubal nephritis, 671 yellow atrophy of the liver, 441 aetiology of, 441 definition of, 441 diagnosis of, 442 pathology of, 441 prognosis of, 442 symptoms of, 442 treatment of, 442 urine in, 442 Adams-Stokes syndrome, 587 Addison's disease, 534 aetiology of, 534 diagnosis of, 535 pathology of, 534 prognosis of, 535 symptoms of, 534 coloration of skin, 534 treatment of, 535 Adenitis, malignant, 75 tropical, 77 tuberculous, 173 Adiposis dolorosa, 840 Adipositas universalis, 273 ^stivo-autumnal fever, 46, 49 Ageusia, 788 Agraphia, motor, 723 Ainhum, 844 Albuminoid heart, 551 liver, 438 Albuminuria, 664 extrarenal, 664 general remarks on, 664 physiological or functional, 665 renal, 664 immediate cause of, 664 Albuminuric retinitis, 680, 778 Alcohol poisoning, 297 Alcoholic coma, 298 Alcoholism, 297 acute, 297 * definition of, 297 diagnosis of, 298 symptoms of, 298 treatment of, 299 chronic, 299 definition of, 299 effects of, 299 symptoms of, 300 879 INDEX. Alcoholism, chronic digestive apparatus, 300 liver, 300 nervous system, 300 vascular changes, 300 treatment, 301 Allantiasis, 312 Amavirosis, 779 hysterical, 779 methyl alcohol, 779 tobacco, 779 toxic, 779 uraemia, 779 Amblyopia, 779 tobacco, 779 American disease, 821 Amok, 827 Amoeba coli, 65 Amoebic dysentery, 64 Amuck, 827 Amyloid disease, heart, 553 liver, 438 aetiology, 438 definition of, 438 diagnosis of, 439 pathology, 438 prognosis of, 439 symptoms of, 439 treatment of, 439 spleen, 514 Amyotrophic lateral sclerosis, 744 setiolog}' of, 744 patholog}' of, 744 symptoms of, 744 treatment of, 745 Anchylostomum duodenale, 858 Anchylostomiasis, 858 Anaemia, in general, 487 hepatic, 450' infantum, 504 aetiology of, 504 diagnosis of, 505 pathology of, 504 prognosis of, 505 symptoms, 506 treatment of, 506 infantum pseudo-leucaemia, 504 lymphatic, 516 aetiology, 516 diagnosis of, 518 pathology of, 517 prognosis of, 518 symptoms of, 517 treatment of, 518 of the liver, 450 primary or essential, 490 chlorosis, 490 aetiolog}' of, 490 blood in, 491 cardiac murmurs in, 490 definition of, 490 diagnosis of, 491 pathology of, 490 prognosis of, 491 Anaemia, symptoms of, 490 treatment of, 491 progressive pernicious, 494 aetiology of. 494 blood in, 495 definition of, 494 diagnosis of, 495 pathology of, 494 prognosis of, 495 symptoms of, 495 treatment of, 495 secondar}' or symptomatic, 487 • cardiac murmuis in, 488 diagnosis of, 489 due to drain of chronic disease, 487 due to haemorrhage, 487 from inanition, 487 symptoms of, 488 treatment of, 489 splenic, 515 aetiology of, 515 diagnosis of, 516 pathology of, 515 prognosis of, 516 symptoms of, 515 treatment of, 516 toxic 487 Anaemias, the, 487 Aneurysm, differential diagnosis of, 602 from aortic incompetency, 602 from mediastinal tumors, 602 from pulsating empyaema, 602 of the abdominal aorta, 602 of the branches, 603 of the coeliac axis, 603 of the aorta, 598 of the ascending aorta, 598 of the descending aorta, 599 of the heart, 555 aetiology of, 598 false, 597 dissecting, 597 traumatic, 597 true, 597 varix or anastomotic, 597 of the hepatic artery, 603 of the pulmonary artery, 603 of the renal artery, 603 of the splenic artery, 603 of the superior mesenteric artery, 603 of the thoracic aorta, 598 diagnosis of, 602 physical signs of, 600 diastolic shock, 600 s}Tnptoms of, 598 pain, 599 pressure, 599 tracheal tugging, 601 voice, 600 of the transverse part of aorta, 599 physical signs, 632 prognosis of, 602, 603 treatment of, 604 INDEX. Aneurysm, varieties of, 597 Angina, 325 follicularis, 327 Ludovici, 325 malignum, 78 membranacea, 78 pectoris, 590 aetiology of, 590 diagnosis of, 591 from hysterical form, 591 pathology of, 591 prognosis of, 592 symptoms of, 591 oppression, 591 pain, 591 parox}'sm, 591 treatment, 592 Angioneurotic oedema, 834 aetiology of, 834 pathology of, 834 symptoms of, 834 treatment of, 835 Anguillula acetici, 857 Anguillulina putrefaciens, 857 Anorexia nervosa, 379 treatment of, 379 Anosmia, 776 Anterior poliomyelitis, acute, 739 chronic, 742 Anthrax, 122 aetiology of, 122 bacillus, 123 diagnosis of, 124 external, 123 malignant, oedema, 123 pustule, 123 in animals, 122 incubation, 123 internal, 123 intestinal anthrax, 123 wool-sorter's disease, 124 pathology of, 123 prognosis of, 124 symptoms of, 123 treatment of, 124 Antimonial poisoning, 294 acute, 294 treatment of, 294 chronic, 294 treatment of, 294 Antitoxin, diphtheria, 84 technique of injection of, 84 untoward effects of, 85 Aortic incompetency, 566 insufficiency, 566 etiology of, 567 physical signs of, 568 capillary pulse, 569 Corrigan pulse, 569 flint murmur in, 568 symptoms of, 567 treatment of, 579 obstruction, 569 56 Aortic incompetency, aetiology of, 569 diagnosis of, 570 physical signs, 569 symptoms of, 569 treatment of, 579 Aphasia, 722 motor, 723 or loss of faculty of speech, 723 sensory, 722 various forms of, 722, 723 Aphthae epizooticae, 128 Aphthous fever, 128 Apoplexy, 716 cerebral haemorrhage, 716 aetiology of, 716 arterial distribution, 716 ■* diagnosis of, 718 pathology of, 716 symptoms of, 717 treatment of, 719 embolism and thrombosis of the cerebral arteries, 720 aetiology of, 720 diagnosis of, 718 patholog}' of, 720 relative frequency, 720 symptoms of, 721 treatment of, 721 meningeal, 766 Appendicitis, 399 aetiology of, 399 bacilli, 400 catarrhal, 400 definition of, 399 diagnosis of, 402 exciting causes, 399 morbid anatomy of, 399. of catarrhal, 399 of gangrenous, 401 of ulcerative, 401 obliterative, 400 pathology and morbid anatomy, 400 predisposing causes, 399 prognosis of, 402 symptoms of, 401 rigidity of muscle, 402 tenderness, 402 tumor, 402 treatment of, 402 diet, 403 medicinal, 403 operative, 404 Arachnidae, 874 Argy^ll-Robertson pupil, 747, 780 Arrhythmia, 587 treatment of, 590 Arithmomania, 800 Arsenical poisoning, 290 acute, 290 symptoms of, 290 treatment of, 290 chronic, 291 symptoms of, 291 882 IXDEX. Arsenical poisoning, treatment of, 292 .\rterio-capillar}- fibrosis, 593 Arteriosclerosis, 593 aetiolog}- of, 593 pathology- of, 593 s}Tnptonis of, 594 treatment of, 595 coronar}-, 553 .Axtkritis deformans, 269 cetiologvi of, 269 definition of, 269 diagnosis of, 271 patholog}- of, 269 prognosis of, 272 S}Tiiptom3 of, 270 multiple, 270 partial or monarticular, 271 treatment ot, 272 vertebral type of, 271 Arthritis, gonorrhcEal, 131 .Arthropoda, 874 -Arachnoidea, 874 Unguatulidea or pentastomes, 450, insecta, 875 Ascariasis, 853 .Ascaris alata, 856 canis, 856 lumbricoides, 853 mystax, 856 tricura, 857 Ascites, 484 aetiology of, 484 character of fluid, 485 chylous, 485 differential diagnosis of, 485 from cyst of the omenttmi, 486 from hydronephrosis, 486 from overdistended bladder, 486 from ovarian cyst, 485 physical signs of, 485 symptoms of, 484 treatment of, 486 Astasia-abasia, 828 Asthenic bulbar paralysis, 838 Asth m a, bronchial, 625 cardiac, 563, 567 uraemic, 669 Ataxia, hereditar}', 751 cerebellar, 752 progressive locomotor, 745 Ataxic paraplegia, 751 family, 751 hereditar}-, 751 Atheroma of the blood-vessels, 593 AthjTea, 528 Atrophia musculorum lipomatosa, 847 Atrophy, acute yellow, of the liver, 441 aetiolog}' of, 441 diagnosis of, 442 patholog}' of, 441 s}Tnptoms of, 442 treatment of, 442 cardiac, 551 Atrophy, f acio-scapulo-humeral type of, 849 juvenile, Erb's form of, 848 progressive, peroneal type of, 849 Auditor)' h}-perssthesia, 785 irritation, 785 or eighth ner%'e, lesions of, 785 Aural vertigo, 7S6 Autumnal catarrh, 608 fever, i Babinski reflex, 98 Bacillar}- dysenter}', 63 Bacillus dysenteriae, 63 BaciUus pestis, 75 Bacillus pneimnoniae, 180 BaciUus typhosus, i Bacteriaemia, 11 1 Banti's disease, 515 Barlow's disease, 279 Basedow's disease, 523 Bedbug, 877 Beef tape-worm, 868 Bell's palsy, 782 Beri-beri, 195 aetiolog}' of, 196 diagnosis of, 197 patholog}- of, 196 prognosis of, 197 symptoms of, 196 treatment of, 197 Big jaw, 127 Bile-ducts, carcinoma, 469 parasites, 470 stenosis, 469 common, inflammation of, 45.3 Bile-passages and gall-bladder, diseases of, 453 Bilharzia hsmatobium, 852 Bilharziosis, 852 Bihar}' cancer, 468, 469 calculus, 460 colic, 462 tract, diseases of, 453 Bilious headache, 835 remittent fever, 33 Bisulphide of carbon poisoning, 311 Black death, 24, 75 plague, 24, 75 vomit, 34 Blackwater fever, 50 Bladder, tuberculosis of, 177 worms, 868 Blepharospasm, 784 Blood, diseases of the, 487 Blood-vessels, diseases of, 593 tuberculosis of, 179 Bloody flux, 61 Body louse, 876 Bone tumor, 127 Borism, 296 symptoms of, 296 treatment of, 297 Bothriocephalus latus, 869 INDEX. 883 Bothxiocephalus Mansoni, 870 Botuiismus, 312 Bowel, carcinoma of, 419 diagnosis of, 419 symptoms of, 419 treatment of, 420 embolic ulcer of, 399 haemorrhagic infarct of, 396 intussusception of, 406 invagination of, 406 nen'ous affections of, 416 derangement of motion, 417 of sensibilit}', 418 enteralgia, 41S secretion neurosis, 418 treatment of, 384 obstruction of, 404 by faecal matter, 408 by foreign bodies, 408 by morbid growths, 408 by stricture, 408 strangulation of, 405 s}-pliilitic ulcer, 399 twists and knots in, 405 ulceration of, 397 Brachial plexus, lesions of, 768 Bradycardia, 5 86 explanation of, 586 treatment of, 5 89 Brain, abscess of, 727 aetiolog}' of, 727 complications of, 728 patholog}' of, 727 prognosis of, 729 symptoms of, 728 treatment of. 729 affections of the blood-vessels of, 720, 722 diseases of, 710 and its membranes, diseases of, 707 railway, 82 8 sclerosis of, 725 tumors of the, 729 ffitiolog}- of, 729 diagnosis of, 730 prognosis of, 733 s}-mptom5 of, 729 of basal ganglia or internal capstde, 733 of base of the, 733 of central or motor region, 731 of cerebeUum, 735 of corpora quadrigemina, 733 of corpus callosum, 733 of crura, 733 of occipital lobe, 732 of parietal area, 732 of pons and medulla oblongata, 732 of prefrontal area, 731 of temporosphenoidal area, 732 treatment, 733 varieties of, 729 wet, 300 Breakbone fever, 43 Brickmaker's anaemia, 858 Bright's disease, acute, 671 chronic, 678 Broadbent's sign, 542 Bromism, 295 s}-mptoras of, 295 treatment of, 296 Bronchi, diseases of, 617 Bronchial asthma, 625 ffitiolog}- of, 625 physical signs in, 626 prognosis of, 626 s^inptoms of, 625 treatment of, 626 catarrh, acute, 617 chronic, 621 dilatation. 62 S tubes, diseases of, 617 Bronchiectasis, 628 setiolog}- of, 628 diagnosis of, 629 patholog}- of, 628 physical signs of, 629 S}-mptoms of, 629 treatment of, 630 Bronchitis, 617 acute, 617 setiolog}' of, 617 patholog}' of, 618 physical signs of, 618 S}Tnptoms of, 618 treatment of, 619 capillar}', 187 chronic, 621 aetiology of, 621 diagnosis of, 622 patholog}' of, 621 physical signs of, 622 prognosis of, 622 s}Tnptoms and course of, 621 treatment of, 622 climatic resorts in, 622 foetid, 622 plastic or fibrinous, 623 etiology of, 624 diagnosis of. 624 patholog}' of, 624 physical signs of, 624 svmptoms of, 624 treatment of, 624 putrid, 622 spasmodic, 625 etiology of, 625 pathology of, 625 ph}-sical signs of, 626 ST.Tnptoms of, 625 treatment of, 626 Bronchocele, 521 Broncho-pneumonia, 1S7 Brown atrophy of the heart, 551 Bubo, climatic, 77 s}'mptoms, 77 treatment, 78 884 INDEX. Bubo, tropical, 77 Bubonic plague, 75 aetiology of, 75 bacillus of, 75 diagnosis of, 76 pathology of, 75 prognosis of, 76 symptoms of, 75 treatment of, 76 serum therapy, 77 varieties of, 77, 78 bubonic form, 76 pestis minor, 75 pestis major, 76 pneumonic form, 76 septicaemic form, 76 Buhl's disease, 508 Bulbar paralysis, 752 aetiology of, 752 pathology of, 753 prognosis of, 753 symptoms of, 753 treatment of, 753 Bulimia, 378 treatment of, 378 Busk's fluke, 853 Cachexia, malarial, 50 thyroidea vel strumipriva vel thyreopriva, 528 Caisson disease, 758 aetiology of, 758 pathology of, 758 symptoms of, 758 treatment of, 759 Calcareous degeneration of heart, 553 Calculi, pancreatic, 476 Calculus, biliary, 460 hepatic, 460 renal, 698 Calliphoria vomitoria, 875 Camp fever, 24 Cancer, gastric, 356 of the gaU-bladder, 468 of the liver, 443 of the oesophagus, 331 of the pancreas, 474 of the pericardium, 543 of the peritonaeum, 483 of the stomach, 356 Cancrum oris, 321 Cannabis indica poisoning, 309 Capillary bronchitis, 187 Carbon disulphide poisoning, 311 symptoms of, 311 treatment of, 311 Carcinoma of the bowel, 419 of the liver, 443 diagnosis of, 445 massive form, 443 nodular form, 443 treatment of, 446 with cirrhosis, ^4^ Carcinoma of the lung, 639 of the stomach, 356 ventriculi, 356 Cardiac arrhythmia, 587 atrophy, 551 dilatation, 546 defects, congenital, 573 treatment of, 585 disease, 543 muscle, degeneration of, 551 albuminoid, 551 amyloid, 553 calcareous, 553 hyaline, 553 neuroses, 585 Cardiospasm, 373 treatment of, 374 Cardio thyroid exophthalmos, 523 Case record, xxv Catarrh, acute bronchial, 617 chronic bronchial, 621 nasal, 607 Catarrhal fever, 38 pneumonia, 187 Catarrhus aestiviis, 608 Cellulitis of the neck, 325 Cephalodynia, 268 Cerebellar hereditary ataxia, 752 Cerebellum, disease of, 734 tumors of, 734 symptoms, 734 Cerebral disease, 710 embolism, 720 localizations of, 731 summary of facts bearing on, 731 haemorrhage, 716 meningitis, 711 softening, 720 thrombosis, 720 Cerebritis, acute, 710 suppurative, 727 Cerebrospinal fever, 95 aetiology of, 96 Babinski's reflex in, 98 brain in, 96 complications and sequelae, 99 cranial nerves in, 96 diagnosis of, 99 from tuberculous meningitis, 100 forms of, 98 abortive, 98 chronic, 98 intermittent, 98 malignant, 98 mild, 98 ordinary, 97 incubation period, 97 Kemig's sign of, 98 lumbar puncture in, 99, 100 pathology' of, 96 predisposing causes of, 96 prognosis of, 100 Quincke's lumbar puncture in, 99, 100 INDEX 885 Cerebrospinal fever, spinal cord in, 96 symptoms of, 97 treatment of, 100 Cestodes, 868 Charcot-Leyden crystals, 154 Charcot's disease, 744 Cheese poisoning, 313 Chiasm and tract, lesion of, 776 Chicken-pox, 229 complications in, 230 varicella gangrenosa, 230 eruption in, 229 incubation in, 229 Chick-pea disease, 315 Chigce, 878 Children, reflex convulsions of, 812 Chill, the congestive, 50 Chills and fever, 47 Chloraemia, 490 Chloral poisoning, 304 Chloralism, 304 symptoms of, 304 treatment of, 304 Chloranaemia, 490 Chloride retention in chronic nephritis, 61 Chloroma, 503 Chlorosis, 490 aetiology of, 490 blood in, 491 definition of, 490 diagnosis of, 491 pathology of, 490 prognosis of, 491 symptoms of, 490 treatment of, 491 Choked disk, 777 Cholecystitis, acute infectious, 458 etiology of, 458 definition of, 458 diagnosis of, 459 patholog}' of, 458 svmptoms of, 459 treatment of, 459 Cholelithiasis, 460 aetiology of, 460 diagnosis of, 465 symptoms of, 461 treatment of, 465 Cholera, 55 aetiology of, 55 bacUlus of, 55 of Koch, 55 collapse in, 57 diagnosis of, 58 differentiation from cholera morbus, 58 epidemics of, 55 mode of infection, 56 pathology of, 56 prevention of, 58 prognosis of, 58 sicca, 57 symptoms of, 57 incubation, 57 Cholera, stage of collapse, 57 of preliminary diarrhoea, 57 of reaction, 58 treatment of, 59 enteroclysis, 60 of attack, 59 protective inoculation, 61 algida, 55 Asiatica, 55 infantum, 391 aetiology of, 391 definition of, 391 pathology of, 391 prognosis of, 392 symptoms of, 391 treatment, 392 maligna, 55 morbus, 387 aetiology of, 387 definition of, 387 pathology of, 387 prognosis of, 388 symptoms of, 387 treatment of, 388 nostras, 387 sporadic, 387 Cholerine, 58 Chorea, acute, 795 aetiology of, 795 pathology of, 796 nature of, 795 prognosis of, 797 symptoms of, 796 treatment of, 797 chronic hereditary, 801 aetiology of, 801 pathology of, 801 prognosis of, 802 symptoms of, 801 treatment of, 802 habit, 800 hereditar}', 801 Huntington's, 801 mild, 796 minor, 795 Sydenham's, 801 Choreiform affections, 799 Chronic anterior poliomyehtis, 742 bronchial catarrh, 621 catarrhal dyspepsia, 337 gastritis, 337 cyanosis, 504 diarrhoea, 383 diffuse meningo-encephalitis, 723 nephritis, 678 endocarditis, 561 gastric catarrh, 337 interstitial hepatitis, 429 pneumonia, 192 malaria, 50 parenchymatous nephritis, 678 rheumatic arthritis, 265 tubal nephritis, 678 886 INDEX. Chronic ulcerative phthisis, 151 valvular disease, 561 Chronically contracted kidney, 678 Chyluria, 709, 865 Cimex lectularius, 877 Cirrhosis of the liver, 429 aetiology, 429 definition of, 429 diagnosis of, 431 pathology hi, 430 prognosis of, 432 symptoms of, 430 treatment of, 432 diet in, 436 Cirrhosis of the lung, 192 Cirrhotic kidney, 683 Claudication, intermittent, 595 CUmate in tuberculosis, 162 Cocaine poisoning, 309 Cocainism, 309 symptoms of, 310 treatment of, 310 Coccidium cuniculi, 850 hominis, 850 oviforme, 450, 850 Cold in the head, acute, 607 Colic, biliary, 462 hepatic, 462 lead, 286 renal, 700 Colica pictonum, 286 Colitis, mucous, 383 ulcerative, 383 CoLLes' law, 135 Colon, dilatation of, 416 Combined valvular lesions, 573 Comedo mite, 874 Compression of spinal cord. 759 aetiology of, 759 pathology of, 759 symptoms of, 759 treatment of, 760 Compression myelitis, 759 Compsomyia macellaria, 875 Congenital absence of kidney, 661 cardiac defects, 573 treatment of, 585 Congestion of the kidney, 666 Congestive chill, 50 Constipation, 411 treatment of, 412 in infants, 415 Constitutional diseases, 245 Consumption, galloping, 150 of the lungs, 149 Contracted kidney, 683 Convulsions, reflex, in children, 812 Convulsive tic, 800 Copodyscinesia, 829 Coprolalia, 800 Coradiposum, 552 Cord, spinal, diseases of membranes of, 735 Coronary arteries, sclerosis of, 553 Corpulence, 273 Corrigan pulse, 569 Cortical epilepsy, 804 Coryza, acute, 607 Costiveness, 411 Country fever, 318 Coup de soleil, 317 Courvoisier's law, 461 Cow-pox, 242 Crab louse, 876 Cramps of cardia, 375 Cranial nerves, diseases of, 775 Cretinism, 529 congenital, 529 endemic, 530 sporadic, 530 treatment of, 530 Cretinoid idiocy, 529 Crises, tabetic, 747 Croup, catarrhal, 506 false, 613 membranous, 78 spasmodic, 613 treatment of, 613 Croupous enteritis, 395 pneumonia, 179 Curschmann's spirals, 626 Cyanosis, chronic, 504 Cyclic vomiting, 379 treatment of, 380 Cycloplegia, 779 Cysticerci, 868 Cysticercus cellulosae, 450 Cysts, echinococcus, 447 hydatidosus, 447 of kidney, 705 of spleen, 515 of the pancreas, 474 Cytozoa, 850 Dairy products, poisoning by, 313 Dandy fever, 43 Davainea Madigascariensis, 871 Deafness, nervous, 786 Dechloridation treatment, 681 Degeneration of the heart, amyloid, 553 calcareous, 553 fatty, or metamorphosis, 552 circumscribed. 552 parenchymatous or albuminoid (cloudy sweUing), 551 Delire du toucher, 800 Delirium cordis, 588 tremens, 302 definition of, 302 diagnosis of, 303 prognosis of, 303 symptoms of, 302 treatment of, 303 Dementia paralytica, 723 aetiology of, 724 pathology of, 724 prognosis of, 725 INDEX. 887 Dementia paralytica, symptoms of, 724 treatment of, 725 Demodex folliculoruin, 874 Dengue, 43 aetiology of, 43 diagnosis of, 44 pathology of, 44 prognosis of, 44 symptoms of, 44 treatment of, 45 Derbyshire neck, 521 Dercum's disease, 840 Dermacentor reticulatus, 23 Dermatosclerosis, 843 Diabetes insipidus, 262 aetiology of, 262 definition of, 262 diagnosis of, 263 pathology, 262 physical and chemical character of the urine, 263 prognosis of, 263 symptoms of, 263 duration of, 263 treatment of, 263 hygienic, 264 medicinal, 264 mellitus, 254 aetiology of, 255 alimentary form of, 255 beta oxy butyric acid in, 257 coma in, 257 definition of, 254 nervous form of, 255 pancreatic form of, 255 pathogenesis of, 255 pathology of, 256 prognosis of, 257 surgery in, 262 symptoms of, 256 boils in, 256 eczema, 256 gangrene, 257 lungs in, 256 polyuria, 256 prognosis of, 257 thirst, 256 uric acid, 256 treatment of, 257 beverages in, 260 diabetic coma, 261 dietetic, 259 hygienic, 261 medicinal, 258 potatoes in, 260 Diarrhoea, acute, 381 chronic, 383 hill, 72 of children, 389 summer, 389 Diazo-reaction 9 Dibothriocephalus latus, 869 cordatus, 870 Dichotophyme gigas, 857 Dietl's crisis, 662 Digestants, artificial, 340 Digestive system, and peritonaeum, diseases of, 320 Dilatation, bronchial, 628 of the colon, 416 symptoms of, 416 treatment of, 416 of the heart, 546 Diphtheria, 78 aetiology of, 78 complications and sequelae, 81 broncho-pnemnonia, 81 capillary bronchitis, 81 heart, 81 nephritis, 81 paralysis, 82 toxic neuritis, 82 contagiousness of, 79 diagnosis of, 82 forms of, 80, 81 in animals, 79 Klebs-Lofiier bacillus, 79 laryngeal, 80 nasal type, 80 pathology of, 79 pharyngeal type, 80 prognosis of, 82 prophylaxis of, 82 symptoms of, 80 laryngeal cough, 80 of nasal, 80 period of incubation, 80 seats of invasion, 79 treatment of, 84 antitoxin, 84 administration of antitoxin for immun- ization, 83, 84 of complications and sequelae, 87, 88 prophylactic, 84 serum therapy, 84 Diphtheritic enteritis, 395 Diplococcus intracellularis meningitidis, 96 pneumonia?, 180 Dipsomania, 299 Diptera, 875 Dipylidium caninum, 870 Disinfection after contagious diseases, 236 Disseminated sclerosis, 725 aetiology of, 725 pathology of, 725 prognosis of, 727 symptoms of, 726 treatment of, 726 Distomiasis, 851 intestinal, 853 of liver, 85 1 of blood, 852 pulmonary, 851 Distomum Buskii, 853 hepaticum, 851 pulmonale, 851 INDEX. Diver's paralysis, 758 Double vision in disease of motor nerves of the eye, 780 Dracontiasis, 866 D ranunculus medinensis, 866 Duchenne's disease, 745 Ductless glands, diseases of, 512 Dukes' disease, 228 Dum-dum fever, 206 Duodenal ulcfr, 397 Duodeno-cholangitis, 453 Dysaesthesia, 785 Dysentery, 61 amoebic, 64 aetiology of, 64 complications, 66 diagnosis of, 67 prognosis of, 67 symptoms of, 66 treatment of, 67 bacillary, 63 catarrhal, 62 aetiology of, 62 diagnosis of, 63 pathology of, 62 symptoms of, 62 treatment of, 67 chronic, 383 pathology of. 384 treatment of, 384 diphtheritic, 67 pathology of, 67 symptoms of, 67 vaccines, 394 epidemic, 63 sporadic, 62 treatment of, 67 tropical, 63 aetiology of, 63 complications of, 64 diagnosis of, 64 pathology of. 63 prognosis of, 64 symptoms of, 64 treatment of, 67 Dyspepsia, 334 acute, 334 atonic, 361 chronic, 337 flatulent, 376 Echinococcus disease, 868 Echinococcus disease of liver, 447 aetiology of, 447 symptoms of, 448 treatment of, 449 Echinorhynchus gigas, 858 moniliformis, 858 Echolaha, 800 Echokinesis, 800 Eclampsia, infantile, 812 puerperal, 813 treatment of, 814 Eclampsia, uraemic, 669 Eczema of tongue, 322 Effects of exposure to high temperatures 316 Egyptian chlorosis, 858 Ehrlich's diazo-reaction, 9 Eighth nerve, lesions of, 785 Elephantiasis graecorum, 208 Eleventh nerve, lesions of, 791 Embolic pneumonia, 194 non-septic, 194 septic, 194 Embolism of cerebral vessels, 720 of portal vein, 452 Emphysema, pulmonary, 631 aetiology of, 632 atrophic, 632 compensatory, 632 interlobular or interstitial, 631 senile, 632 vesicular, 632 diagnosis of, 633 pathology of, 632 physical signs of, 633 prognosis of, 633 symptoms of, 633 treatment of, 633 Empyaema, 650 aetiology of, 650 pathology of, 650 physical signs of, 651 prognosis of, 651 symptoms of, 650 treatment of, 651 operation in, 651 Encephalitis, acute, 710 aetiology of 710 pathology of, 710 prognosis of, 711 symptoms of, 710 treatment of, 711 suppurative, 727 Encephalopathia satumalis, 288 Endarteritis, chronic, 593 Endocarditis, acute, mild or simple form, 556 aetiology of, 556 diagnosis of, 559 pathology of, 557 prognosis of, 559 symptoms of, 558 treatment of, 559 chronic, 561 aetiology of, 561 definition of, 561 pathology of, 561 prognosis of, 572 treatment of, 572 severe or malignant form, 556 aetiology of, 556 diagnosis of, 559 pathology of, 557 prognosis of, 559 INDEX. 889 Endocarditis, symptoms of, 558 treatment of, 560 Endocardium, diseases of 556 Enteric fever, i aetiology of, i albuminuria in, 5, 9 ambulatory form of, 2, 5 antiseptic treatment of, 11, 17 bacteriology of, i bath treatment of, 13 bed sores in, 8 blood changes in, 8 boils in, 8 bone lesions in, 8 cardiac complications in, 8 chills in, 4, 5 chlorine and treatment of, 12 cholecystitis in, 8 circulatory system in, 4, 19 clinical chart of, 3 complications in, 7 constipation in, 6 contagiousness of, i course of, 2 Currie-Jiirgensen bath in, 13 delirium in, 5, 6 diagnosis, 8. 9 diazo-reaction of urine in, 9 diet in, 10, 21 disinfection in, 9 of stools in, 9 Ehrlich's reaction in. 9 eliminative and antiseptic treatment of, 1 1 eruption of, 2 facies of, 4 haemorrhage in, 7 in children, i, 13 incubation of, 2 indications for alcohol in, 14, 19 influence of age on, i of seasons on, i inoculation against, 10 leucocytes in, 8 management of convalescence in, 21, 22 meteorism in, 2 methods of reducing temperature in, 13 milk leg in, 2 7 mode of conveyance of, i nervous or meningeal form of, 5 parotitis in, 7 pathology of, i perforation in, 7 peritonitis in, 7 Peyer's patches in, i predisposing causes of, i prodromal symptoms, 2 prophylaxis in, 9 pulmonary form, 7 relapses in, 4 renal form, 5 rose-colored spots in, 2 sequelae of, 7 serum therapy in, 1 1 Enteric fever, skin rashes in, 2 specific treatment of, 11 splenic enlargement in, 5 symptoms of, 2 temperature in, 3 thrombosis in, 2, 7 tongue in, 5 treatment of, 10 by cultures of serum, 1 1 of complications, 20 of convalescence, 21, 22 of special symptoms, 18 tympanitic distention in, 2 typhoid spine in, 8 unusual forms of onset, 5 urine in, 9 vsralking form of, 2, 5 Widal reaction, 9 Enteritis, amoebic, 64 acute dyspeptic, of children, 389 aetiology of, 389 pathology of, 389 prognosis of, 390 symptoms of, 389 treatment of, 390 chronic catarrhal, 383 aetiology, 383 definition of, 383 pathology of, 384 prognosis of, 384 symptoms of, 384 treatment of, 384 croupous, 395 diphtheritic, 395 follicular, 393 phlegmonous, 396 pseudo-membranous, 395 aetiology of, 395 definition of, 395 pathology of, 395 symptoms of, 395 treatment of, 396 simple acute catarrhal, 381 aetiology of, 381 definition of, 381 diagnosis of, 382 pathology of, 381 symptoms of, 382 treatment of, 382 Enterocolitis, acute, 393 aetiology of, 393 definition of, 393 pathology of, 393 prognosis of, 393 symptoms of, 393 treatment of, 394 chronic, 383 Enteroptosis, 366 Ephemeral fever, 199 Epidemic catarrhal fever, 38 jaundice, 201 Epidemic cerebrospinal meningitis, 95 cholera, 55 890 INDEX. Epidemic dysentery, 63 parotitis, 88 roseola, 218 stomatitis 128 Epilepsia acuta, 812 Epilepsy, 802 aetiology, 802 pathology of, 803 physiology of, 805 prognosfe of, 805 symptoms of, 803 of clonic spasm, 803 of coma, 803 of grand mal, 803 of hysterical, 817 of Jacksonian, 804 of petit mal, 804 of psychical, 804 of tonic spasm, 803 treatment of, 805 asylum, 808 of convulsion, 807 Jacksonian, 804 pre cursive 804 Equilibrium, disturbance of, associated with defect of hearing, 786 Eetiology of, 786 prognosis of, 787 symptoms of, 787 treatment of, 787 Erb's form of juvenile hereditar}' atrophy, 848 Ergotism, 313 symptoms of, 313 treatment of, 314 Erichsen's disease, 828 Eructation of gas, nervous, 376 Erysipelas, 102 aetiology of, 102 bacillus of, 103 complications of, 104 diagnosis of, 104 facial, 103 pathology of, 103 prognosis of, 104 relapses and recurrences of, 104 sequelae of, 104 symptoms of, 103 incubation, 103 treatment of, 104 serum in, 105 Erythromelalgia, 833 etiology of, 833 pathology of, 834 prognosis of, 834 symptoms of, 834 treatment of, 834 Eustrongylus gigas, 857 Exophthalmic goitre, 523 Eyeball, lesions of the motor nerves of, 779 Eyes, phenomena of paralysis of motor nerves of, 779, 780, 781 Facial hemiatrophy, 837 aetiology of, 837 pathology of, 838 symptoms of, 838 treatment of, 838 nerve lesions of, 782 paralysis of, 782 aetiology of, 782 diagnosis of, 783 symptoms of, 782 treatment of, 783 spasm, 784 aetiology of, 784 prognosis of, 784 symptoms of, 784 blepharospasm, 784 treatment of, 784 Falling sickness, 802 Fallopian tubes, tuberculosis of, 178 False croup, 613 Family periodical paralysis, 839 Famine fever, 30 Farcy, 125 acute, 126 chronic, 126 ^ Fasciola hepatica, 851 Fasciolopsis Buskii, 853 Fascolidae, 851 Fatty degeneration of the heart, 552 infiltration of the heart, 552 of the liver, 437 aetiology of, 437 diagnosis of, 438 pathology of, 437 prognosis of, 438 symptoms of, 438 treatment of, 438 metamorphosis of heart, 552 . myocarditis, 552 Febricula, 199 aetiology of; 199 ^ diagnosis of, 200 symptoms of, 199 treatment of, 200 Febris flava, 33 Fever, aestivo-autumnal, 49 and ague, 45 aphthous, 128 breakbone, 43 bilious remittent, 33 camp, 24 cerebrospinal, 95 dandy, 43 ephemeral, 199 epidemic catarrhal, 38 famine, 30 glandular, 201 hospital, 24 intermittent, 47 irritative, 199 jail, 24 malarial, 45 Malta, 28 INDEX. 891 Fever, miliary, 202 mountain, 23 nasha, 54 paludal, 45 paratyphoid, 22 pernicious malarial, 50 protracted, idiopathic continued, 200 putrid: 24 relapsing, 30 remittent, 49 * scarlet, 220 ship, 24 simple continued, 200 spotted, 23, 24, 95 swamp, 45 tick, 204 typhoid, I typhus, 24 yellow, 3s Fibrinous pneumonia, 179 Fibroid heart, 553 phthisis, 158 Fibrous myocarditis, 553 Fievre inflammatoire, 318 Fifth nerves, lesions of, 781 paralysis of -motor portion, 781 of sensory portion, 782 Filaria Bancrofti, 864 diurna, 864 hominis oris, 867 immitis, 867' labialis, 867 loa, 867 medinensis, 866 perstans, 864 sanguinis hominis, 864 trachealis et bronchialis, 867 . Filariasis, 864 treatment of, 867 Filatov's spots, 215 Fish poisoning, 312 treatment of, 313 Flea, 877, 878 Flies, parasitic, 875 Flint murmur, 568 Floating kidney, 662 Eetiology of, 662 diagnosis of, 663 - symptoms of, 662 treatment of, 663 • Florida fever, 318 Flukes, 851 Wood, 852 Busk's, 853 » intestinal, 853 liver, 851 lung, 851 Faecal impaction, 408 Folie pourquoi, 800 Follicular tonsillitis, 327 Food poisoning, 312 treatment of, 313 Foot and mouth disease, 128 Foot and mouth disease, aetiology, 129 incubation, 129 prognosis of, 129 symptoms of, 129 treatment of, 129 Fourth disease, 228 Fourth nerve, lesions of the, 780 Framboesia, 211 Friedreich's ataxia, 751 aetiology of, 751 pathology of, 751 symptoms of, 751 treatment of, 752 Functional diseases of nervous ^stem, 795 Fungus foot, 198 Galactotoxismus, 313 Gall-bladder, acute inflammation of, 458 cancer of, 468 neoplasms of, 468 Gall ducts, neoplasms of, 469 parasites of, 470 stenosis of, 469 Gallop rhythm, 587 Galloping consumption, 150 Gall-stone, 460 acute impacted, 462 diagnosis of, 462 prognosis of, 462 symptoms of, 462 chronic impacted, 462 diagnosis of, 465 results of, 464 symptoms of, 462 due to obstruction of the common duct, 463 due to chronic obstruction of the cystic duct, 462 treatment of, 465 preventive, 465 Gangrene of the lung, 641 symptoms of, 641 treatment of, 642 Gas, nervous eructation of, 376 treatment of, 376 Gastralgia, 377 symptoms of. 377 treatment of, 378 Gastrectasis, 361 acute, 364 Gastric cancer, 356 catarrh, acute, 334 chronic, 337 dilatation, 361 acute, 364 fever, i, 334 hypersesthesia, 376 symptoms of, 377 treatment of, 377 hyperacidity, 369 hyperperistalsis, 575 symptoms of, 575 892 INDEX. Gastric hyperperistalsis, treatment of, 575 lavage, 339 neuralgia, 377 ulcer, 345 Gastritis, acute catarrhal, 334 etiology of, 334 definition of, 334 pathology of, 334 stomach contents in, 334 symptoms of, 334 treatment of, 334 chronic catarrhal 337 eetiology of, 337 definition of, 337 pathology of, 337 stomach contents in, 338 symptoms of, 337 treatment of, 337 dietetics of, 342 diphtheritic. 344 mycotic, 344 phlegmonous or suppurative^ 343 traumatic and toxic, 343 Gastrodiaphany, 362 Gastrodiscus hominis. 853 Gastrodynia, 377 Gastro-enteric fever, i Gastro-enteritis, acute, 389 aetiology of, 389 definition of, 389 pathology of, 389 symptoms of, 389 treatment of, 390 Gastrophelus equi, 876 Gastro-intestinal catarrh, 389 Gastroptosis, 366 Gastroscopy, 362 Gastrosuccorrhoea, 369 Gastroxynsis, 369 General paralysis, 723 pares-is, 723 Geographical tongue, 322 Gerlier's disease, 207 German measles, 218 Giant urticaria, 834 Gigantorhyncus, 858 Gilles de la Tourette's disease, 800 Gin liver, 429 Glanders and farcy, 125 aetiology of, 125 diagnosis of, 126 incubation, 125 pathology of, 125 prognosis of ^ 127 symptoms of, 125 treatment of, 127 Glands, ductless, diseases of, 512 Glandular fever, 201 aetiology of, 202 diagnosis of, 202 pathology of, 202 symptoms of, 202 treatment of 202 Glandular tuberculosis, 173 Glenard's disease, 366 Glossitis, 323 chronic superficial 323 Glosso-labio-laryngeal paralysis, 752 Glossopharyngeal nerve, lesions of, 787 Glottis, oedema of, 616 Glycosuria, 254 Goitre, exophthalmic, 523 aetiology of, 523 diagnosis of, 525 pathology of, 523 prognosis of, 525 symptoms of, 524 Stellwag's sign, 524 von Graefe's, 524 treatment of, 526 serum in, 527 simple, 521 aetiology, 521 pathology, 521 symptoms of, 521 treatment of, 522 . Gonorrhoeal arthritis, 131 diagnosis of, 132 pathology of, 131 symptoms of, 132 treatment of, 132 varieties of, 132 endocarditis, 131 infections, 130 septicaemia and pyaemia, 131 Gout, 245 aetiology of, 245 pathology of, 248 pathogenesis of, 246 retrocedent or metastatic, 250 symptoms of, 249 of chronic, 250 of irregular or atypical. 250 of typical acute, 249 pharyngitis, 249 treatment of, 250 dietetic, 251 • medicinal, of acute. 250 American, 252 Goutiness, 252 Gouty kidney, 683 Grain poisoning, 313 ergotism, 313 convulsive, 314 gangrenous, 313 lathvrism or lupinosis, 315 pellagra, 314 treatment of, 314 Grand mal, 803 Granular kidney, 679 Graphospasmus, 830 Graves' disease, 523 Gravel 698 Grip, 38 Guinea-worm, 866 Gull's disease, 529 INDEX. Habit chorea, 800 spasm, 800 Haematemesis, 380 treatment of, 352 Haematochyluria, 865 Haematoma of dura mater, 711 Haematoporphyrinuria, 305, 306 Haematorrhachis, 766 Haematothorax, 656 Haematozoon malariae, 46 Haematuria, idiopathic, 706 symptoms of, 706 treatment of, 707 Haemoglobinuria, 50, 707 epidemic, 508 paroxysmal, 708 toxic, 708 Haemopericardium, 543 Haemophilia, 509 aetiology of, 509 "Hefinition of, 509 pathology of, 510 prognosis of, 510 symptoms of, 510 treatment of, 511 Haemoptysis, treatment of, 170 Haemorrhage, cerebral, 716 Haemorrhagic diseases of the new-born, treatment of, 509 infarct of the bowel, 396 infarct of lung, 194 syphilis of the newly-born, 508 Haemorrhoids, 420 aetiology of, 421 definition of, 420 pathology of, 420 symptoms of, 421 external 421 internal, 421 treatment of, 421 Haemothorax, 656 Harvest bug, 874 Haschisch poisoning, 309 symptoms of, 309 treatment of, 309 Hay asthma, 608 Hay-fever, 608 aetiology of, 608 symptoms of, 608 treatment of, 609 Headache, bilious, 835 sick, 835 Head louse, 876 Heart, albuminoid degeneration of, 551 and blood-vessels, diseases of, 537 aneurysm of, 555 arrhythmia of, 587 treatment of, 590 atrophy of, 551 block, 587 brown, 551 chronic valvular defects of, 561 congenital defects of, 573 893 508 Heart, dilatation of, 546 aetiology of, 546 diagnosis of, 548 pathology of, 546 physical signs of, 547 prognosis of, 548 symptoms of, 547 treatment of, 548 » Nauheim baths, 548 diseases of, 537 exhaustion, 316 definition of, 316 symptoms of, 316 treatment of, 317 fatty degeneration of, 552 fibroid degeneration of, 553 hypertrophy of, 543 murmurs, table of, 563 nervous palpitation, 585 diagnosis of, 586 treatment of, 588 neuroses of, 585 parenchymatous degeneration of, 551 rupture of, 555 tuberculosis of, 179 valvular disease of, 561 Heberden's nodes, 270 Hemeralopia, 779 Hemianopsia, 777 homonymous, 777 Hemicrania, 835 Hepatic artery and vein, diseases of, 450 calculus, 460 intermittent fever, 463 Hepatitis, acute parenchymatous, 441 interstitial, 429 suppurative, 425 aetiology of, 425 diagnosis of, 427 pathology of, 426 prognosis of, 428 symptoms of, 427 treatment of, 428 Hereditary ataxia, 751 ataxic paraplegia, 751 » aetiology of, 751 pathology of, 751 prognosis of, 752 symptoms of, 751 treatment of, 752 cerebellar ataxia, 752 Hill diarrhoea, 72 aetiology of, 72 pathology of, 72 symptoms of, 72 treatment of, 72 Hobnail liver, 429 Hodgkin's disease, 516 Hodgson's disease, 599 Hook-worm disease, 858 Hour-glass stomach, 365 aetiology of, 365 definition of, 365 894 INDEX. Hour-glass stomach, pathology of, 366 symptoms of, 366 treatment of, 366 Huntington's chorea, 801 Hutchinson's teeth, 138 HyaUne degeneration of heart, 553 Hydatid disease, 868 of lungs, 639 Hydrocephalus, acute, 714 aetiology, 714 diagnosis, 715 patholog}% 714 prognosis, 715 symptoms, 715 treatment, 715 chronic, 715 Etiology, 715 pathology, 715 symptoms, 716 treatment, 716 Hydrochloric acid, nervous hypersecretion of, 369 Hydronephrosis, 694 aetiology of, 695 diagnosis of, 696 pathology of, 695 prognosis of, 696 S3Tnptoms of, 695 treatment of, 696 Hydropericardium, 543 Hydroperitonaeum, 484 Hydrophobia, 114 aetiology of, 114 diagnosis of, 116 incubation, 115 Pasteur treatment, 117 pathology of, 114 prognosis of, 116 symptoms of, 115 treatment of, 116 Hydropneumothorax, 654 Hydrothorax, 654 Hymenolopsis nana, 870 diminuta, 870 lanceolata, 871 Hyperacidity, gastric, 369 H}'peraemia of the liver, 450 active, 450 treatment, 450 passive, 451 ffitiolog}', 451 patholog}' of, 451 s},Tiiptoms of, 451 treatment of, 451 Hyperchlorhydria, 369 aetiology of, 369 definition of, 369 diagnosis of, 370 prognosis of, 370 symptoms of, 369 treatment of, 370 diet, 371 Hjqjerorexia, 378 Hyperosmia, 776 Hypertrophic pulmonary osteoarthropathy, 842 Hypertrophy of heart, 543 aetiology of, 544 diagnosis of, 545 pathology of, 544 physical signs of, 545 prognosis of, 545 symptoms of, 544 treatment of, 545 Hypochlorhydria, 372 diagnosis of, 372 symptoms of, 372 treatment of, 373 diet in, 373 HypochyHa, 372 Hypoglossal ners'e, lesions of, 794 aetiolog)' of, 794 symptoms of, 794 treatment of, 795 Hysteria, 816 aetiolog)' of, 816 prognosis of, 819 symptoms of, 816 traumatic, 828 treatment of, 819 Hysterical epilepsy, 817 fever, 819 stigmata, 818 Ichthyotoxismus, 312 Icterus, 453 catarrhalis, 453 gravis, 441 neonatorum, 458 Idiopathic continued fever, 200 Ileo-cohtis, acute, 381, 393 Ileus, 404 Immunization against tuberculosis, 162 Impacted gall-stone, 462 Impulsive tic, 800 Infantile convulsions, 812 aetiology of, 812 diagnosis of, 812 prognosis of, 812 symptoms of, 812 treatment of, 813 eclampsia, 812 palsy, 739 sciu-vy, 279 treatment of, 280 spinal paralysis, 739 Infarct of bowel, haemorrhagic, 396 of lung, haemorrhagic, 194 Inflammatory rheimiatism, 105 Influenza, 38 aetiology of, 38 complications of, 40 diagnosis of, 40 incubation of, 39 patholog}' of, 39 prognosis of, 40 INDEX. 895 Influenza, symptoms of, 39 treatment of, 40 varieties of, 39 Insects, 874 Insolation, 317 Insular sclerosis, 725 Intermittent claudication, 595 fever, 47 tetanus, 814 Internal capsule, lesions of, 733 Interstitial nephritis, chronic, 683 pneumonia, chronic, 192 suppurative nephritis, 691 Intestinal catarrh, acute, 381 obstruction, 404 acute and chronic, 404 definition of, 404 diagnosis of, 404 symptoms of, 404, 405, 406, 409 treatment of, 409 Intestine, embolic ulcer of, 399 primary tuberculous ulceration of, 398 syphilitic ulcer of, 399 Intestines, diseases of, 381 obstruction of, 404 malignant growths of, 419 nervous affections of, 416 Intoxications, including the effects of ex- posure to high temperatures, 286 Intracranial tumors, 729 Intrathoracic tumors, 657 Introduction, xxiii Intussusception, 406 treatment of, 407 Invagination, intestinal, 406 lodism, 295 symptoms of, 295 Iridoplegia, 779 accommodative, 780 reflex, or Argyll-Robertson pupil, 780 skin, 780 Irritation of auditory nerve, 785 Irritative fever, 199 Itch mite, 874 Ixodiasis, 875 Jacksonian epilepsy, 804 Jail fever, 24 Japanese river fever, 203 Jaundice, 453 acute catarrhal, 453 aetiology of, 453 definition of, 453 diagnosis of, 455 pathology of, 454 prognosis of, 455 symptoms of, 454 treatment of, 455 acute febrile, 201 epidemic catarrhal, 201 malignant, 441 neonatorum, 458 obstructive, 453 Jaundice, of the new-born, 458 toxic, 457 symptoms of, 457 Jerkers, 801 Jigger, 878 Jumpers, 801 Justus' test, 139 Juvenile muscular dystrophy, 848 Kakk6, 195 Kala-azar, 206 Kemig's sign, 98 Kidney, abscess of, 691 amyloid, 689 aetiology of, 689 diagnosis of, 690 duration of, 690 pathology of, 690 prognosis of, 690 symptoms of, 690 treatment of, 691 anomalies of form and position, 661 congenital absence of, 661 floating, 662 horseshoe, 661 lobulated, 661 cirrhotic, 683 calculi, 698 carcinoma of, 703 congestion of, 666 acute, 666 chronic, 666 aetiology of, 666 diagnosis of, 667 pathology of, 667 prognosis of, 667 symptoms of, 667 treatment of, 667 p3.ssive, 666 contracted, 683 cysts of, 705 congenital, 705 dermoid, 705 differential diagnosis of, 706 echinococcus or hydatid, 706 hydronephrosis, 694 retention or obstruction, 705 treatment of, 706 derangement of circulation, 666 diseases of, 661 gouty, 683 granular, 679 lardaceous, 689 large white, 678 movable, 662 aetiology of, 662 diagnosis of, 663 symptoms of, 662 treatment of, 663 surgery in, 664 sarcoma of, 703 sclerotic, 683 small white, 679 896 INDEX. Kidney, stone in, 698 surgical, 691 tuberculosis of, 177 tumors of, 703 diagnosis of, 704 symptoms of, 704 treatment of, 705 waxy, 689 Kinepox, 2^2 King's evil, 173 Koplik's spots, 215 Korsakoff's disease, 301 Kreotoxismus, 312 Kubisagari, 206 Labyrinthine vertigo, 786 Lacquer poisoning, 311 symptoms of, 311 treatment of, 312 Lacunar tonsillitis, 327 La Grippe, 38 Landry's paralysis, 753 Lardaceous disease of the kidney, 689 liver, 438 Large white kidney, 678 Laryngeal anaesthesia, 790 muscles, paralysis of, 788 Laryngitis, acute catarrhal, 610 chronic catarrhal, 611 aetiology of, 611 pathology of, 61 r symptoms of, 611 treatment of, 612 spasmodic, 613 tuberculous, 614 aetiology of, 614 diagnosis of, 615 , pathology of, 614 prognosis of, 615 symptoms of, 615 treatment of, 615 Larynx, adductor paralysis of, 789 bilateral abductor paralysis of, 789 diseases of, 610 spasm of, 789 total paralysis of, 789 unilateral abductor paralysis of, 788 Latah; 801 Lateral sclerosis, 742 amyotrophic, 744 Lathy rism, 315 Lead poisoning, 286 acute, 287 aetiology of, 286 chronic, 287 pathology of, 286 prognosis of, 289 symptoms of, 287 black line, 287 treatment of, 289 Leontiasis ossea, 842 Leprosy, 208 anaesthetic form of, 209 Leprosy, aetiology, 208 diagnosis of, 209 pathology of, 208 prognosis of, 209 symptoms of, 209 treatment of, 209 tubercular, 209 Leptomeningitis, acute, 712 aetiology of, 712 diagnosis of, 713 pathology of, 713 prognosis of, 713 symptoms of, 713 treatment of, 714 cerebral, 712 spinal, 764 acute, 764 chronic, 763 Leptus autumnalis, 874 Leucaemia, 498 aetiology of, 498 definition of, 498 diagnosis of, 502 patholog}' of, 498 prognosis of, 502 symptoms of, 499 blood changes, 500, 501, 502 treatment of , .502 Leucanaemia, 503 Leucocythaemia, 498 Leucoplakia buccalis, 323 aetiology of, 323 definition of, 323 symptoms of, 323 treatment of, 323 Leucoplasia, 323 Leucoderma, 844 Lice, 876 Lingual ichthyosis, 323 psoriasis, 323 Lingulata rhinaria, 875 Lipomatosis luxurians muscularis, 847 Lithaemia, 252 aetiology of, 252 symptoms of, 252 treatment, 252 Liver, abnormalities in shape and position of, 422 abscess of, 425 active hyperaemia of, 450 acute yellow atrophy of, 441 altered shape of, 422 amyloid, 438 anaemia of, 450 cancer of, 443 carcinoma of, 443 changes in hepatic artery and vein, 452 cirrhosis of, 429 aetiology of, 429 pathology of, 430 prognosis of, 432 symptoms of, 430 treatment of, 432 INDEX. 897 Liver, diseases of, 422 blood-vessels of, 450 dislocation of, 422 echinococcus disease of, 447 fatty, 437 infiltration of, 437 metamorphosis of, 437 floating, 423 flukes, 851 hydatid cyst of, 447 hyperEemia of, 450 lardaceous, 438 morbid growths of, 443 movable, 423 neoplasms of, 443 parasites of, 447 passive hyperasmia of, 451 saicoma of, 444 syphilis of, 439 waxy, 438 Lobar pneumonia, 1 79 Lobular pneumonia, 187 Local asphyxia, 832 Localization of cerebral disease, 730 Lockjaw, 118 Locomotor ataxia, 745 aetiology of, 745 pathology of, 746 prognosis of, 748 symptoms of, 746 treatment of, 748 Louse, body, 876 crab, 877 head, 876 Ludwig's angina, 325 Lues venerea, 134 Lumbago, 267 Lumbar puncture, 99, 100 Lumpy jaw, 127 Lung, abscess of, 639 cavities in, 152 cirrhosis of, 192 diseases of, 631 emphysema of, 631 fever, 179 fibroid induration of, 192 gangrene of, 641 syphilis of, 637 tuberculosis of, 150 tumors of, 638 carcinoma, 638 physical signs, 639 lymphoma, 639 sarcoma, 638 Lupinosis, 315 Lymph scrotum, 865 vulva, 865 Lymphadenitis, tuberculous, 173 Lymphadenoma, general, 516 Lymphadenosis, 516 Lymphatic glands, tuberculosis of, 173 Lymphatism, 519 Lyssa, 114 57 Madura foot, 198 Maladie de la tic convulsif, 800 Malaria, chronic, 50 Plasmodium of, 46 Malarial cachexia, 50 fever, 45 aestivo-autumnal, 46, 49 algid form, 50 chronic form, 50 chnical chart of, 48 clinical varieties, 47 comatose form, 50 complications of, 51 diagnosis of, 51 favoring causes, 45 geographical .distribution, 45 hEemoglobinuria, 50 incubation of, 47 intermittent form of, 47 irregular forms of, 49 pathology of, 47 Plasmodium, 46 prognosis of, 51 prophylaxis against, 51 quartan, 46, 47 quotidian, 47 remittent form, 49 seasons favoring, 46 symptoms of, 47 tertian, 46, 47 treatment of, 51 Mali-mali, 801 Malignant adenitis, 75 growths of intestines, 419 symptoms of, 419 treatment of, 420 jaundice, 441 purpuric fever, 95 pustule, 122 Malleus humidus, 125 Malta fever, 28 aetiology of, 29 distribution of, 29 pathology of, 29 symptoms of, 29 treatment of, 30 Mammary gland, tuberculosis of, 179 Mania-a-potu, 302 treatment of, 303 Marsh fever, 45 Maw worm, 853 Measles, 214 ( aetiology of, 214 clinical chart of, 215 com.' )lications and sequelae of, 216 con/ piousness of, 214 diagnosis of, 216 pathology of, 214 pneumonia in, 216 prognosis of, 216 prophylaxis of, 216 symptoms of, 214 bronchitis, 214 898 INDEX. Measles, incubation, 214 Koplik's sign, 215 treatment of, 216 Meat poisoning, 312 symptoms of, 312 treatment of, 313 Median nerve, lesions of, 768 Mediastinal alsscess, 659 disease, 6^7 tumors, 6^7 diagnosis of, 658 pathology of, 659 symptoms of, 657 treatment of, 660 Mediastino-pericarditis, indurative, 659 Mediterranean fever, 28 Megrim, 835 Melituria, 254 Membranes of the brain, diseases of, 711 Membranous croup, 78 Meniere's disease, 786 Meningeal apoplexy, 766 Meningitis, epidemic cerebrospinal, 95 spinal, 763 tuberculous, 714 eetiology, 714 diagnosis, 715 pathology of, 715 prognosis, 714 symptoms, 715 treatment, 715 Meningococcus, 96 Meningoencephalitis, diffuse, 723 Menopause, neurasthenia of, 825 Mercurial poisoning, 292 acute, 292 treatment of, 292 chronic, 292 symptoms of, 293 treatment of, 293 Mercurealism, 292 Merycism, 375 treatment of, 376 Mesogonimus, heterophyes, 853 Micrococcus lanceolatus, 180 melitensis, 29 Migraine, 835 aetiology of, 835 prognosis of, 836 symptoms of, 835 treatment of, 836 Mild chorea, 796 Miliary fever, 202 aetiology of, 202 diagnosis of, 203 duration of, 203 pathology of, 203 prognosis of, 203 symptoms of, 203 treatment of, 203 Milk sickness, 129 aetiology of, 130 diagnosis of, 130 Milk sickness, pathology of, 130 prognosis of, 130 symptoms of, 130 treatment of, 130 Miltzbrand, 122 Mimetic facial paralysis, 782 spasm, 784 Miner's anaemia, 858 Mites, 874 Mitral insufficiency, 562 aetiology of, 562 diagnosis of, 564 mechanism of, 562 murmur, 563 physical signs, 563 sjonptoms of, 563 treatment of, 578 obstruction, 564 aetiology of, 565 diagnosis of, 566 mechanism of, 564 murmur in, 565 physical signs of, 565 symptoms of, 565 treatment of, 579 Monoplegia facialis, 782 Morbilli, 214 Morbus astralis, 802 divinus, 802 maculosus, 505 neonatorum, 508 Werlhofii, 507 sacer, 802 Morphine habit, 306 Morphinism, 306 prognosis of, 307 symptoms of, 306 treatment of, 307 Morphinomania, 306 Morphea, 844 Morvan's disease, 756 Mosquitoes and yellow fever, 33, 36 Motor agraphia, 723 aphasia, 723 nerves of eye, diseases of, 779 Mountain fever, 23 Mouth, and tongue, diseases of, 320 dry, 324 Mucous colitis, 383 Multiple arthritis deformans, 270 neuritis, 770 sclerosis of brain and cord, 725 Mumps, 88 aetiology of, 88 complications of, 89 diagnosis of, 89 pathology of, 88 prognosis of, 89 s}'mptonis of, 88 treatment of, 89 Murmurs, heart, table of, 563 Musca domestica, 875 Muscular atrophy of peroneal t}-pe, 849 INDEX. Muscular dystrophy, juvenile, 848 of Landouzy-Dejerine type, 840 system, diseases of, 846 Musculospiral nerve, neuritis of, 768 Myalgia, 267 ' Myasthenia gravis, 838 Mycetoma, 198 aetiology of, 198 symptoms of, 198 treatment of, 198 Mycotic stomatitis, 320 MyeHtis, diflfuse, acute and chronic 72c etiology of, 736 pathology of, 736 prognosis of, 738 symptoms of, 736 treatment of, 738 acute anterior polyomyelitis of children 739 etiology of, 740 pathology of, 740 prognosis of, 741 symptoms of, 740 treatment of, 741 Myelomalacia, 739 Myiasis, 875 Myocarditis, 551 acute suppurative, 555 fatty, 552 fibrous, 553 aetiology of, 553 diagnosis of, 554 pathology of, 553 physical signs, 554 prognosis of, 554 symptoms of, 554 treatment of, 554 interstitial, 553 parenchymatous, 551 Myocardium, diseases of, C45 Myositis, 846 acute, 846 haemorrhagic, 846 infectious, 846 ossif}ing, 874 progressiva ossificans, 847 suppurative, 846 Myotonia congenita, 808 Myriachit, 801 Mytilotoxismus, 312 Myxoedema, 528 aetiology of, 528 diagnosis of, 530 pathology of, 529 prognosis of, 530 symptoms of, 529 treatment of, 530 899 Nakra fever, 54 Nasa fever, 54 Nasha fever, 54 Nauheim treatment, 548 Neapolitan fever, 28 Nemathelminthes, 853 Nematodes, or round worms, 8^5 Neoplasmata cerebri, 729 Neoplasms of peritoneum, 484 of kidney, 703 of lungs, 639 of thyroid gland, 532 Nephritis, acute, 671 aetiology of, 671 complications of, 673 pneumonia, 673 diagnosis of, 673 pathology of, 672 glomerular changes, 672 interstitial changes, 672 tubal changes, 672 prognosis of, 674 symptoms of, 672 irrine, 673 treatment of, 674 chronic arterial, 683 aetiolog}' of, 683 complications of, 686 diagnosis of, 686 pathology of, 684 prognosis of, 687 symptoms of, 685 cardiac, 686 hypertrophy of the left ventricle, 686 urme, 685 treatment of, 687 chronic haemorrhagic, 683 chronic interstitial, 683 chronic parenchymatous, 678 etiology of, 678 diagnosis of, 680 pathology of, 678 prognosis of, 680 symptoms of, 679 duration of, 680 urine, 680 treatment of, 680 diet, 681 dechloridation in, 68 r septic and pyaemic, 691 suppurative interstitial, 691 aetiology of, 691 diagnosis of, 693 pathology of, 692 prognosis of, 693 symptoms of, 692 urine, 693 treatment of, 694 Nephrolithiasis, 698 aetiology of, 698 diagnosis of, 700 Rontgen rav in pathology of, 699 prognosis of, 701 symptoms of, 699 treatment of, 701 Nephroptosis, 662 Nephrj'drosis, 694 701 900 INDEX. Nerve, circumflex, affections of, 768 median, 768 musculospiral, 768 treatment of lesions of, 769 ulnar, 768 Nerves, peripheral, diseases involving, 767 Nervous affections of intestines, 416 treatment of, 417 Nervous deafness, 786 symptoms of, 786 treatment of, 786 eructation of gas, 376 exhaustion, 821 fever, i hypersecretion of hydrochloric acid, 369 prostration, 821 system, diseases of, 710 functional diseases of, 795 Neuralgia, see migraine, p. 835 Neurasthenia, 821 aetiology of, 821 prognosis of, 821 symptoms of, 821 treatment of, 822 Neurasthenia of the menopanse, 825 symptoms of, 825 treatment of, 826 Neuritis, 767 localized, 767 aetiology, 767 pathology of, 767 sjTnptoms of, 768 treatment of, 769 multiple, peripheral, 770 aetiology of, 770 pathology of, 770 prognosis of, 772 symptoms of, 770 treatment of, 772 Neuroses of the stomach, 369 occupation, 829 of heart, 585 of intestines, 416 traumatic, 828 New-born, hasmorrhagic diseases of, 508 syphilitic diseases of, 508 Ninth nerve, lesions of, 787 Noma, 321 Nose, diseases of, 607 Nyctalopia, 779 Nystagmus, 780 Obesity, 273 aetiology of, 273 definition of, 273 diets in, 274 symptoms of, 273 treatment of, 274 Obstruction of bowel, 404 Occupation neuroses, 829 aetiology of, 830 pathology of, 830 prognosis of, 830 Occupation neuroses, symptoms of, 830 treatment of, 831 Ocular palsy, 780 treatment of, 781 CEdema, angioneurotic, 834 CEdema of glottis, 617 treatment of, 618 (Espohagismus, 331 CEsophagitis, acute, 330 aetiology of, 330 definition of, 330 pathology of, 330 symptoms of, 330 treatment of, 330 chronic catarrhal, 331 (Esophagus, benign stricture of, 332 aetiology of, 332 symptoms of, 332 treatment of, 332 cancer of, 331 symptoms of, 332 treatment of, 332 dilatations of, 333 symptoms of, 333 treatment of, 333 diseases of, 330 spasm of, 331 aetiology of, 331 symptoms of, 331 treatment of, 331 Oculomotor nerve, diseases of, 779 Olfactorj' nerves, diseases of, 775 Onomatomania, 800 Ophthalmoplegia, 780 Open-air treatment in tuberculosis, 164 Opium poisoning, see morphinism Oppler-Boas bacillus, 357, 363 Opsonic therapy in tuberculosis, 172 Optic atrophy, 777 gray, 777 haemorrhage, 778 nerve affections, 776 and tract, 776 neuritis, 777 aetiology of, 777 pathology of, 777 symptoms of, 777 Osteitis deformans, 842 Osteo-arthritis, 269 Osteo-arthropathy, 842 Ovaries, tuberculosis of, 178 Oxyuris vermicularis, 855 Pachymeningitis, 711 external, 711 haemorrhagic, 711 internal, 711 pseudo-membranous, 712 purulent, 712 spinal, 763 cervical hypertrophic, 763 external, 763 haemorrhagic, 764 ESTDEX. 901 Pachymeningitis, internal, 763 Paget's disease, 842 Painter's palsy, 288 Palpitation of heart, 585 Paludal fever, 45 Pancreas, cancer of, 474 diagnosis of, 474 morbid anatomy of, 474 symptoms of, 474 cysts of, 475 diseases of, 470 Pancreatic abscess, 471 calculi, 476 Pancreatitis, acute, 470 definition of, 470 acute gangrenous, 472 acute haemorrhagic, 471 acute suppurative, 471 chronic, 473 Papillitis, 777 Parageusia, 788 Paralysis, acute ascending, 753 aetiology of, 754 pathology of, 754 prognosis of, 754 sjTnptoms of, 754 treatment of, 754 agitans, 810 aetiology of, 810 pathology of, 810 prognosis of, 811 symptoms of, 811 treatment of, 812 bulbar, 752 general, 723 aetiology, 724 pathology, 724 prognosis, 725 symptoms, 724 treatment, 725 glosso-labio-larj'ngeal, 752 Landry's, 753 of the tongue, the soft palate, and lips, 752 periodical, 839 pseudo-hypertrophic, 847 Paramyoclonus, multiplex, 809 aetiology of, 809 symptoms of, 810 treatment of, 810 Paranephritis, 697 aetiology of, 697 diagnosis of, 698 pathology of, 697 symptoms of, 698 treatment of, 698 Paraplegia, ataxic, 751 aetiology of, 751 pathology of, 751 prognosis of, 752 symptoms of, 751 treatment of, 752 spastic, 742 Parasites, animal, 850 of the Hver, 447 Parasitic diseases, 850 flies, 875 insects, 874 Paratyphoid fever, 22 Parenchymatous degeneration of heart, 551 myocarditis, 551 Paresis, general, 723 Paretic dementia, 723 Parkinson's disease, 810 Parosmia, 776 Parotitis, acute, 324 treatment of, 325 epidemic, 88 secondary, 324 Parry's disease, 523 Pasteur's treatment of hydrophobia, 117 Pediculosis, 876 Pediculus capitis, 876 vestimentorum, 876 pubis, 877 Peliosis, 505 rheumatica, 506 Pellagra, 314 prognosis of, 315 symptoms of, 315 treatment of, 315 Pentastomum constrictum, 875 denticulatum, 450 taenioides, 450, 875 Peptic ulcer 345 Pericarditis, 537 acute, 537 aetiology of, 537 definition of, 537 diagnosis of, 539 pathology of, 537 physical signs, 538 Broadbent's sign, 542 Friedreich's sign, 542 of chronic adhesive, 542 pleuropericardial friction sound, 540 Rotch's sign, 539 prognosis of, 540 symptoms of, 538 treatment of, 540 chronic adhesive, 542 symptoms of, 542 treatment of, 542 Pericardium, adherent, 542 calcification of, 543 cancer of, 543 diseases of, 537 paracentesis of, 541 tuberculosis of, 176 Perihepatitis, 424 aetiology of, 424 definition of, 424 diagnosis of, 424 pathology of, 424 prognosis of, 425 s)maptoms of, 424 902 INDEX. Perihepatitis, treatment of, 425 Perinephric abscess, 697 Perinephritis, 697 Periodical paralysis, 839 Peripheral nerves, affections of, 767 neuritis, 770 Perisplenitis, 513 Peristaltic unrest, 375 Peritonaeum, cancer of, 483 diseases of, 11.76 neoplasms of, 483 tuberculosis of, 175 Peritonitis, acute, 476 aetiology of, 476 definition of, 476 diagnosis of, 479 pathology of, 477 physical signs, 478 prognosis of, 480 symptoms of, 478 treatment of, 480 of acute general, 480 chronic, 480 circumscribed, 482 diffuse, 482 hysterical, 479 in typhoid fever, 7 tuberculosis, 175 Peritonsillar alDScess, 329 Perityphlitis, 399 Pernicious anaemia, 494 jj^ malarial fever, 50 algid type, 50 comatose type, 50 haemorrhagic type, 50 temperature, 50 treatment of, 53 Pertussis, 90 Peruvian warts, 212 Pest, the, 75 Pestis major, 76 minor, 75 Pestilential or putrid fever, 24 Petechial fever, 95 Petit mal, 804 Pharyngitis, acute catarrhal, 325 aetiology of, 325 definition of, 325 pathology of, 326 symptoms of, 326 treatment of, 326 Pharynx, diseases of, 325 Phthisis, acute, 150 broncho-pneumonic, 150 chronic ulcerative, 151 fibroid, 158 physical signs of, 158 symptoms of, 158 florida, 150 pneumonic form of, 150 pulmonalis, 150 Piles, 420 Pin worm, 855 Pityriasis of tongue, 322 Plague, bubonic, 75 Plasmodium malariae, 46 Plathelminthes, 851, 868 cestodes, 868 trematodes, 851 blood fluke, 852 liver fluk e, 85 1 lung fluke, 851 Pleura, diseases of, 643 hydatid disease; 657 neoplasms of, 656 carcinoma, 656 enchondroma and lipoma, 657 sarcoma, 656 tuberculosis of, 175 Pleurisy, 643 acute, fibrinous, 643 aetiology of, 643 pathology of, 643 physical signs of, 643 prognosis of, 643 symptoms of, 643 treatment of, 644 chronic adhesive, 653 etiology, 653 pathology, 653 physical signs, 653 symptoms, 653 treatment, 653 diaphragmatic, 644 dry, 643 exudative, 645 haemorrhagic, 656 purulent, 650 serous, 645 aetiology of, 645 pathology of, 645 physical signs of, 646 symptoms of, 646 treatment of, 647 tapping, 648 thoracocentesis La, 648 suppurative, 650 tuberculous, 175 Pleuritis, 643 Pleurodynia, 268 Plumbism, 286 Pneumogastric nerve, lesions of, 788 cardiac branches of the, 790 aetiology of, 790 diagnosis of, 790 gastric and oesophageal branches of the, 790 involving the nucleus and trunk, 788 larj'ngeal branches of the, 788 symptoms of, 789 pharyngeal branches of the, 788 aetiology of, 788 symptoms of, 788 pulmonarv branches of the, 790 treatment of, 791 Pneumonia, acute infectious, 179 INDEX. 903 Pneumonia, acute infectious, setiology of, 179 bacillus of, 179, 180 clinical chart of, 181 complications of, 183 diagnosis of, 184 pathology of, 180 physical signs of, 182 prognosis of, 184 prophylaxis of, 184 treatment of, 184 broncho-, 187 aetiology of, 187 diagnosis of, 189 pathology of, 188 physical signs, 189 prognosis of, 190 symptoms of, 188 treatment of, 190 catarrhal, 187 chronic interstitial, 192 aetiology of, 192 diagnosis of, 193 pathology of, 192 physical signs of, 193 prognosis ot. 193 symptoms of, 193 treatment of, 193 croupous, 179 embolic, 194 non-septic, 194 septic, 195 fibrinous, 179 herpes, 182 lobar, 179 lobular, 187 prune-juice expectoration, 182 syphilitic, 637 Pneumonic phthisis, 150 Pneumonitis, 179 Pneumopericardium, 543 Pneumothorax, 654 setiology of, 654 diagnosis of, 655 physical signs of, 655 Hippocratic succussion, 655 metallic tinkling, 655 symptoms of, 655 treatment of, 655 Podagra, 245 Poliomyelitis, acute anterior, 739 aetiology of, 740 pathology of, 740 prognosis of, 741 s)miptoms of, 740 treatment of, 741 chronic anterior, 742 patholog}' of, 742 S}T2iptoms of, 742 treatment of, 742 Pollen catarrh, 608 Polycythaemia, 504 Polymyositis hasmorrhagica, 846 Polyneuritis, 770 Porencephalus constrictus, 875 Portal vein, thrombosis and embolism of, 452 Posterior spinal sclerosis, 745 Pox, 134 Presystolic murmur, 565 Primary lateral sclerosis, 742 Proctitis, 420 epidemic gangrenous, 71 aetiology of, 71 pathology of, 71 symptoms of, 71 treatment of, 71 Professional spasm, 829 Progressive bulbar palsy, 752 aetiolog}' of, 752 pathology of, 753 prognosis of, 753 symptoms of, 753 treatment of, 753 facial hemiatrophy, 837 general paralysis of the insane, 723 muscular atrophy, type Duchenne-Aran, pernicious anaemia, 494 spastic paraplegia, 742 spinal muscular atrophy, 742 aetiology of, 742 pathology of, 742 prognosis of, 742 symptoms of, 742 treatment of, 742 Prostate gland, tuberculosis of, 178 Protracted idiopathic continued fever, 200 setiolog}' of, 200 symptoms of, 200 treatment of, 200 Prune- juice expectoration, 182 Pseudo-angina, 591 Pseudo-hypertrophic paralysis, 847 Pseudo-hypertrophy of muscles, 847 Pseudo-leucaemia, 516 aetiology of, 516 definition of, 516 diagnosis of, 518 pathology of, 517 prognosis of, 518 symptoms of, 517 treatment of, 518 splenic, 515 Pseudo-membranous croup, 613 enteritis, 395 Psilosis, 73 Psorospermiasis, 850 Psychical epilepsy, 804 epileptic equivalent, 804 Psychosis polyneuritica, 301 Ptomaine poisoning, 312 treatment of, 313 Ptosis, 780 Ptyalism, 324 treatment of, 324 Puerperal eclampsia, 813 904 Pulex irritans, 877 penetrans, 878 Pvdmonary abscess, 639 consumption, 151 emphysema, 631 syphilis, 637 Pulmonic insufficiency, 572 obstruction, 572 Pulse, irregular, 587 delirium cordis, 588 embryocardial, 588 explanation of, 588 gallop rhythm, 587 peculiarities of, 587 varieties of, 587 Pulsus bigeminus, 587 paradoxus, 538, 542, 587 trigeminus, 587 Purinaemia, 252 aetiology of, 252 definition of, 252 diet in, 252 symptoms of, 252 treatment of, 252 Purpura, 505 arthritic, 506 treatment of, 507 fulminans, 507 haemorrhagica, 507 treatment of, 507 Henoch's, 506 simple arthritic, 506 Putrid sore throat, 78 Pyaemia, iii aetiology of, in diagnosis of, 112 prognosis of, 113 symptoms of, 112 treatment of, 113 Pyelitis, 691 Pyelonephrosis, 691 Pylephlebitis, 452 Pylethrombosis, 452 Pylorospasm, 374 treatment of, 374 Pylorus, hypertrophic stenosis of, 360 aetiology of, 360 definition of, 360 pathology of, 360 symptoms of, 360 treatment of, 360 Pyothorax, 650 Pyopneumothorax, 654 Pyroplasma hominis, 23 Pyrosoma bigeminum, 23 Quincke's lumbar puncture, 99, 100 Quinsy sore throat, 329 aetiology of, 329 definition of, 329 pathology of, 329 symptoms of, 329 treatment of, 329 INDEX. Rabies, 114 Rachitis, 280 Rag-picker's disease, 124 Railway brain, 828 spine, 828 Raynaud's disease, 832 aetiology of, 832 pathology of, 832 prognosis of, 833 symptoms of, 832 treatment of, 833 Reaction of degeneration, 740 Rectum, cancer of, 419 Recurrent typhus, 30 Reichmann's disease, 369 Relapsing fever, 30 aetiology of, 30 clinical chart of, 31 incubation in, 31 pathology of, 31 prognosis of, 32 relapse in, 32 spleen in, 31 symptoms of, 31 treatment of, 32 Remittent fever, 49 chill in, 49 diagnosis of, 51 prodromal symptoms of, 49 treatment of, 53 Renal cirrhosis, 683 colic, 700 dropsy, 679 epistaxis, 706 haemorrhage, 706 sand, 699 sclerosis, 683 stone, 698 Ren mobilis, 662 Respiratory system, diseases of, 607 Retina, affections of, 778 functional disturbances of, 779 haemorrhage into, 778 hyperaesthesia of, 779 organic disease of, 778 Retinal haemorrhage, 778 Retinitis, 778 nephritic, 68c, 778 pigmentosa, 778 syphilitic, 778 Revaccination, 244 Rhachitis, 280 Rheumatic fever, 105 purpura, 106 Rheumatism, acute articular, 105 aetiology of, 105 clinical chart of, 107 complications of, 107 pathology of, 106 prodrome, 106 prognosis of, 108 recurrence, 107 symptoms of, 106 INDEX. 905 Rheumatism, acute articular, treatment of, 106 chronic, 265 aetiology of, 265 definition of, 265 pathology of, 265 symptoms of. 265 treatment of, 265 < muscular, 267 aetiology of, 267 definition of, 267 diagnosis of, 267 symptoms of, 267 cephalodynia, 268 lumbago, 267 pleurodynia, 268 stiff neck or torticollis, 267 treatment of, 268 Rheumatoid arthritis, 269 Rhinitis, acute, 607 symptoms of, 607 treatment of, 607 vaso-motor, 608 Rickets, 280 aetiology of, 280 definition of, 280 diagnosis of, 283 shape of chest, 281 pathology of, 281 prognosis of, 283 symptoms of, 282 treatment of, 283 Rock fever, 28 Rocky Mountain fever, 23 Room disinfection, 236 Rose cold, 608 Roseola, 218 Rotch's sign, 539 Rotheln, 218 Round worm, 853 Rubella, 218 aetiology of, 219 diagnosis of, 219 incubation of, 219 prognosis of, 220 symptoms of, 219 treatment of, 220 Rubeola, 214 Rumination, 375 Salicyluric acid in urine, 109 test for, 109 Salivary glands, diseases of, 324 inflammation of, 324 Sanatorium treatment in tuberculosis, 164 Sand flea, 878 Sarcoma of the liver, 444 of lung, 638 Sarcophila carnaria, 875 Sarcoptes scabiaei, 874 Saturnism, 286 Scanning speech, 751 Scarlatina, 220 Scarlatina, aetiology of, 220 clinical chart of, 223 complications and sequelae, 223 diagnosis of, 224 haemorrhagic, 223 maligna, 223 miliaris, 222 pathology of, 221 prognosis of, 225 prophylaxis of, 225 scarlatina anginosa, 223 symptoms of, 221 raspberry tongue, 222 strawberry tongue, 222 treatment of, 225 Scarlet fever, 220 Schistosomum Cattoi, 853 haematobium, 852 Schott treatment, 548 Sciatica, 773 aetiology of, 773 prognosis of, 774 symptoms of, 773 treatment of, 774 Sclerodactyly, 844 Scleroderma, 843 Sclerose en plaques, 725 Sclerosis, amyotrophic lateral, 744 aetiology of, 744 pathology of, 744 symptoms of, 744 treatment of, 745 disseminated, 725 insular, 725 lateral, 742 multiple, 725 of coronary arteries, 591 of liver, 429 Scorbutus, 276 Scotoma, 779 Scrivener's palsy, 830 Scrofula, 173 Scurvy, 276 aetiology of, 276 definition of, 276 diagnosis of, 278 prognosis of, 278 symptoms of, 277 treatment of, 278 infantile, 279 aetiology of, 279 definition of, 279 diagnosis of, 279 pathology of, 279 prognosis of, 280 symptoms of, 279 treatment of, 280 Seat-worm, 855 Seminal vesicles, tuberculosis of, 178 Septicaemia, iii aetiology, in and pyaemia, in bacilli. III 9o6 INDEX. Septicaemia, diagnosis of, 112 prognosis of, 113 symptoms of, 112 treatment of, 113 Serum, Trunecek's, 596 Seven-day fever, 30 Seventh nerve, lesions of, 782 Shaking palsy, 810 Shell-fish poisoning, 312 Shiga's bacillus, 389 Ship fever, 24 Sick headache, 835 Simple continued fever, 200 or round ulcer, 345 Sinuses of brain, thrombosis of, 722 Siriasis, 317 Sixth nerve, lesions of, affecting the eye- baU, 780 Slows, 129 Sleeping-sickness, 206 pathology of, 206 symptoms of, 206 treatment of, 206 Smallpox, 231 aetiology of, 231 cHnical chart of, 233 complications of, 235 contagium of, 231 diagnosis of, 235 forms of, 232 confluent, 234 discrete, 232 haemorrhagic, 234 purpura variolosa, 234 variola haemorrhagica pustulosa, 234 variolae sine varioHs, 235 varioloid, 235 pathology of, 231 piognosis of, 236 prophylaxis of, 236 symptoms of, 232 incubation, 232 initial rashes, 233 diffuse scarlatinous, 233 muscular pain, 232 treatment of, 236 Smoker's tongue, 323 Sore throat, 325 Spasm of larynx, catarrhal, 613 Spasmodic croup, 613 tabes dorsalis, 742 Spastic paraplegia, 742 aetiology, 743 pathology of, 743 symptoms of, 743 treatment of, 744 Spastic spinal paralysis, 742 aetiology, 743 pathology of, 743 prognosis of, 743 s3Tnptoms of, 743 treatment of, 744 Speech, derangements of, 723 Spinal accessory nerve, lesions of, 791 symptoms of, 792, 793 spasm of, 793 treatment of, 793 cord, acute affections of, 735 and meninges, tumors of, 761 symptoms of, 761 treatment of, 762 compression of, 759 aetiology of, 759 pathology of, 759 prognosis of, 760 symptoms of, 759 treatment of, 759 diseases involving the, 735 haemorrhage into the substance'of, 757 membranes, haemorrhage into, 766 extrameningeal, 766 intrameningeal, 766 treatment, 767 meningitis, 763 tumors of, 761 paralysis of children, 739 Spine, railvi'ay, 828 Spirillum fever, 30 Spirochaeta of Obermeier, 30 pallida, 134 refringens, 134 Splanchnoptosis, 366 Spleen, abscess of, 513 amyloid, 514 diseases of, 512 echinococcus, 515 in anthrax, 124 in cirrhosis of the liver, 43 1 in leucaemia, 499 in malaria, 47 in typhoid fever, 2 in typhus fever, 25 neoplasms of, 514 rupture of, 514 wandering, 512 Splenic anaemia, 515 pseudo-leucaemia, 515 apoplexy, 122 fever, 122 Splenitis, 513 Splenomegaly, tropical, 206 Spondylitis deformans, 271 Sporozoa, 850 Spotted fever, 23, 95 Sprue, 73 aetiology of, 73 pathology of, 73 symptoms of, 73 treatment of, 74 Sputum, tuberculous, 154 St. Anthony's fire, 102 Status epilepticus, 804 lymphaticus, 519 Stegomjaa fasciata, 33 Stenocardia, 590 Stenosis, hypertrophic, of pylorus, 360 INDEX. 907 Stigmata, hysterical, 818 Stokes- Adams syndrome, 587 Stomach, acute dilatation of, 364 bilocular, 365 cancer of, 356 aetiology of, 356 diagnosis of, 357 pathology of, 356 prognosis of, 358 stomach contents in, 357 symptoms of, 356 treatment of, 358 surgery in, 359 chronic catarrh of, 337 dilatation of the, 361 aetiology of, 361 definition of, 361 diagnosis of, 362 pathology of, 361 physical signs of, 362 stomach contents in, 363 symptoms of, 361 treatment of, 363 dietetic, 364 surgery in, 364 diseases of, 334 hour-glass, 365 neuroses of, 369 ulcer of, 345 Stomatitis, 320 aphthous, 128 epidemic, 128 gangrenous, 321 - aetiology of, 321 definition of, 321 pathology of, 321 symptoms of, 321 treatment of, 322 mycotic, 320 prophylaxis against, 320 treatment of different forms of, 320 Stone, kidney, 698 Strangulation of intestine, 405 Strongyloides intestinalis, 857 Struma exophthalmica, 523 simple, 521 St. Vitus' dance, 795 SulphonethA'lmethane poisoning, 305 symptoms of, 305 treatment of, 305 Sulphonal poisoning, 305 Sulphonmethane poisoning, 305 symptoms of, 305 treatment of, 305 Sunstroke, 317 Eetiology of, 317 definition of, 317 pathology of, 317 prognosis of, 318 symptoms of, 317 treatment of, 318 Suprarenal capsule, diseases of, 534 Surgical kidney, 691 Swamp fever, 45 Swelled head, 127 Sydenham's chorea. 795 ' Symmetrical gangrene of extremities, 83a Syphilis, 134 acquired, 136 aetiology of, 134 diagnosis of, 139 initial sore, 136 pathology of, 136 condyloma acuminatum, 137 latum, 136 gumma, 137 treatment of, 139 mucous patch, 136 papular eruption, 136 pustular eruption, 136 syphUides, 136 macular, 136 squamous, 136 venereal wart, 137 primar}', 136 secondar}', 136 symptoms of, 137 tertiary, 137 hereditary, 135, 138 germ infection, 135 Hutchinson's teeth, 138 sperm infection, 135 transmission, 135 treatment of, 143 of the liver, 439 diagnosis of, 440 symptoms of, 440 treatment of, 440 of lungs, 637 of the newly-born, haemorrhagic, 508 pulmonary, 637 Syphilitic ulcer of bowel, 399 Syringomyelia, 755 aetiology of, 755 pathology of, 755 prognosis of, 756 symptoms of, 755 treatment of, 756 Tabes dorsalis, 745 aetiolog}' of, 745 course of, 746 pathology of, 746 prognosis of, 748 symptoms of, 746 arthropathies, 747 crises in, 747 gait, 747 girdle pains, 746 incoordination, 747 motor phenomena, 747 reflex, 746, 747, 748 Romberg's sign, 747 sensor}^, 747 vasomotor and trophic phenomena, 747 visceral pain, 747 9o8 Tabes dorsalis, treatment of, 748 mesenterica, 175 Tabetic crises, 747 Table of heart murmurs, 563 Tachycardia, 586 explanation of, 586 paroxysmal, 586 strumosa, 523 treatment o^, 588 Tsnia, 868 Africana, 871 canina, 870 confusa, 871 cucvunerina, 870 echinococcus, 868 ehptica, 870 flavopuncta, 870 lanceolata, 871 lata, 869 Madagascariensis, 871 marginata, 871 mediocanellata, 868 nana, 870 saginata, 868 solium, 869 Tape-worms, 868 beef, 868 dog, 870 fish, 869 pork, 869 treatment of, 872 Temperature, effects of high, 316 Tent life for the tuberculous, 165 Tenth nerve, lesions of, 788 Testicles, tuberculosis of, 178 Tetanilla, 814 Tetanus, 118 aetiology of, 118 bacillus of, 118 diagnosis of, 120 head, 119 pathology of, 119 predisposing causes of, 119 prognosis of, 120 symptoms of, 119 treatment of, 120 antitoxin in, 120 varieties of, 119 idiopathic, 119 neonatonma, 119 traumatic, 119 Tetany, 814 aetiology of, 814 pathology of, 815 prognosis of, 815 symptoms of, 815 treatment of, 815 The pox, 134 Thermic fever, 317 treatment of, 318 Third nerve, lesions of, 779 Thomsen's disease, 808 Thoracocentesis, technique of, 648 INDEX. Thomhead worms, 858 Thread worms, 855 Thrombosis and emboUsm, of cerebral ar- teries, 720 of venous sinuses of brain,. 722 primary, 722 secondary, 722 of portal vein, 452 Thymus death, 519, 533 gland, diseases of, 533 Thyrocele, 521 Thyroid gland, congestion of, 523 diseases of, 521 Ungual, 533 neoplasms of, 532 Thyroiditis, acute, 523 Tic, convulsive, 800 generalized, 800 impulsive, 800 localized, 800 simple, 800 with explosive utterances, 800 Tick fever, 204 Ticks, 874 Tinnitus aurium, 785 aetiology of, 786 treatment of, 786 Tobacco poisoning, 310 symptoms of, 310 treatment of, 310 Tongue, diseases of, 322 eczema of, 322 geographical, 322 pityriasis of, 322 Tonsillar abscess, 329 Tonsillitis, 327 acute folUcular, 327 aetiology of, 327 definition of, 327 pathology of, 328 symptoms of, 328 treatment of, 328 acute lacunar, 327 acute parenchymatous, 329 acute ulcerative, 327 phlegmonous, 329 Tonsils, diseases of, 325 Topical diagnosis of cerebral lesions, 731 Torticollis, or wry-neck, 267, 792 congenital, 792 pathology of, 792 spasmodic, 793 treatment of, 793 Toxic jaundice, 457 Trachea, diseases of, 619 Tracheo-bronchitis, acute, 617 Transverse myelitis, 735 Traumatic hysteria, 828 neuroses, 828 aetiology of 828 pathology of, 829 prognosis of, 829 sjTuptoms of, 829 INDEX. 909 Traumatic neuroses, treatment of, 829 Trematodiasis, 851 Trembles, 129 Trichina spiralis, 861 Trichiniasis, 861 Tnchiuris trichiura, 857 Trichinosis, 861 Trichocephalus dispar, 857 Tricuspid insufficiency, 570 physical signs of, 570 jugular pulse, 570 treatment of, 580 obstruction, 571 physical signs of, 571 treatment of, 580 Trifacial nerve, lesions of, 781 symptoms of, 781 paralysis of motor portion of the, 781 of sensory portion of the, 782 treatment of, 782 Trional poisoning, 305 Trigeminus, lesions of, 781 Trismus, 118 Tropical adenitis, 77 bubo, 77 dysentery, 63 splenomegaly, 206 Trunecek's serum, 596 Trypanosoma fever, 205 gambiense, 205 Evansi, 205 Bnicei, 205 Trypanosomiasis, 205 treatment of, 206 Tubercle, 146 anatomy and history of, 146 calcareous infiltration of, 147 caseation of, 146 degeneration of, 146 fibroid change in, 147 histogenesis of, 146 retroactive inflammation caused by, 146, r .'47 softening of, 146 Tuberculous peritonitis, 175 ulcer of bowel, 398 Tuberculin test for tuberculosis, 157 Tuberculosis, 144 aetiology of, 144 age, 145 bacillus of, 144 climate, 145 food, 145 heredity, 145 race, 145 sanitation, 145 sex, 145 shape of chest, 146 traumatism, 146 acute general miliary, 148 diagnosis of, 148 prognosis of, 149 symptoms of, 148 Tuberculosis, acute general miliary, treat- ment of, 149 acute general of meningeal form, see tuberculous meningitis, 714 acute general of pulmonary form, 149 diagnosis of, 149 physical signs of, 149 symptoms of, 149 treatment of, 150 acute miliary, 147 pathology of, 147 acute pneumonic pulmonary, 150 symptoms of, 150 treatment of, 151 types of, 150 chronic pulmonary, 151 diagnosis of, 157 pathology of, 151 physical signs of, 155 prognosis of, 159 symptoms of, 153 chronic ulcerative, 150 diffuse general, 147 immunization against, 162 of the heart and blood-vessels, 179 of the kidney, 177 miliary granulations in, 177 pathology of, 177 primary foci in, 177 symptoms of, 177 treatment of, 177 of the l3Tnphatic glands, 173 aetiology of, 173 diagnosis of, 174 prognosis of, 174 symptoms of, 173 tabes mesenterica, 175 treatment of, 176 of the mammary glands, 179 of the ovaries. Fallopian tubes, and uterus, 178 of the pelvis of the kidney, ureters, and bladder, 177 of the pericardium, 176 of the peritonaeum, 175 of the pleura, 175 of the serous membranes, 175 of the testicles, prostate gland, and sem- inal vesicles, 178 pathology of, 146 degenerations of tubercle, 146 secondary inflammatory processes, 147 prophylaxis of, 159 pulmonary, 150 treatment of, 162 climatic, 162 dietetic, 165 hygienic, 163 medicinal, 167 of symptoms of, 169 open air, 164 sanatorium, 164 tent, 165 9IO INDEX. Tuberculosis, treatment of, tuberculin, 171 ulcerative, 150 Tuberculous laryngitis, 614 bronchial lymph-nodes, 152 broncho-pneumonia, 151 cavities, 152 lymphadenitis, 173 meningitis, 714 pleurisy, 15? pneumonia, 152 sputum, 154 tumors of the intestines, 419, 420 ulceration of intestine, primary, 398 Tumors of the spinal cord and membranes, 761 symptoms of, 761 treatment of, 762 varieties of, 761 Twelfth nerve, lesions of, 794 Typhlitis, 399 Typhoid fever, see enteric fever, i spine, 8 Typhus abdominalis, i exanthematicus, 24 fever, 24 aetiology of, 24 clinical chart of, 26 contagiousness, 25 diagnosis of, 27 eruption of, 26 incubation of, 25 pathology of, 25 prognosis of, 27 symptoms of, 25 treatment of, 27 icteroides, ^^ tropicus, 33 Tyrotoxismus, 313 Ulcer, embolic, of stomach, 345 of intestine, 399 gastric, 345 aetiology of, 345 course and termination of, 347 definition of, 345 diagnosis of, 347 haemorrhage 346 pathology of, 346 prognosis of, 347 symptoms of, 346 treatment of, 348 operative, 355 of duodenum, 397 aetiology of, 397 pathology of, 397 prognosis of, 397 treatment of, 398 peptic, 345 perforating, of stomach, 345 round, of stomach, 345 syphilitic, of intestine, 399 thrombotic, of stomach, 345 Ulceration of the bowel, 397 primary tuberculous of intestine, 398 symptoms of, 398 treatment of, 398 Ulcerative colitis, 383 endocarditis, 556 Ulcus ventriculi, 345 Uncinaria Americana, 858 duodenalis, 858 Uncinariasis, 858 Undulant fever, 28 Unilateral progressive facial atrophy, 837 Uraemia, 668 symptoms of, 669 treatment of, 669 Ureter, tuberculosis of, 177 Uricacidaemia, 252 Uricaemia, 252 Urinary system, diseases of, 661 Urticaria, giant, 834 Uterub, tuberculosis of, 178 Vaccination, 243 complications of, 244 operation of, 243 symptoms following, 243 Vaccine disease, 242 Vaccinia, 242 bacteriology of, 242 disease, humanized lymph in, 243 generalized, 244 phenomena of, 243 rashes, 244 , nature of, 244 treatment of, 244 Vagus nerve, lesions of, 788 Valvular (cardiac) defects, 561 congenital, 573 pathology, 561 relative frequency of, 562 disease, chronic, prognosis of, 574 treatment of, 574 of dropsy, 584 of dyspnoea, 583 of irregularities of heart action and palpitations, 584 lesions, associated or combined, 573 Valvulitis, 561 Varicella, 229 aetiology of, 229 diagnosis of, 230 prognosis of, 230 symptoms of, 229 treatment of, 230 Variola, 231 Variolae sine variolis, 235 Vaso-motor and trophic derangements, 832 rhinitis, 608 Veronal poisoning, 306 symptoms of, 306 treatment of, 306 Verruga, 212 Vesicular emphysema, 632 INDEX. Vinegar eel, 857 Visceroptosis, 366 ffitiology of, 367 definition of, 366 symptoms of, 367 treatment of, 367 Vocal cord, paralysis of, 789 Volvulus, 405 Vomiting, cyclic, 379 Waxy kidney, 689 liver, 438 Weil's disease, 201 aetiology of, 201 diagnosis of, 201 pathology of, 201 prognosis of, 201 symptoms of, 201 treatment of, 201 Wernicke's test, 777 Wet brain, 300 Whooping-cough, 90 aetiology of, 90 complications and sequelae of, 92 diagnosis of, 92 pathology of, 91 prognosis of, 92 symptoms of, 91 treatment of, 92 Winckel's disease, 508 Wool-sorter's disease, 122, 124 Word-blindness, 722 Word-deafness, 722 911 Worms, 851,853 bladder, 450 flat, 868 gviinea, 866 hook, 858 maw, 853 pin, 855 round, 853 seat, 855 thread, 855 Writer's cramp, 830 aetiology of, 830 symptoms of, 830 treatment of, 831 Wry-neck, 792 Xerostomia, 324 ' • Yaws, 211 Yellow atrophy of the liver, acute, 441 fever, ^;^ Eetiology of, ^^ albuminuria in, 35 clinical chart of, 35 diagnosis of, 35 jaundice in, 34 mosquitoes and, ^2, 36 pathology of, 3;^ prognosis of, 32 prophylaxis of, 36 slow pulse of, 34 symptoms of, 34 treatment of, 36 by senun, 38 COLUMBIA UNIVERSITY LIBRARIES TMs book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. 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