COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX641 20350 RC46 .L81 1901 A manual of the prac RECAP (Columbia Hntorriiity M ^ in the (Citu nf ^nu ^ork SrtVmtrp Utbrary Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofpracticeOOIock A MANUAL OF THE PRACTICE OF MEDICINE BY GEORGE ROE LOCKWOOD, M.D, Attending Physician to Bellevue Hospital, New York SECOND EDITION, REVISED WITH J03 ILLUSTRATIONS, MANY OF THEM ESf COLORS PHILADELPHIA AND LONDON W. B. SAUNDERS & COMPANY 1901 Copyright, 1901, by W. B. SAUNDERS & COMPANY. ELECTHOTVPEO BY PRESS OF WESTCOTT & THOMSON. PHILAOA. W- B. SAUNDERS & COMPANY. TO HORACE DENNETT AS A TOKEN OF RESPECT AND AFFECTION THIS BOOK IS RESPECTFULLY DEDICATED BY THE AUTHOR PREFACE TO THE SECOND EDITION. In preparing this edition, the entire book has been sub- jected to a thorough revision. Many portions have been entirely rewritten, and a number of new subjects have been introduced. Among the new sections may be mentioned Bubonic Plague, Gastroptosis, Gastric Analysis, and Reichmann's Disease. The subject of Malaria has been entirely re- written. The section on Diseases of the Digestive System also has been largely rewritten, especially the following subjects : Gastritis ; Dilatation of the Stomach ; Gastric Atony; Ulcer of the Stomach; Gastric Neuroses; Enteritis; Colitis, etc. Throughout the book, wherever it seemed necessary, new matter has been added, to bring the subject down to date. 5 PREFACE. It has been the aim of the author to present in this manual the essential facts and principles of the practice of medicine in a concise and available form. It is hoped that the work will meet the requirements of those who hereto- fore have been obliged to resort to the larger works of refer- ence with which medical literature is so v/ell supplied. In the arrangement of the subject-matter the admirable classification of Osier has been adopted with but a few un- important modifications. Acknowledgment of the author's indebtedness is hereby made to those writers from whose articles illustrations have been taken for use in this manual, credit in each case being given in the text. The author also desires to extend his thanks to Mr. Thomas F. Dagney, of Mr. Saunders' publi- cation rooms, for the preparation of the index and for valu- able suggestions of a varied character while the manual was going through the press. CONTENTS. I. THE INFECTIOUS DISEASES. PAGE Typhoid Fever 17 Typhus Fever 43 Relapsing Fever 48 Small-pox 51 Vaccinia 59 Varicella 60 Scarlet Fever 61 Measles 70 Rubella • 74 Ei^idemic Parotitis 76 Whooping-cough 78 Epidemic Influenza 81 Dengue 85 Epidemic Cerebro-spinal Meningitis 87 Diphtheria 93 Erysipelas 106 Pysemia Ill SepticEemia . . II3 Cholera 1 15 Yellow Fever 120 Syphilis 124 Acquired Syphilis 125 Hereditary Syphilis 131 Acute Miliary Tuberculosis 133 Malarial Fever 138 Anthrax 15 1 Hydrophobia 153 Tetanus 156 Leprosy • . 160 Glanders 162 Actinomycosis 164 Milk Sickness 166 Weil's Disease 167 Bubonic Plague 167 II. DISEASES OF THE CIRCULATORY SYSTEM. Diseases of the Pericardium 169 Pericarditis 169 Purulent Pericarditis 177 Chronic Adhesive Pericarditis 178 Tubercular Pericarditis 179 Cancerous Pericarditis . 180 Hydropericardium 181 Hffimopericardium 181 Pneumopericardium 181 9 lO CONTENTS. PAG1-: 2. Diseases of the Heart 182 llypertropliy and Dilatation 182 • Hyperiropliy 1S6 Dilatation 189 Acute Eniiocaaluis 196 Maliijnant Endocarditis 200 Ciironic Endocarditis 204 Atheroma 206 Mitral Incompetency 207 Mitral Stenosis 2IO Aortic Kegurtjitation 214 Aortic Stenosis 218 Tricuspid Regurgitation 220 Tricuspid Stenosis 221 Pulmonary Regurgitation 221 Pulmonary Stenosis 222 3. Diseases of the Myocardium 227 Acute Myocarditis 227 Chronic Myocarditis .... 228 Syphilitic Slyocarditis 230 Degeneration of the Myocardium 230 Aneurysm of the Heart 236 Rupture of the Heart 237 4. Neuroses of the Heart .' 238 Palpitation 238 Tremor Cordis 239 Intermittent Action 239 Tachycardia 240 Brachycardia 241 Angina Pectoris 242 Pseudo-angina 245 Exophthalmic Goitre 246 5. Congenital Malformations 250 6. Diseases of the Arteries 252 Arterio-sclerosis 252 Syphilitic Arteritis 255 Aneurysm 256 Aneurysm of the Abdominal Aorta ...... 263 III. DISEASES OF THE RESPIRATORY SYSTEM. Diseases of the Lnr\-nx 265 Spasm of the Larynx 265 Acute Catarrhal Laryngitis 267 Chronic Catarrhal Laryngitis 269 Membranous Laryngitis 270 Tubercular Laryngitis 271 Syphilitic Laryngitis 272 CEdematous Laryngitis 273 Diseases of the lironchi 274 Acute Catarrhal Bronchitis 274 Acute Croupous Bronchitis 278 Chronic Catarrhal Bronchitis 279 Chronic Croupous Bronchitis 281 Bronchiectasis 281 Asthma 283 Diseases of the Lungs 288 Circulatory Disturbances 288 CONTENTS. 1 1 PAOE Congestion of the Lungs 288 Qiclema of the Lungs 289 Puhnonary Hemorrhage 290 Bronclio-pulmonary Hemorrhage, or Hsemoplysis . , . . 290 Pulmonory Apoplexy 293 Lobar Pneumonia 294 Bronclio-pneumonia ^og Broncho-pneumonia in Adults tj- Interstitial Pneumonia ti^ Interlobular Emphysema ^21 Vesicular Emphysema 921 Gangrene of the Lung ^26 Aljscess of the Lung -728 Syphilis of the Lung ^29 New Growths of the Lung ,,0 Echinococcus Cysts of the Lung 0^2 Tubercular Liflammations in General ^^2 Tubercular Diseases of the Lung ,,5 Acute Pulmonary Tuberculosis T^y Chronic Pulmonary Tuberculosis -s.q Acute Pulmonary Phthisis -^.a Chronic Pulmonary Phthisis ^_^g Diseases of the Pleura o5o Fibrinous or Dry Pleurisy ^go Pleurisy with Effusion -152 Purulent Pleurisy t^q Chronic Pleurisy oy^ Tubercular Pleurisy ^y5 Pneumothorax ,yy New Growths of the Pleura ,gj Hydrothorax •,82 Haemothorax Diseases of the Mediastinum 382 Lymphadenitis • . ,gT 384 386 Mediastinal Tumors Abscess of the Mediastinum Emphysema of the Mediastinum ,§5 Mediastinal Hsematoma ,gy Diseases of the Thymus Gland .jgy IV. DISEASES OF THE DIGESTIVE SYSTEM. 1. Diseases of the CEsophagus • 388 Acute CEsophagitis 388 Chronic CEsophagitis 389 Stenosis of the CEsophagus 389 Cicatricial Stenosis 389 Cancerous Stricture 391 Spasmodic Stenosis 392 Dilatations and Diverticula 393 Paralysis of the CEsophagus 394 Rupture of the CEsophagus 394 Varix of the CEsophagus , 394 2. Diseases of the Stomach 395 Acute Catarrhal Gastritis 395 Toxic Gastritis 397 Acute Croupous Gastritis 398 Acute Suppurative Gastritis 398 1 2 COXTEXTS. PACE Mycotic and Parasitic Gaslriiis 399 Chronic Catarrhal Gastritis 399 Atony 407 l)ilatation of the Sioniacli ; Gastrectasis 411 L'icer of the Stomach 416 Cancer of the Stomach 424 Non.cancerous Tumors of the Stomach 431 (iastroptosis 43' Hemorrhage from the Stomach 433 Gastric Nemoses 43'' Sensory Neuroses 43/ Secretory Neuroses 439 Motor Neuroses 44^ 3. Diseases of tlie Intestines 442 Morning Diairhrea 442 Acute Catarriial Enteritis 443 Clnonic Catarrhal Enteritis 445 Plilegnionous Enteritis 447 I'seuilomenibranous Enteritis 44^ Mucous Cohtis 44S Diarrhieal Diseases of Ciiildren 450 Acute Dyspeptic Diarrhcea 451 Acute Entero-coHtis 451 Cholera Infantum 453 Cholera Morbus 456 Colitis 457 Acute Catarrhal Colitis 45S Tropical or Amoebic Colitis ... 459 Acute Croupous Colitis 461 Ciironic Colitis and Chronic Dysenteiy 463 Appendicitis 465 .-\cute Catarrhal Appendicitis 465 Acute Suppurative Appendicitis 467 Gangrenous Appendicitis 471 Chronic A]i]iendicitis 473 Ulceration of the Intestine 474 Cancer of the Intestine 479 Cancer of the Rectum 480 Cancer of the Caput Coli 481 Cancer of the Duodenum 482 Non-cancerous Tumors of the Intestine 482 Intestinal Obstruction 482 Hemorrhage from the Intestine 487 Fecal Accumulation 489 Amyloid Degeneration of the Intestine 492 4. Diseases of the Peritoneum 492 Acute Peritonitis 492 Acute Peritoneal Sepsis 493 Acute Diftuse Peritonitis 494 Acute Circumscribed Peritonitis 497 Chronic Peritonitis 499 Chronic Hemorrhagic Peritonitis 501 Tul^eicular Inflammations of the Peritoneum 502 Acute Tul>erculosis of the Peritoneum 502 Acute Tubercular Peritonitis 502 Chronic Tubercular Peritonitis 504 Cancer of the Peritoneum ; 505 Ascites 307 5. Diseases of the Liver 510 CONTENTS. 13 PAGE Functional Disturbances of the Liver ^10 Circulatory Disturbances of the Liver 512 Diseases of the Capsule of the Liver 513 Acute Perihepatitis ^ 513 Chronic Fibrinous Perihepatitis 514 Syphilitic Perihepatitis 515 Acute Parenchymatous Hepatitis 515 Cirrhosis of the Liver 517 Atrophic Cirrhosis 517 Hypertrophic Cirrhosis 522 Syphilitic Cirrhosis 1523 Abscess of the Liver 525 Tubercular Disease of the Liver • 530 Nev^r Growths of the Liver 530 Hydatid of the Liver 534 Fatty Liver 536 Amyloid Liver 538 Jaundice 539 Acute Febrile Jaundice 542 Catarrhal Jaundice 542 Cholelithiasis 543 Cancer of the Gall-ducts 551 Diseases of the Blood-vessels of the Liver 551 Diseases of the Pancreas 553 Hemorrhage 553 Acute Hemorrhagic Pancreatitis 553 Gangrenous Pancreatitis 555 Suppurative Pancreatitis 555 Chronic Pancreatitis 555 Pancreatic Cysts 555 Cancer of the Pancreas . . . '. 557 V. DISEASES OF THE KIDNEY. Congenital Malformations of the Kidneys 559 Movable Kidney 559 Anomalies of the Urinary Secretion 561 Albuminuria 561 Hsematuria 5^4 Hsemoglobinuria 565 Pyuria , 567 Peptonuria 567 Phosphaturia S^'^ Lithsemia ; Uricsemia 568 Oxaluria 569 Chyluria 570 Indicanuria 570 Glycosuria 57° Lipuria 57° Acetonuria ^Ti- Acute Congestion of the Kidneys 571 Chronic Congestion of the Kidneys , 57I Acute Degeneration of the Kidneys . 572 Chronic Degeneration of the Kidneys 573 Acute Exudative Nephritis 574 Acute Diffuse Nephritis 57^ Chronic Bright's Disease 579 Chronic Diffuse Nephritis with Exudation 579 Chronic Diffuse Nephritis without Exudation 583 14 co.vr/^xjs. PAGE Waxy Dcijeneration of ihe Kiilney 589 Tubercular Diseases of the Kidney 590 Tuberculosis of the Kidney 590 Tubercular ryelunephritis 590 Suppurative Disease of the Kidney 592 Tumors of the Kidney 595 Cysts of the Kidney 597 P}elitis 59S Hydronephrosis 599 Nephrolithiasis 600 Perinephritic Abscess 606 VI. CONSTITUTIONAL DISEASES. Acute Articular Rheumatism 607 Pseudo-Rheumatism 614 Chronic Anicular Ulieumalism 614 Muscular Rheumatism 616 Gout 617 Arthritis Deformans 624 Diabetes Mellitus 627 Glycosuria 633 Diabetes Insipidus 634 ScuTvy 635 Rickets 63S Purpuric Diseases 640 Symptomatic Purpura 641 Purpura Rheumatica 642 Purpura Hemorrhagica 642 Haemophilia 645 VII. DISEASES OF THE BLOOD AND THE LYMPHATIC GLANDS. Anamia 647 .Secondary Anoemia 647 Chlorosis 650 Pernicious Anaemia 652 Leucocytosis 655 Leukaemia 656 Pseudo-leukaemia 660 Addison's Disease 664 Tuberculosis of the Lymph-glands 666 VIII. DISEASES OF THE NERVOUS SYSTEM. I. Diseases of the xMembranes of the Brain 668 (a) Diseases of the Dura Mater 668 Acute External Pachymeningitis 668 Acute Internal Pachymeningitis 668 Chronic Internal Pachymeningitis 669 Syphilitic Pachymeningitis . . . , ' 670 (d) Diseases of the Pia Mater 670 Tubercular Meningitis 670 Acute Non-tubercular Meningitis 673 Syphilitic Meningitis 675 Chronic Meningitis 675 CONJ'EN'J'S. PAGI-; Meningeal Hemorrhage 676 2. Diseases of tlie Blood-vessels of the Brain 678 Congestion 678 Anremia . . . . ^ 679 Qidema 57^ Cerel:)ral Hemorrhage 679 Embolism of the Cerebral Arteries 684 Thrombosis of the Cerebral Arteries 687 Aneurysm of the Cerebral Arteries 687 Thrombosis of the Venous Sinuses 689 Cerebral Endarteritis goo 3. Diseases of the Brain-substance , 692 Cerebral Localization 692 Abscess of the Brain 697 Tumors of the Brain 699 Cerebral Atrophy in Children 704 Cerebro-spinal Sclerosis 707 General Paresis 708 Chronic Hydrocephalus 710 Syphilis of the Brain 711 4. Diseases of the Spinal Cord 714 (fl) Affections of the Meninges 714 Diseases of the Dura Mater 714 Diseases of the Pia Mater 715 Acute Leptomeningitis 71c Chronic Leptomenmgitis 717 Hemorrhage into the Spinal Membranes • 718 (J>) Diseases of the Blood-vessels 71^ Anaemia 71^ HyperEemia 71^ Hemorrhage into the Cord 71^ Caisson Disease 720 (f) Diseases of the Substance of the Cord 722 Acute Anterior Poliomyelitis 722 Anterior Poliomyelitis in Children 722 Anterior Poliomyelitis in Adults . . . . ■. 726 Subacute and Chionic Poliomyelitis 726 Progressive Muscular Atrophy 727 Amyotrophic Lateral Sclerosis . 7^0 Bulbar Paralysis 7-51 Ophthalmoplegia 733 Lateral Sclerosis 733 Locomotor Ataxia 735 Hereditary Ataxia 742 Ataxic Paraplegia 743 Myelitis, Acute and Chronic . . . 743 Acute Ascending Paralysis 747 Syringo-myelia 74S Compression-myelitis 745 Tumors of the Spinal Cord 7c;o Brown-Sequard's Paralysis 7^1 5. Diseases of the Cranial Nerves 7^1 Olfactory Nerve 7:;! Optic Nerve 751 Third Nerve 7C2 Fourth Nei^ve 753 Fifth Nerve 7C3 Sixth Nerve 754 Seventh Nerve 754 i6 co.vrAWJ's. PAGE Auditor)- Nerve 757 CIlos'*o-phan, ngeal Nerve 759 l'neuiiu>gastric Nerve 759 Spinal Acccssoiy Nerve 762 Hypoj;lossal Nerve 764 6. Diseases of the Periplieral Nerves 765 Neuritis 765 Localized Neuritis 765 Multiple Neuritis 768 Neuromata 772 Neuralgia 773 7. General Ncr\ous Diseases 776 Infantile Convulsions 776 Kpilepsy 778 I'aialysis Agitans 784 Acute Delirium 786 Chorea 787 Choreiform Affections 793 Tetany 794 Migraine 795 Occupation -neuroses , 797 Neurasthenia 798 Hysteria 800 Sunstroke 807 Delirium Tremens 810 8. Vaso- motor and Trophic Disorders 811 Raynaud's Disease 811 Acute Circumscribed CEdenia 812 Facial Hemiatrophy 813 Myxcedema and Cretinism 813 Scleroderma 815 Acromegaly 815 IX. DISEASES OF THE MUSCLES. Myositis 817 Progressive Muscular Dystrophy 817 Paramyoclonus Multiplex 819 Thomsen's Disease 819 X. AXLMAL PARASITES. Trematodes 821 Nematodes 821 Ascaris Lumbricoides 821 Oxyuris Vermicularis 822 Anchylostoma Duodenale 823 Trichocephalus Dispar 823 Trichina Spiralis S23 Filaria Sanguinis Hominis 825 Cestodes 826 Echinococcus Disease 827 A MANUAL OF THE PRACTICE OF Medicine. L THE INFECTIOUS DISEASES. TYPHOID FEVER. Definition and Synonyms. — Typhoid fever is an acute infectious disease caused by a specific bacillus, and is cha- racterized anatomically by lesions of the intestinal and mesenteric glands and by enlargement of the spleen. The disease runs a febrile course of three or four weeks, with a characteristic eruption and systemic symptoms. Synonyms : Typhus kvev {German); Abdominal typhus; Ileo-typhus; Enteric fever; Autumnal fever. Etiology. — Typhoid fever is one of the most widely spread of all the infectious fevers ; it occurs in all countries and in all climates, though it is more frequent in the tem- perate zones. It may occur at any time of the year, but it is most commonly seen in late summer and in early fall, hence the name " autumnal fever " which has sometimes been applied to it. It seems to occur with especial fre- quency after hot. dry summers. The disease affects the sexes equally, although in hospital practice more cases are met with in men, because they more readily apply for hospital treatment. The disease may occur at any age, but young adults between the ages of fifteen and twenty-five are especially susceptible. After the age of thirty-five the disease appears progressively infrequent. There is in this disease, as in all infectious diseases, a great difference in personal susceptibility, some individuals being more readily infected than others who have been sub- 2 ' 17 1 8 MANUAL OF THE PRACTICE OE MEDICLYE. jccted to the same degree of exposure. In cities strangers are more susceptible to this fever than old inhabitants. The development of the disease after exposure is fa\ored by any inflammatory condition of the intestine, the entrance of the germ into the lymphatics being favored b)' the epithelial desquamation resulting from the catarrhal process. A low and sickly condition of the general health does not seem to increase the susceptibility to infection. The disease appears in both epidemic and endemic forms. The epidemics are usually local, affecting a group of houses, an institution, or a part of a town. The longer the epidemic, the more diffi- cult it often is to trace the source of infection. It appears as an endemic disease where it had previously existed as an epidemic, and it is endemic in almost all large cities. The source of infection is with difficulty traced in endemic cases. The actual exciting cause of typhoid fever is now proved to be the infection of the patient by a specific germ known as the bacillus typhosus, or Eberth's bacillus. This germ is a short, mobile bacillus whose length is equal to one-third the diameter of a red blood-cell, and having rounded bulbous ends which often present a shining appearance, due rather to alterations in its protoplasm than to spore-growth, as was at first supposed. In its appearance and growth this germ closely resembles the bacterium coli coinvnoic, or ordinary colon-bacillus, from which it is hard to differentiate it. The typhoid bacillus grows with ease in almost every kind of nutritive media, and it possesses extraordinary vitality. It may persist in drinking-water or in the soil for weeks or for months, and may even increase in number. It grows with great rapidity in milk without altering its appearance or taste; and so great is its tenacity of life that it ma}^ remain impris- oned in ice for months without losing its virulent properties. In the accumulations of privy-vaults and sewers it finds conditions most favorable for its growth and activity. Cultures are killed by a temperature of 60° C, by carbolic acid (l : 200), and by corrosive-sublimate solution (i : 2500). Cultures resist drying for several days, but the growth of the bacilli is retarded by exposure to sunlight. The bacillus obtains entrance to the body through the TYPHOID FEVER. 1 9 alimentary canal, and enters the intestinal lymphoid tissue probably through abrasions of the epithelial coat. It has been found in the lymphoid tissue of the intestines, in the mesenteric glands, the spleen, the liver, at times in the blood taken from the rose spots, and occasionally in the urine. It has been found also in some of the complicating lesions of the disease. The bacilli are found in clusters in the intes- tinal contents and the stools of patients, and are thrown out from the body in this way. They are not eliminated from the lungs or the skin. Methods of Infection. — The disease is in no sense per- sonally contagious, cases of typhoid being received into the general wards of hospitals without risk. The bacilli being cast off only in the dejecta of the patient, it is from the stools and urine that danger of infection arises. If the stools are thoroughly disinfected and the bacilli are killed, there is no further risk of a spread of the infection. If the stools are not disinfected, however, the bacilli will live and thrive in them, and this infected sewage, draining into water- supplies, will spread the disease among those who drink of such water. It is important also that the urine should be disinfected in like manner. There are three ways by which the infection of typhoid may occur : The first method is by direct infection from stools or urine. While not common, infection has occurred among attendants on the sick and among those who have washed the soiled linen of typhoid patients, the germs being trans- ferred from infected hands to the food, and thus obtaining entrance to the body. The second method of infection is by contamination of the water-supply. This is the usual source of infection, and it explains the origin of epidemics of the disease that occur from time to time in towns, in institutions, and in villages. Contamination of drinking-water with filth and sewage will not produce the disease unless to such sewage is added the specific germ. Interesting investigations of epi- demics frequently show their origin in the contamination of the water-supply by the dejecta of a single typhoid patient. 20 MAXrAL OF THE PRACTICE OF MEDICIXE. even though months may have elapsed between the infec- tion of the sewage and the consequent contamination of the water-supply. The source of contamination is most easily traced in small epidemics, and examples of epidemics in hotels, villages, and towns so traced are to be found reported in full in medical literature. In the same way the infection may be conveyed by impure ice, after the thawing of which the germs regain their vitality. The third method of infection is by food. The bacilli may be conveyed by milk, in which they readily thrive, and to which they are added by impure water, used either to wash the cans or to dilute the milk. A very prolific cause for t)'phoid fever in late years has been from the injection of oysters that have been placed in contaminated fresh water to sweeten them before they are sent to market. There are reports of epidemics apparently caused by eat- ing meat of diseased cattle, but this mode of infection is not yet definitely determined. Poor drainage, sewer-gas, and imperfect hygiene will not of themselves cause the disease: they only offer favorable conditions for the growth and development of the bacillus. Pathology. — The lesions are divided into those essential to, and those complicating, the disease. EssENTi.AL Lesions. — The essential lesions consist in — I. Changes in the lymph-glands of the intestine ; 2. Changes in the mesenteric glands ; 3. Enlargement of the spleen. I. The clianges in the intestinal lymphoid tissue are seen in both the solitary and the agminated glands, but espe- cially in the latter. They are most constant in Peyer's glands of the lower portion of the ileum, and they may appear here alone. In about one-third of the cases the glands of the caecum and colon are affected. There are rare cases in which the intestinal lesions are not developed. Congestion and Hyperplasia. — The first change consists in the congestion and swelling of the lymph-follicles, noticed on the second day of the disease. Toward the end of the first week there is added an increase in number of the cell- ular elements, some cells resembling the ordinary lymphoid cells, while others are large and round with several nuclei. TYPHOID FEVER. 21 This hyperplasia further increases the size of the gland. The cellular increase is not entirely confined to the gland, but infiltrates the mucous membrane in its vicinity, small isolated foci being also seen in the muscular, the sub- serous, and even the serous coats of the intestine. In these .masses of lymphoid cells the bacilli are constantly found. This cellular increase persists during the second week of the disease. In very mild cases, the lesion goes no further than this, but resolution occurs, the congestion disappears, the cells undergo fatty degeneration and absorption, and the gland assumes again its normal appearance. Necrosis. — In most cases, however, the lesion progresses to such a degree that resolution becomes impossible. The swelling of the gland presses on its blood-vessels, and, cut- ting off its blood-supply, induces a condition of anaemia- necrosis, and in consequence of this condition and of the direct action of the bacilli upon the tissues the cells die and are cast off, either gradually, by a process of ulceration, or en masse, by a process of gangrene. In either case an ulcer is left, the walls and floor of which are composed of infiltrated glandular tissue, and by the further disintegration of these infiltrating cells the ulcer may increase in size and in depth. Such ulceration may perforate through the entire intestinal wall, or the separation of the slough may be the cause of hemorrhage. The process of ulceration occupies the third week of the disease. Cicatrisation. — During the fourth week the ulcer begins to cicatrize and the normal glandular elements are re-formed. In some cases an ulcer may cicatrize in some portions and extend in others. Cicatrization should be complete toward the close of the fourth week, but the ulcer may remain sluggish and inactive until the sixth or the eighth week. 2. Changes in the mesenteric glands are of the same nature and intensity as those in the intestine, the only difference being that the products of necrosis cannot be thrown off, but form foci of softened purulent matter containing bacilli. Small foci may eventually be absorbed, while larger ones may become dry and cheesy and enclosed by a fibrous 22 MA.VL'AL OF THE PRACTICE OF MEDICINE. capsule. At nn\- time a fresh focus ma)' rupture into the peritoneal ca\'it)-. 3. TJic spleen rec]^ularl\' becomes increased in size and harder in consistency. These changes proceed until the third week, after which the spleen becomes soft and pulpy and returns to its normal size. In rare cases the spleen becomes soft, but does not increase in size. Rupture or a gangrenous abscess of the spleen may occur. Complicating Lesions. — i. Pcrilonitis. — This condition may be caused in a variety of ways — either from perforation of the intestine by an ulcer, from rupture of a softened mes- enteric gland, or from rupture, abscess, or infarction of the spleen. In some cases no cause can be found for the peri- tonitis. 2. Catarrhal or Croupous Enteritis. — Severe inflamma- tions are rare, though a mild catarrhal enteritis is com- monly seen. 3. Parotitis. — This condition may occur during the second or third week, and may proceed to the formation of an abscess. 4. The liver becomes hypersemic and increased in size. The cells become swollen and coarsely granular. There may be foci of lymphoid cells in the substance of the organ. 5. The kiihieys show parenchymatous degeneration of the cells of the convoluted tubules. In rare cases there may be acute nephritis. There may be small foci of infil- trating lymphoid cells which may proceed to suppuration, causing so-called " miliary abscesses." In these cellular foci Eberth's bacilli are found ; they may be present also in the urine in these cases. 6. The heart-muscle is soft and flabby and may be the seat of waxy degeneration. There may be degeneration of any of the voluntary muscles. In rare cases pericarditis with efi'usion of serum or of pus is found. 7. The pharyjix or the larynx is often the seat of a ca- tarrhal or croupous inflammation. QEdema of the glottis may occur, and ulceration of the larynx occurs in a certain number of cases. Necrosis or sloughing of the cartilages may occur. Platf, I. — ■ "■- Disease J L — i 31 32 1 — :- T —r " '~^ — — 107" : 106° 107° : 106° 105° 105° 104° 104° 103° 103° 102° : 102° 101° A 101° 100° : /S / 100° 99° / 98° -r -- • — ^ . -;- 98° 97° y. 97° •. ■ 1 • • i • 107° 106° 105 104 103' 102' 101° 100' 99' 98° 97° 22 23 sr 52 m i 53 n 54 ^ 55 56 n 57 58 ^-t: Plate 3. 107° 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° TYPHOir ) ■■EVER V LAT ; I. — — — — — — ^ ^ 1 i 4 — i r~ s i £ 1 1 1 12 1 3 r 14 15 16 17 18 19 -I— 20 21 22 23 24 25 26 27 28 29 30 31 32 107°- P- H J T : ''' : T T ~~ 77 7" ~T" 7 7 7 -7 7 7" -^ - 106° _ s : : : 105°. ^ A -A . 104° A -V 1^. V ^ y{ \ / r? ■ / \ ■; \ ; i^H!^:^ ^/ ^ 99 / ; : 1 : \/ :\ A ■'iL : : 1 ^ 87° \ 1 : : i i;|i : Sc M c 1 „n KT «„ „, TYPHOID FEVER. Plate 3. 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Gangrene or abscess of the lung may be found, and pleurisy with effusion occurs in a small number of the cases. There may be thrombosis of some of the larger veins, especially of the femoral ; less frequently there is thrombosis of the cerebral sinuses. Symptoms. — As the symptoms are so complex and the clinical aspect of the disease so varied, it seems best to con- sider each symptom at first in detail, and then to give a general description of their clinical grouping. Fever. — In a typical case the temperature should run a self-limited course of four weeks' duration, each week pos- sessing characteristics of its own. During the first week the temperature gradually mounts, higher in the evening than in the morning, and higher each day than on the day pre- vious. The maximum, which is reached by the end of the week, is between 103° and 104° F. The lowest morning temperature is between 6 and 8 a. m. ; the highest evening temperature is between 6 and 9 p. m. During the second week the temperature remains fairly stationary ; there are morning remissions, but these are slight. The temperature in the first part of the third week con- tinues like that of the second week, but toward the close of the third week the morning remissions become more marked, the evening rise remaining the same. During the fourth week the morning remissions become more marked, while the evening exacerbations decrease ; toward the close of the week the morning temperature becomes normal, and, the evening rise becoming progress- ively less, the evening temperature becomes also normal and the case is completed. This typical temperature is depicted on Plate i. While this temperature curve is typical of typhoid fever, such a regular schematic chart is seldom met with in actual prac- tice, variations in the course being exceedingly common. 24 M.tXr.lL OF THE PRACTICE OE MED/C/XE. The commonest variations of each week will be separately considered. J^rria/ions iu tJic First Week. — {ii) It is seldom that we obtain the temperature of the first few days, as the disease begins so insidiousl)- that it is not until the fourth or fifth day, as a rule, that the patient comes under observation. (/^) Some cases plunge at once into their fever, the onset being sudden, the temperature attaining its maximum upon the second or third day. This sudden onset is frequently accompanied b\- a chill, (r) In some cases the temperature of the first week is markedly remittent, the evening rise being frequently preceded by a chill and followed by sweat- ing. Such cases are difficult to diagnose from malarial fever. Exceptions to the Second and Third Weeks. — {a) The tem- perature may fall to normal by lysis at the close of the second week. These are the cases in which the lesion in the glands docs not progress to ulceration. (/;) During the second and third weeks the fever may be slight — between 99° and loi'^ F. — and the morning temperature may even be normal. This may indicate a mild attack if the other symptoms be mild in proportion, but if the other symptoms be severe the low temperature is not a good sign. These cases with slight fever seem especially liable to relapses. {c) During the third week the temperature may remain steadily high with but slight diurnal variations. In bad cases the temperature may remain steadily high, persisting during the fourth, fifth, sixth, seventh, and eighth weeks. Such cases are apt to be fatal. In some cases the temper- ature suddenly mounts up before death, reaching a height of 109° to 111° F. (Plate 2, Fig. i). Exceptions to the Fourth Week. — The temperature may fall somewhat toward the end of the fourth week, but may still continue a little elevated, running between 99°, 100°, and 101° F. until the sixth, seventh, eighth, or ninth week. With this slight, steady temperature there may be profuse sweat- ing. These symptoms seem due to unhealed intestinal ulcers. In some cases a slight evening rise of temperature to 99° or 100° F. may be noticed during the fifth and sixth weeks, M o to o M o o J1 o o ra o O -J o o o o o 9d * 2, -^ 2>$i ^^ ■■•< <- — *" > ■-^ II V^^ i r\ ■■^ II <^ n II CD C D CD O O » CD O M O O M M M OOP M W P o o o -1 1-1 M Jl CD -0 o o c II J bO I 09 V S 1 / I DC ..... r^ ~ "^ == -r. -^ -| DO c;i -; T — ., ■i^ "K 03 ■v If 1 1 1 1 CO c D CD O O CD O M O O C M 05 iJ 1 s \ ^ -' 1- o 03 •~^ > <-^ N ;> f^ g \ / ^ IS5 - _ ~ !Il^ — i^ — ^, V /. ~ 1 TYPHOID FEVER. 2$ without Other unfavorable symptoms. This rise may be due either to a depressed nervous state or to some insidious comphcation. A sudden fall in the temperature with a subsequent rise is significant of an intestinal hemorrhage. The more severe the hemorrhage the more decided the initial fall of temperature (Plate 2, Fig. 2). The further modifications in the temperature caused by complications, and the relapses, will be considered under separate headings. Ptilse. — During the first week the pulse is full, dicrotic, and about 100. During the second and third weeks it becomes quicker and feebler in direct proportion to the gravity of the case. A pulse persistently over 140 is of serious import. In some cases the pulse is feeble without being rapid. The weakness of the heart's action is of more consequence than mere rapidity, and may endanger the life of the patient, especially during the third and fourth weeks. In some cases there may be attacks of syncope or even collapse, in either of which the patient may die. In other cases the feebleness of the heart allows of venous conges- tion and cyanosis, which further endanger the life of the patient. From the poor circulation thrombi may occur in any of the larger veins. A sudden marked increase in the rapidity and feebleness of the pulse indicates, as a rule, perforation or hemorrhage. Gastro-intestinal Synipioins. — The appetite is lost early in the disease, and does not return until convalescence. The tongue at first is moist and coated. In severe cases it has a tendency to become dry, due rather to the severity of the disease than to the fever. In very severe cases the tongue becomes dry and brown, and brownish crusts, or sordes, collect upon the teeth and gums, interfering with articulation and deglutition. This is a bad sign. The pharynx is usually inflamed during the first week of the disease. Nansca and vomiting may occur at any time in the dis- ease, but they are not usually severe if the diet and medi- cation be judicious. In some cases, however, vomiting is 26 MAXi'AL OF THE PKACTICE OF MEDICIXE. SO severe as to interfere with the feeding of the patient, and it may even cause death by exhaustion. Diah'hcca is usually present, althou<^h in some places, as in New York, and in certain epidemics constipation is the rule. The diarrhoea depends less upon the extent of the ulcerations than upon the severity of the associated enteritis, and it is rarely marked until after the beginning of the second week. It may last a few days only or may continue throughout the disease, or it may alternate with constipation. The stools are abundant, thin, offensive, and of a grayish- yellow color, and are described as suggestive of pea soup. It is a true fecal diarrhoea, resembling the normal contents of the small intestine. The passages var}' in number from two to five daily, more frequent passages being rare. The common occurrence of constipation as a symptom must always be borne in mind. Tyvipanitcs develops in the second week in a great majority of cases, and it is due to paresis of the inflamed intestinal wall interfering with peristalsis. Tympanites usually causes bulging of the abdominal wall, although in some cases rigidity on palpation is alone detected. When once developed it is apt to persist throughout the disease. In moderate degree it does no more actual harm than to render the patient uncomfortable, but if excessive it dis- places the diaphragm upward, interferes with the action of heart and lungs, excites nausea and vomiting, and increases the danger of perforation. Tympanites is a sign of serious import. Pain and toidcrncss over the abdomen are commonly ob- served, and are usually more pronounced in the right iliac fossa. These symptoms are of no diagnostic significance. Gurgling in the right iliac fossa is too common in other diseases to be distinctive. HcmorrJiagcs from the bowels are a serious symptom. It is important to distinguish the sources of bleeding. (i) There may appear slight hemorrhages during the first ten days of the disease, coming not from ulcers, for none exist at so early a date, but from the congested TYPHOID FEVEK. 2/ mucous membrane. They are trifling in amount, and indi- cate merely a severe degree of complicating enteritis. (2) The characteristic hemorrhages of the disease occur after the close of the second week, and are caused by the separation of the sloughs from the intestinal ulcerations. They occur in about 5 per cent, of cases, and are always of grave significance, for not only is the hemorrhage fre- quently fatal in itself, but it also denotes extensive and deep intestinal ulceration. The hemorrhage varies in amount from a few drops to several pints or more. When once a hemorrhage has occurred, others are liable to follow. The blood passed by the rectum may be fluid and red, or dark and clotted, or even tarry in appearance, according to its amount and the length of time it has been retained in the bowel. In some cases of rapidly fatal hemorrhage death may ensue before any blood at all has been passed. The symptoms caused by a severe hemorrhage appear suddenly — faintness, syncope, even collapse, a rapid and feeble pulse, great dyspnoea with restlessness (the so-called "air-hunger"), great pallor, and cold extremities. The mind, if clouded before, usually becomes clear and active. The temperature, as shown on Plate 2, Fig. 2, undergoes a fall of several degrees, perhaps to normal or even to subnormal, and this is followed usually by a subsequent rise to a higher plane than before the hemorrhage. From such a hemorrhage the patient may die in acute anaemia. In some rare cases the hemorrhage seems to exert a beneficial effect upon the course of the disease. Subsequent hemorrhages may follow at intervals. (3) During convalescence there may be small repeated hemorrhages without other unfavorable symptoms. These hemorrhages come from sluggish ulcers which have not yet cicatrized. Nervous Symptoms. — During the first week headache is usually a pronounced symptom. It is usually dull in character, although in rare cases it may be severe, sharp, and associated with photophobia and convulsive twitchings, closely resembling in this respect the headache of menin- gitis. During the first week there are apt to be sleeplessness 28 jMAXi'AL OF THE PRACTICE OF MEDICINE. and restlessness at night. Associated with the headache there is often nose-bleed during the first week. During the second week the headache and restlessness give way to a mental apathy which is exceedingly charac- teristic. The face is utterly without vivacity, with a vacant, listless expression. The pupils are generally dilated. The patients answer questions correctly, although with apparent lack of effort and interest, and often respond only to re- peated and persistent questioning. If left alone, they lie quietly and do not seem to take any concern about them- selves. This condition of apathy is in sharp contrast to the animated, cheerful condition of acute miliary tuber- culosis, and is a strong point of differential diagnosis be- tween the two diseases. It is important to remember that in rare cases this apathy is not seen. Delirium is seen in the majority of cases, varying in degree from confusion of ideas to acute mania ; it is, how- ever, less commonly seen than formerly, owing to im- proved therapeutics. During the first week there may occur a delirium which is apt to be acute and violent. This condition, however, is not common. The commonest form of delirium, which appears after the second week of the dis- ease, is of the low muttering variety, the patient lying quietly and talking incoherently. This form more usually appears only at night, although it may in severe cases last into the daytime as well. There may be a disposition of the patient to get out of bed, requiring careful watching. This delirium often alternates with periods of stupor which may become more profound, passing into semi-coma or even coma. In a few cases this form of delirium alternates with a more active and noisy variety. In many cases there appears no delirium at all, and the number of these cases seems to increase with the increasing applications of the hydropathic and antipyretic treatment of the disease. In all cases muscular prostration is noticeable from the first and increases with the disease. There may be mus- cular weakness of the bladder, causing retention of urine. The passage of urine should always be inquired about, as the patient may not speak of it because of the mental TYPIJOID FEVER. 29 apathy of the disease. There may be weakness of the sphincter ani with incontinence of feces. In bad cases there are twitchings and automatic move- ments of the muscles, especially of the hands. These symptoms, frequently spoken of as " subsultus tendinum" and "carpholog-ia," belong to the latter part of the disease. In rarer cases convulsive movements and muscular rigidity are seen in the first week of the disease, associated with the acute headache already alluded to. Hyperaesthesia of the skin, which is occasionally met with, may be extreme. Spleen. — The spleen is almost invariably increased in size, the enlargement being usually appreciable by the close of the first week. After the third week it diminishes in size. In rare cases the spleen may remain normal in size should there be depletion by severe diarrhoea or by hemor- rhage. The enlargement of the spleen is more accurately determined by palpation than by percussion, as the splenic area is apt to be obscured by tympanites. In the majority of cases the spleen is tender on palpation. Urine. — The urine shows during the first week the changes commonly seen in fever, being concentrated and depositing urates on cooling. During the course of the disease it is apt to contain a little albumin and casts from parenchyma- tous degeneration of the kidney, which degeneration, how- ever, is never very severe. Ehrlich describes a color reac- tion which he considers characteristic of typhoid fever. To employ the test two solutions are prepared, one a Yz per cent, solution of sodium nitrite, the other a Y per cent, solution of hydrochloric acid saturated with sulphanilic acid ; 40 parts of the first solution are mixed with i part of the second, and equal parts of this mixture and urine are thoroughly shaken in a test-tube. Upon the addition of ammonia a brownish-red reaction is observed, whereas in normal urine a brownish-yellow, without any reddish, tinge is observed. This reaction is not obtained after the third week of the disease ; but, while present during the earlier stages of the fever, it is not considered a pathognomonic 30 MANUAL OF THE PRACTICE OF MEDIC EXE. test, as it may be seen in other diseases, such as acute tuberculosis or measles. Eruption. — The eruption of typhoid fever is very charac- teristic. It consists of small round spots, about pin-head in size, of a rose-pink color which disappears on pres- sure, the spots being slightly elevated. In severe cases they may be hemorrhagic. They appear usually from the seventh to the twelfth day, although they may be seen as early as the third and as late as the twentieth day. They are present in typical relapses. They appear in successive crops, each crop lasting two or three days, but they do not appear after the third week. They usually are seen on the abdomen, but may be found on the chest, thighs, and back as well, and in rare cases may be more generally distributed. The eruption is usually scanty. There may be only two or three spots, and unless care is exercised they may be over- looked entirely. Blood. — The blood-serum of patients with typhoid fever possesses the property of causing arrest of motility and agglutination of the specific bacilli when added to pure culture. This is the so-called Widal reaction, and is of importance in diagnosis. The reaction is rarely absent, although it may be delayed until the third week or even until a relapse, and the reaction may be present months after the original attack. It is of importance when present, as it occurs in no other disease, but negative results in the early stages of typhoid mean nothing. Leucocytosis in typhoid fever is not marked. When a leucocytosis of twelve to fifteen thousand or over occurs, a complication is to be suspected. Course of the Disease. — IncKbation. — The period of incubation lasts a week or ten days, during which time there are apt to be indefinite symptoms — headache, lassitude, and slight digestive disturbances. These symptoms are neither characteristic nor well marked. The onset is usually gradual, so that it is hard to tell exactly the first appearance of the disease; in practice, however, the first noted advent of fever is considered the definite time of onset. TYPIIOfD J' EVER. 3 I During- the first week the temperature rises from day to day ; there are sore throat and probably epistaxis, dull headache with sleeplessness and restlessness, possibly a lit- tle wandering at night, and a slight apathetic condition dur- ing the day. The appetite is wholly lost. There may be nausea or vomiting ; the bowels may be either loose or con- fined. The pulse varies from 80 to lOO and is of fair force. By the end of the week the spleen is felt enlarged and the eruption appears on the abdomen. Patients differ consider- ably as to the severity of these symptoms and as to their reaction to them, some patients being much prostrated, while others even well advanced in the disease are around and out. These "walking cases" are more usually seen in hospital practice, and they greatly increase the mortality rate. These walking cases may not come under observation until hemorrhage or perforation has occurred. Occasionally the onset is more acute. {a) In some cases the disease begins with a chill and a rapid rise of tem- perature, {b) In other cases there appear acute nervous symptoms resembling those of meningitis — headache, pho- tophobia, rigidity of the neck, and muscular twitching, [c) In other cases the onset of the disease is accompanied by severe bronchitis, which renders the diagnosis between typhoid fever and acute tuberculosis one of great difficulty. [d) In other cases the disease may be ushered in by severe nausea and vomiting, while in rare cases the symptoms of acute nephritis, with smoky urine containing albumin and casts, are the first observed. During the second week the symptoms become aggravated; the temperature remains steadily high, and the headache gives way to mental apathy. There may be at night sleep- lessness and slight delirium, which in severe cases continues at intervals into the day. The pulse is a little more rapid and feeble. The eruption is more apparent. The lips and tongue are apt to be dry. Prostration becomes more and more marked. There may be diarrhoea or constipation. There is apt to be meteorism. At the close of the week the patient may die with severe nervous symptoms or from an early hemorrhage or from perforation, while very mild 32 MAXUAL OF THE PRACTICE OF MEDICIXE. cases may defcrvesce. These mild cases defervescing- at the close of the second week are frequently spoken of as " aborted typhoids," and constitute the set of cases in which the intestinal lesion does not progress to ulceration. During the third week the temperature remains high, but the morning remissions become more marked. The pulse is more rapid and feeble, with a tendency to heart failure in severe cases. Cerebral symptoms are prominent, the apathy alternating with muttering delirium. Emaciation and prostration are extreme. The tongue becomes dryish. There may be retention of urine and incontinence of feces. During the third week there is danger of perfora- tion, peritonitis, hemorrhage, and pulmonary complications. During the fourtJi iveek the temperature finally reaches the normal, the pulse becomes stronger, cerebral symptoms disappear, the tongue becomes moist and clean, and the patient complains only of hunger and weakness. In some cases the fourth week may show no improvement over the third, but the symptoms will continue into the fifth, sixth, or seventh week without mitigation. At the end of this time the symptoms may improve and the patient recover, or they may become more pronounced and lead to a fatal termina- tion. In other cases the temperature begins to fall in the fourth week, but does not quite come down to normal, the patient continuing with a slight irregular fever for from one to three weeks longer. In severe cases this fever is ac- companied by a continuance of general symptoms to some degree, the protraction of convalescence being due to unhealed intestinal ulcers. In others, although the fever continues in this way, the general symptoms rapidly dis- appear, and the patient improves daih'. These cases seem due to post-febrile anaemia or to nerve-exhaustion. Insidious Cases. — Besides this regular form we find cases of an irregular type. These cases are usually seen in epidemics of some size, and they run an insidious course. The pulse is but slightly affected, and the temperature is but slightly increased, varying between 99° and 100° F. In rare cases there is no fever. Headache, restlessness, sleep- lessness, and prostration are noticed. There may be diar- TYPHOID FEVER. 33 rhoea or constipation, but the enlargement of the spleen and the eruption are the only marked characteristic symptoms. These cases may not be sick enough to be in bed, or even in the house ; the course is about four weeks, and while the prognosis is generally good, such light cases are as liable as the severer forms to hemorrhage and perforation. Typhoid in CJiildren. — Typhoid fever in children differs from that in adults in that there is less danger of hemor- rhage or perforation, the pulse is more apt to be rapid and feeble, the cerebral symptoms are more prominent, and the temperature reaches its maximum earlier in the disease, is more remittent (hence often called " infantile remittent fever "), and often falls by crisis. The eruption is frequently slight or absent. Typhoid in the Aged. — Typhoid fever in the aged runs an insidious and frequently a fatal course. The temperature is not so high as in adults, but the cerebral symptoms and prostration are more marked. Hypostatic pneumonia, heart failure, and nephritis are frequent complications. Complications. — Perforation of the intestine, which is a most serious complication, occurs in 6 per cent, of cases. It is rare before the third week, although it has been noted on the eighth day. It may occur in convalescence. It is more apt to occur in severe cases frequently associated with hem- orrhage. It seems to be favored by meteorism, vomiting, and dietetic errors. The intestinal contents entering the peritoneal cavity, there results perforating peritonitis. In very severe perforations the first symptom is pain in the abdomen, followed by a lowering of the temperature with a subsequent rise, collapse, and death in a few hours, the condition of peritoneal septicaemia being produced. In less severe cases there is time for the production of a puru- lent peritonitis, which runs a course with typical symptoms, or, should the patient already be severely ill, the abdominal symptoms will be less marked, there may only be an increase of temperature, a more rapid and feeble pulse, and a hastened fatal termination. Diagnosis in such cases is difficult, espe- cially if there previously existed abdominal tenderness and tympanites. Peritonitis with the above symptoms is also 34 MAXi'AL OF THE PRACTICE OF MEDICIXE. .seen as the result of any of the other causes mentioned under the head oi hsio)is. Sucli a non-perforative peritonitis runs a longer course and nia)^ be recovered from. The other complications oS. t}-phoid are various, and only a brief mention of the most important can be made. The pharynx is often inflamed in the first week. Otitis media may occur at any time. Parotitis may occur in the third or the fourth week and may proceed to suppuration. The larynx maybe the seat of a catarrhal inflammation or of ulceration. There may be oedema of the glottis or peri- chondritis of the arytenoid cartilages, which may eventuate in necrosis of the cartilages. Bronchitis is common at any time of the disease. Broncho-pneumonia and hypostatic pneumonia are seen in severe cases. They add but few subjective symptoms, being marked by the regular symptoms of the disease and by the apathetic condition of the patient. The temperature is apt to be raised, the pulse becomes weaker and quicker, and the physical signs are present. Lobar pneumonia, gangrene of the lung, and pleurisy with effusion are occasionally seen. Thrombosis of the femoral vein is frequently seen, accom- panied by pain and oedema and by the cord-like feeling of the vein. Catarrhal or croupous enteritis or colitis may occur in severe degree. Albumin and casts are usually present in the urine in small amounts, from a mild form of acute degeneration of the kidney. Less frequently there is an acute exudative nephritis with diminution in the amount of urine and con- siderable amount of albumin and casts. In rare cases the urine may be suppressed. When the kidney is involved in this way there are not apt to be ura;mic symptoms, but the temperature and pulse are affected for the worse, and the patient is apt to do badly. There may be pyelitis, with the passage of mucus and pus from the kidney ; in the urine either Eberth's bacillus or the colon bacillus may be found. TYPHOID /■•/■: TEA'. 35 Subcutaneous or subperiosteal abscesses may develop, in the latter case frequently associated with caries or necrosis of the bone. In these abscesses Eberth's bacilli are found sometimes with the colon bacilli. These periosteal ab- scesses may appear during convalescence, and are very slow in healing". Malarial infection may complicate typhoid fever at any time. During the course of the fever the added infection gives a remittent character to the temperature-curve, while if the malarial infection show itself during convalescence, the temperature is more characteristic, being markedly re- mittent or even intermittent. Examination of the blood shows the presence of the malarial organism. Relapses and Recrudescences. — Relapses are seen in from 3 to 1 8 per cent, of the cases, varying in the different epidemics. A relapse is a second attack of typhoid with a repetition of the symptoms of the first attack, and is pro- duced by a reinfection of the intestine from sloughs derived from some part above. The intermission between the original attack and the beginning of the relapse may extend to twenty-five days, the usual period being from five to eight days. It is not necessary to have an intervening period without high temperature, as the relapse may occur in the fourth week, before the temperature comes down to normal. There may be only one relapse or there may be several, becoming progressively milder and occurring at longer intervals. The symptoms appear sooner and are of shorter duration than those of the primary attack. The temperature attains its maximum on the third to the fifth day ; the eruption is scanty, and as a rule appears on the third, fourth, or fifth day. The other symptoms are much less severe than those of the primary attack. The duration of the relapse is usually from ten to fourteen days, although it may last as long as thirty-nine days. The conditions predisposing to relapse are not known, although it seems as if constipation were a predisposing factor. Relapses are to be distinguished from the so-called 36 M.-IXrAL OF THE PRACTICE OF MEDICIXE. " recrudescences," or temporary rises of temperature, of convalescence. These rises usually occur from dietetic errors or from over-exertion. We have a rise of tempera- ture occurring^ suddenly and remaining for from one to five days without the enlargement of the spleen or the eruption. These recrudescences do not add anj' element of danger : they only retard convalescence by just so much. Plate 2, Fig, I, shows the temperature of recrudescence alone, and Plate 3 shows the temperature of recrudescence and relapse. Convalescence is always slow and tedious, usually re- quiring months before the patient is in robust health again. Convalescence may be interrupted in several ways. There may be an irregular fever which will last for several weeks. There may be perforation or hemorrhage or peritonitis during convalescence. The mind may remain feeble for days or weeks. Some patients can hardly be said to con- valesce at all, but remain feeble, emaciated, and anaemic, and die exhausted, the autopsy usually revealing extensive cicatrices. There may be peripheral neuritis with paralysis of groups of muscles. Gastro-intestinal symptoms may per- sist — vomiting, diarrhcea, or dysentery. The hair usually falls out during convalescence, but grows again. The prognosis varies in hospital and private practice and in various epidemics. The mortality in mild epidemics is from 5 to 15 per cent. ; in hospital practice, from 15 to 25 per cent. In the German military hospitals, when the patients are young and vigorous and are treated early, the mortality is from i to 8 per cent. A guarded prognosis must always be given, as mild cases may turn out badly and serious cases may recover. The liability to perforation, peritonitis, or hemorrhage lends unknown factors to each case. As a rule, patients with high and continuous temper- ature, or with an early involvement of nervous centres, as shown by muttering delirium with muscular tremors or with excessive meteorism and diarrhoea, are apt to do badly. The earlier a patient is treated and sent to bed, the better the prognosis. Fat, elderly people and those addicted to TYPHOID FF.VER. 3/ alcohol stand the disease badly. Perforation and peritonitis are nearly uniformly fatal. Recovery from a relapse is to be expected, as the symptoms are rarely severe, and per- foration, hemorrhage, and peritonitis are infrequent. Treatment. — P^'ophy lactic. — Typhoid fever is largely a preventable disease, and the prophylactic treatment consists in destroying the germ where it is known to exist, and in preventing its admission to the human body. To accom- plish the first object the following rules should be rigor- ously obeyed, and be persisted in until convalescence is thoroughly established : The bed-linen and the clothes of the patient must be boiled for at least half an hour after being soaked in a strong antiseptic solution. The following are types of the disin- fectant solution to be employed : I^. Bichloride of mercury, 3ij ; Potassium permanganate, 3ij ; Water, i gallon. — M. I^. Chloride of lime (best quality), siv; Water, i gallon. — M. Those washing or handling soiled bed-linen must cleanse their hands frequently in one of these solutions, especially before eating. The intestinal discharges, urine, and vomited matters must be mixed thoroughly with sufficient disinfecting fluid for at least half an hour before being emptied from the vessel. From time to time disinfecting fluid must be poured down water-closets or privy-vaults. The discharges must not be emptied into any privy-vault that is near the water-supply. The nates of the patient must be cleansed and disinfected thoroughly after each defecation. To prevent the admission of the germ into the body the drainage, the sewage, and the water-supply must be sani- tary. The source of every epidemic should be traced in the most painstaking manner, and means should be taken to avert future infection. During an epidemic drinking-water and milk should be boiled, and care should be exercised 38 MAXC.4L OF THE PRACTICE OF MEDICINE. that ice taken from polluted water is not used. With perfect disinfection of the dejecta and with perfect drainage not allowing pollution of water-supplies, typhoid fever should never occur. General JManagevieiit. — The patient should be put to bed as early as possible, and be kept there until convalescence has been established for one week. The use of the bed-pan and urinal should be insisted on. The room should be large, airy, and moderately cool. Care should be taken to prevent bed-sores by keeping the sheets smooth and clean and by washing the patient's back morning and night with alcohol and tannic acid, and after careful drying dusting it with starch-powder or with bismuth. The mouth and the teeth should be kept scrupulously clean, to avoid infection of the middle ear and of the parotid gland. Moreover, by cleansing the mouth the liability to pneumonia and stomach fermentation is much lessened. For this purpose listerine and water (i : 8) or boracic-acid solutions (i : 24) are of ser- vice. The services of a good nurse should be obtained, as nursing is one of the most important factors in the treat- ment of the case. In severe cases two nurses are necessary. The diet should be fluid and easily digestible, milk being the ideal food. If given properly, there are but very few patients who cannot take it. From three to four pints should be given in the twenty-four hours, in divided quanti- ties at short intervals. As a practical rule, a glassful every two hours in the day and when awake at night will guide its administration in the majority of cases. Personal attention must be given to the feeding of the patient to know exactly how much is taken and how well it is borne. In case pure milk is not well borne, as shown by nausea or vomiting, or by the finding of undigested curds in the stools, the milk should be reduced in quantity or be diluted with lime-water or any of the aerated waters, or should be peptonized. In case these measures fail, the patient may be fed with koumiss or with matzoon. In the rare cases in which milk cannot be taken at all the reliable preparations of beef peptonoids, beef tea, white of tgg with water, Nestle's food, etc. may be given in its stead, although they are to be avoided if possible. TYrilOID FEVER. 39 Alcohol should not be given as a routine treatment, but only when especial indications for it arise. Medical Treatment. — As there is no specific drug capable of exerting a direct cure for the disease, the treatment is mainly an expectant one, controlling those symptoms that exert a baneful effect on the patient, threaten his recovery, and cause him discomfort. The only internal treatment that seems to be of any service is the use of intestinal antiseptics for disinfecting the alimentary tract, to prevent fermentation and tympanites, and to guard, if possible, against auto-infec- tion and relapses. The drugs used are salol, ^-naphthol, bismuth salicylate, and creosote, and high enemata of weak tannic-acid solutions. These measures seem in some cases to be of service. Except for these, the treatment is entirely symptomatic. Fever. — In the treatment of the fever there exists a diver- sity of opinion, some recommending its reduction as soon as a moderate point is reached (102.5° F.), others preferring the temperature to run its own course unless it reaches too high a degree (105° to 106° F.). It is certain that the mor- tality of typhoid has been lessened materially by antipyretic treatment, and that whereas a few patients seem to be no worse for their fever, in the great majority of cases the re- duction of the fever is accompanied by an improvement of all the symptoms. It seems, then, that the best treatment is to keep the temperature reduced, provided this can be done without harm or risk to the patient. The best method of doing this is by the use of hydrotherapy, first insisted on by Brand, but modified to suit individual cases, no strict rule being rigorously applied. Brand's original method consists in the immersion of the patient in a bath of 60° F. for fifteen minutes, repeated every three hours so long as the temperature is 102.2° F. by the rectum. During the bath cold water is applied to the head and the surface of the body is briskly rubbed. After the bath the patient is dried, wrapped in blankets, and given a hot alcoholic drink if chilliness is apparent. No internal antipyretics are employed. Under the Brand treatment it is claimed that not onlv is 40 MAXCAL OF THE PRACTICE OF MEDICINE. the temperature reduced, but that there is also a tonic effect produced on the circulatory and nervous centres, the intellect becomes clearer, the stupor less marked, muscular twitchings disappear, and insomnia is lessened, the patient frequently falling into a refreshing sleep. Complications are rendered more infrequent, and, what is most important, the mortality is reduced to a minimum. Brand's statistics show but twelve deaths in 1223 cases, a mortality of but i per cent. Not a patient died who came under treatment prior to the fifth day. These statistics, however, arc taken from German militar}- hospitals, where the patients are young, robust, and are treated early. Ordinarily, under this treatment the mortality is about 7 per cent. No effect is claimed in reducing the duration of the disease nor in less- ening the liabilty to relapses. The contraindications are intestinal hemorrhage, perforation or danger of perforation, and peritonitis. Bronchitis and pneumonia do not prevent the treatment. While this extreme method may be applicable in military hospitals and in robust, insensitive patients, its rigorous employment in all cases has decided disadvantages and requires modification. As a general rule, then, the modi- fied bath must be employed, the temperature being 80° to 90° F. at the commencement and being gradually reduced 10° F. by the addition of cold water. This bath should be given whenever the temperature is 102.5° F. or over, provided it be not more frequent than every three hours. Friction of the body and affusion of the head should be employed in all cases. For nervous, sensitive patients who are in mortal dread of such a modified bath the wet pack may be employed. The bedding being protected by a rubber blanket, the patient is wrapped in wet sheets closely applied by brisk- friction. From time to time the patient is sprinkled with cool water. The most simple method of hydrotherapy is the sponging of the body with water or with water and alcohol. If done for ten or fifteen minutes this will cause a slight reduction in temperature, but the method is too inefficient to be of TV/' //Off) FEVER. 41 much benefit in severe cases. The slush bath may be used, the bed being protected by a rubber sheet raised at the sides, so as to form a trough, in which the patient hes. If skilfully done, five gallons of water may be used, and the results seem as radical as the bath, without many of its disadvantages. The use of internal antipyretics is attended by many dis- advantages, and is less frequently employed now than for- merly. While the temperature may be reduced by these drugs, there is also a depression of the nervous and circula- tory centres, so that stimulants may be required to over- come the effects of the drugs. The actual mortality seems to be slightly increased by their use. The drugs most fre- quently employed for this purpose are antipyrine (gr. x), phenacetine (gr. v), and antifebrine (gr. ij). They were formerly given in much larger doses than at present. Qui- nine is now given, not to reduce temperature, but for its tonic effect. Whatever antipyretic is used should be given in small doses repeated in two hours if necessary, and not too great a fall of temperature should be produced, the re- duction of a degree or a degree and a half being usually sufficient. The pulse should be watched carefully, with special regard to its weakness rather than its rapidity. Alcohol is the best stimulant, in the form of whiskey or champagne, and when indicated must be given freely until its effect is noticed, even if 8 to 12 ounces of whiskey be given in the twenty-four hours. Strychnine may be combined with the alcohol, and is of service. Digitalis may also be employed. In cases where there is a rapid feeble pulse with marked septic symptoms, large rectal enemata and of intestinal disinfect- ants often are of benefit. Vomiting is best treated by regulating the diet. Bismuth and oxalate of cerium are occasionally serviceable. If vom- iting seems to be due to the tympanites, the latter condition should be treated. In severe cases rectal feeding may have to be resorted to. For the diarrlicea opium by the mouth or the rectum, with the addition of the ordinary astringent drugs, is to be 42 MAXi'AL OF TN£ rRACTICE OF MEDICINE. given. The stools should be examined to sec that the diarrhoea is not caused by undigested curds. Constipation is to be treated in the first week by saline laxatives or by castor oil. Later in the disease enemata are preferable, so that the bowel is emptied every second day. For the tympanites turpentine stupes or 5-minim doses of turpentine in capsule constitute the best treatment. Intes- tinal antiseptics, as salol, ^-naphthol, or creosote, may be of service, while the insertion of a soft rectal tube may afford relief. For JicniorrJiagcs the patient should be kept absolutely quiet, opium in full doses being given. The use of internal astringents does not seem to do good. Applications of heat to the abdomen may be employed. Ice should not be used, as it increases intestinal peristalsis. The diet should be restricted, although the patient may be given acid drinks and cracked ice. In case of severe hemorrhage external warmth and stimulants should be used. Subcutaneous in- jections of warm sterilized saline solutions may be given. The treatment of perforation is that, in the first place, of collapse — by warmth to the body and free stimulation, while opium should be given in full doses. Should the perforation occur in a robust person or during convalescence, the question of laparotomy and closure of the perforation should be considered. Peritonitis is to be treated by the cold abdominal coil and by opium in full doses. In selected cases laparotomy and drainage may be resorted to. The nervous symptoms are best controlled by the hydro- pathic treatment, which, acting as a tonic on the nervous centres, reduces the restlessness, allays the delirium, and promotes sleep. Where this treatment can be employed drug sedatives are seldom needed. Where drugs are needed phenacetine (gr. v, q. 3 h.) will relieve the headache and restlessness, sulphonal (gr. x-xx) or chloralamide (gr. x-xv) will promote sleep. In severer cases opium may be neces- sary. Complications are to be treated on general principles. Treatment of convalescence is trying to physician and to TVrilUS FEVER. 43 patient alike. The greatest care should be exercised in the management of the diet, as the patients are ravenously hungry and clamor for food. The patient should be kept in bed for five days after the temperature is normal, and on a fluid diet — not necessarily, however, on milk. No solid food should be given for at least ten days. At the end of this time one solid meal may be given in the middle of the day, of chop or mutton with a baked potato, and afterward a gradual change to three meals a day may be allowed. There are cases where the evening temperature remains irregularly high. These cases are benefited by quinine and solid food. During convalescence attention should be given to the digestion and the bowels, and tonics should be administered. A change of air is to be recommended, and patients should not be allowed to return too soon to business and daily cares. The results of serum-therapy in typhoid fever have not seemed to justify its continuance as a means of treatment. The preventive inoculations of typhoid serum a-re now being practised on a large scale in the English army, but the experiment is of too recent a date to enable any conclusions to be drawn as to its efficacy. The recrudescences are to be treated by a milk diet and rest in bed while the fever remains high. The treatment of a relapse does not differ from that of the original attack. TYPHUS FEVER. Definition and Synonyms. — Typhus fever is an acute contagious disease with an acute onset, a characteristic eruption, and a febrile movement of about two weeks' dura- tion. Synonyms: Cerebral typhus ; Exanthematic typhus; Spotted, Camp, Jail, or Ship fever. Etiology. — Typhus fever is endemic in England, Ireland, and Russia, and to a less extent in Poland, Galicia, and cer- tain parts of Southeast Europe. A i^w cases occur every year in New York and Philadelphia. From time to time the disease occurs in other places in epidemics. These epi- demics have usually followed wars or famines, the disease being regularly favored by the overcrowding of people in jails, houses, or camps, by poor hygiene, by starvation, and 44 MAXL'AL OF THE PRACTICE OF MEDICINE. by filth. It never arises spontaneously, but al\va)-s from soniQ previous case. It is one of the most highly conta- gious diseases known, being equally virulent throughout its course. The poison of the disease has not as yet been demonstrated, although it is known to be given off from the bodies of the sick and the dead, to be carried in the air, and to be retained in bedding, clothes, carpets, etc. for a considerable time, so that the poison is conveyed not only from person to person, but also by clothing and bed-rooms. But a very few persons are exempt if they be sufficiently exposed, and the more prolonged and concentrated the exposure the more certainly will they be attacked. One attack usually procures immunity. While no age is exempt, the majority of cases occur between the fifteenth and thir- tieth years. Pathology. — The eruption is the only characteristic lesion. After death there may be found a number of mor- bid conditions common to any of the severe infectious diseases. Symptoms. — The period of incnbation is about twelve days, although cases may develop as early as twelve hours or as late as three weeks after exposure. The onset is abrupt, although in some cases it is preceded for a few days by malaise and frontal headache. The initial symptoms are a chill, a rise of temperature, headache, and prostration. The chill, which is usually sharp and severe, may be repeated. The temperature rises suddenly, attaining its maximum from the third to the fifth day, reaching 103° F. in mild and 105° F. in severe cases. During the first week the tempera- ture remains steadily continuous, becoming somewhat higher in the second week, but with morning remissions. In bad cases there may be hyperpyrexia. From the twelfth to the fourteenth day comes the crisis, the temperature falling rapidly — sometimes a drop of 4° to 5° F. in a i^^ hours, although usually it takes twenty-four to forty-eight hours before the temperature reaches the normal ; this fall of temperature is accompanied by an improvement of all the ! CD m u. CD -J c CD CD o M O O o M O H o O 1 o •J' 2 ' 3 ■0 -'-^-:-l. 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It may be so severe and sudden that the patient will fall in the street without previous warning. Nausea and vomiting are commonly present, and may be distressing. The tongue is heavily coated in the first week, later having a tendency to become dry and brown, with sordes on the teeth and gums. The bowels are usually con- stipated, although there may be diarrhoea. The pulse is rapid and full, being between lOO and 120; it becomes more rapid and feeble during the second week. Marked slowness of the pulse may be observed at any time of the disease and may continue into convalescence. A drop in the pulse without improvement in other symptoms is not a good sign. The urine usually shows the presence of albumin and casts in moderate amounts from an acute degeneration of the kidney. More rarely there are present the urinary changes of acute exudative nephritis. Early in the disease there is a look about the patient which is often of diagnostic value. The face assumes a dusky flush, the conjunctivae are injected, and the expres- sion is dull and vacant, the whole appearance suggesting marked intoxication. The pupils are contracted. The characteristic eruption appears from the third to the fifth day, although it may be seen as early as the second and as late as the seventh day. It consists of small, irreg- ularly rounded spots, of a dirty-pink color, appearing first on the abdomen and chest, and becoming more general, although rarely seen on the face. It appears in one crop, and is all out in from two to five days, lasting from seven to ten days and then slowly fading. It is usually abundant, though in some cases it may be scanty. At first the spots are slightly elevated and disappear on pressure, but after 46 MAXi'AL OF THE PRACTICE OF MEDICINE. several days they become petechial and more perma- nent, remaining after pressure. They have no well-defined margin. In children the eruption resembles that of measles, and from the mottled appearance given by it to the skin the eruption has been termed the Diulbeny rash. In some cases there is added a diffused, deep mottling of the skin with large purplish blotches ; in others there are hemor- rhagic spots or a general erythema. These manifestations are not characteristic and are inconstant. Cerebral symptoms are marked and appear early. The headache, so marked at the onset, usually becomes masked by other nervous s\'mptoms by the end of the first week. Delirium is a fairly constant symptom. In very severe cases it may come on in the first twenty-four hours of the disease in the form of an acute mania. In less severe cases it is not seen until the end of the first week. It may then be only a mild delirium at night, or it may be more decided, persisting throughout the day. This latter form is often associated with delusions which at any time may render the patient violent. In severe cases, during the second week there may be observed alternately with the delirium a form of deep stupor known as "coma vigil," in which the eyes are wide open but the patient is unconscious. Deafness may appear in the second week without assign- able cause, but from it the patient usually recovers. If the case is to end fatally, the temperature rises, often to io6° or io8° F. before death, the delirium and stupor be- come more decided, there may be retention of urine and incontinence of feces, the pulse becomes more rapid and feeble, and death occurs from exhaustion from the toxaemia. Should the patient survive until the third week, death usu- ally results from a complicating pneumonia. If the case is to recover, on about the fourteenth day there is a decided fall in the temperature, the patient frequently falling into a refreshing sleep from which he awakes weak but convalescent. In some cases this crisis occurs as early as the seventh day, or at this time there may be a decided remission in the temperature, practically an abortive crisis. TYPHUS J' EVER. 47 which is to be considered a favorable omen. In other cases the crisis may be deferred as late as the twenty-first day. In some epidemics light cases are seen, running a mild course, with a temperature usually under 102° F., with but moderate cerebral symptoms. The crisis usually occurs between the seventh and the twelfth day. Occasionally there are observed in severe epidemics malignant cases in which the patient is overwhelmed by the virulence of the disease. There are rapidly developed a sudden tempera- ture, usually high, progressive heart failure, stupor, and coma, and death may result in from twelve to twenty-four hours or within two or three days. In these cases no regular eruption is seen, but ecchymoses and hemorrhagic spots are irregularly developed. Complications. — There may be broncho-pneumonia, which in rare cases is complicated by gangrene of the lung. Gangrene of the extremities or cancrum oris in children has been observed. Meningitis is rare and is always fatal. Abscesses in the skin and the joints may occur, and suppurative parotitis is not uncommon. There may be hemorrhages into the skin or from any of the mucous membranes accompanying serious cases. Throm- bosis of large veins or of cerebral sinuses may occur. Convalescence is usually rapid at first, although it is months before it is complete. There are no relapses. The patient may be left dull and feeble-minded, from which con- dition the recovery is gradual. A few patients develop acute mania in convalescence, but the ultimate prognosis is gen- erally good. Paralysis from post-febrile neuritis is not uncommon. Prognosis. — The mortality is from 10 to 20 per cent., varying with the nature of the epidemic, the previous con- dition, and the age of the patient. The disease is rarely fatal in young subjects, but is very serious in those past adult life. Complicating inflammations alter the prognosis according to their nature. Treatment. — The patient should be isolated thoroughly from the start. To lessen the danger of contagion to nurse and to physician, the windows must be opened freely to 48 MANUAL OF THE PRACTICE OF MEDICINE. admit fresh air. If possible, the patient should occupy two rooms, one by day and one by night, the freest ventilation thus being afforded. In epidemics the cases are best treated in tents, the patients being protected in winter by extra bedding. This fresh-air treatment is not only a prophylactic measure, but seems also to lessen the actual mortality. Windows should be protected by bars in case mania dev^elops. There is no specific treatment for the disease. Formerly mineral acids were so considered, but they are given now only because they afford a pleasant acidulated drink and do no harm. The treatment, then, is entirely symptomatic. The tem- perature is best treated by hydrotherapy, as in typhoid fever, the bath being given as soon as the temperature reaches 103° F. Internal antipyretics should be avoided if possible, because of their depressing effect. Alcohol in some form is demanded in almost all cases, and it may be given in large doses until a good effect is observed on the heart's action : 10 to 20 ounces of whiskey may be required in the twenty-four hours. The delirium and headache should be treated by sedatives combined with hydrotherapy. Other symptoms should be treated on general principles. RELAPSING FEVER. Definition and Synonyms. — Relapsing fever is an acute infectious, contagious disease due to a spirillum, and cha- racterized by a febrile paroxysm of about six days' duration, followed usually by one or more similar recurrences at reg- ular intervals. Synonyms: Famine fever; Spirillum fever ; Relapsing typhus. Etiology. — The disease is a rare one, occurring in epi- demics which last but a short time and then die out, leaving, except in very rare exceptions, no endemic cases. Epi- demics were seen in Philadelphia in 1844, and in New York and Philadelphia in 1847 and 1869. The last epidemic of any importance was in Russia in 1886. Epidemics have frequently been associated with those of typhus fever, the spread of both diseases being favored by td m CD CD CD -4 00 o o cgooooo oo CD o M L\2 W rfi Oi Q oooooo oo M o o So to • Vt- ■~*a. (-• - . '"""— — — T-T ■ J / bO N*^ ''"^ ^ ?' ■ ■ ^ M ^ / / rfi v >>-- X c;i s, " *^-^ 05 ^ -^^^ >• »• • •■• ,,*.-'-^ r • • • H . ■"■ ^ «^ ^ ^ _— ■"^ 00 n V ^ n ^-^ ' CO a> ■^ "^ ^ _,,.»»■ •^ o ..!> t w l i^. rS y •-^ (T* ■«^^ to t -1 1 ,— , -d ^ CO frt • ^•^ ♦•~- sis ^ •^^ 1-1 •n, ^•*^ CJl ^""-^ ■"^p- f '• y M "> '^•n >s » • • - • era P' 2, L- ■^-^ .,.|.... M "-■^ ■ ^, •V t!S ^^ >•• • "C -rTT. 00 ^ •d CO i 1 S o r^ -■^ l(^ \ _^ ■•c ^ Oi "A" S o V a \ \ 1, J ♦ / -0 <. ■ ■ ■ 1 o ^ , — .... „ 00 =i ^v^ 13 % .... |. . .. ^ J CD c ^^ '^ rH O -1 ■>._. ^ , > o k-^ s^ 3 > .^ ■0 o -^ X ••■<- -<^7 W V tr ^^i-:' r^ ^ s. ^ > V^ / / CJi / * a. S_ en p' » 2 a, .y ^, V. . . > .y < \ > / *, 00 \ » 1 ^ CO ! 1 1 1 Ci 3 CD J 00 C i ; 3 C o 2 ^ o -1 h o O 1 SMALL- POX. 53 ache and backache are common to the onset of all severe infections, there is no disease in which they are so marked as in small-pox, and their occurrence should excite appre- hension, especially during an epidemic or occurring in an unprotected patient who has been exposed to the disease. Vomiting is usually severe and distressing, and prostra- tion is an early symptom, the patient taking to his bed at the very onset. The pulse is rapid and full, increasing in rapidity with the rise of the fever, and becoming weak in proportion to the severity of the disease. Nervous symp- toms belong to the severer cases. There may be active delirium, especially in patients with high fever. Convul- sions in place of the chill may initiate the disease in chil- dren. There are usually considerable restlessness and gen- eral apprehension. The eyes are bright ; the skin is hot and dry ; the spleen is enlarged, and albumin and casts may be found in the urine in small amount. There is no characteristic eruption in the stage of inva- sion, although an initial rash may be observed. This rash appears with more frequency in some epidemics than in others, as a rule, however, appearing in from lO to 15 per cent, of all cases. It consists of an erythema which may be diffuse or macular, closely resembling the eruption either of scarlet fever or of measles, although it differs from both in its localization. It is often associated with small hemor- rhagic spots. This initial erythema occurs on the second day, and it appears usuall}^ on the hypogastrium, the inner surfaces of the thighs and opposing surfaces of the side of the chest, and the inner side of the arms — regions which are usually exempt from the regular eruption. This early rash lasts but a short time and then fades away. The stage of invasion lasts regularly three days, during which time the symptoms continue, the temperature usually becoming somewhat higher, so that it may reach 105° to 107° F. {b) Stage of Eniption. — The eruption is peculiar in that it passes through successive stages in development, becom- ing in turn macules, papules, vesicles, and pustules. Begin- ning on the fourth day of the disease, there appear small 54 MAXr.lI. OF THE PRACTICE OF MEDICIXE. round, slightly raised spots, involving first the face, the edge of the- hairy scalp, and the backs of the wrists, and extending within twenty-four hours over the trunk, the arms, and, last of all, the legs. On the second day of the eruption the spots become papules which are hard to the feel, suggesting bird- shot imbedded in the skin. By the third day the papules change to vesicles which have each a depressed umbilicated centre without any tendency to rupture. Should these vesicles be pricked, they do not completely discharge their contents. Vesiculation is complete on the sixth day ; the vesicles then become pustular. The central umbilication usually disappears, so that there result pustules each with a rounded summit surrounded by a zone or areola of inflamed and swollen skin which burns and itches and causes the feeling of distressing tension. The face is now strikingly swollen and disfigured ; the eyelids are closed by oedema. In severe cases the skin between the pustules becomes diffusely inflamed, adding to the distress and dis- figurement of the patient. The pustules are completely developed on the eighth or ninth day of the eruption, and after continuing for about three days begin to dry up and to form scabs and crusts w^iich, falling off, leave pigmented spots that persist for months. If the ctiks vera has been involved by the pustules, permanent depressed white cica- trices must necessarily result. The desiccation requires a week or ten days for its completion, and it is attended by much itching. There are usually similar eruptions in various mucous membranes, especially those of the mouth, pharynx, nasal cavities, larynx, and trachea, and less frequently of the upper portion of the oesophagus, the bronchi, the conjunc- tiva, the vagina, and the rectum. When the eruption appears on mucous membranes, it is modified by the heat, moisture, and friction of the parts, and, instead of pustules being formed, the vesicles become macerated and form ulcers, more or less deep, which may become confluent. As the eruption appears the temperature suddenly falls — not, however, quite to the normal, but still remaining a little high. The constitutional symptoms remit in their SMALL- POX. 55 severity, especially the headache and backache, so that the patient feels quite comfortable, and often is able to leave the house and to apply for treatment at a hospital or a dis- pensary. The amelioration of the symptoms continues until the pustular stage is reached, when there is developed a rise of temperature to ioi° to 105° F. with a return of all the symptoms. This fever, which is termed the secondary or suppurative fever, is often remittent. During this stage there may be active delirium, so that the patient may do himself or his attendants bodily injury. The distress during this period from the itching, tension, and burning of the skin is almost unbearable. The patient is disfigured and often is hardly recognizable. The period of secondary fever lasts for from three to eight days, and then as desiccation is established the temperature gradually falls and convalescence is begun. The hair frequently falls out, and in some cases does not grow again. 2. TJie Confluent Form. — Here the typical symptoms are present in the most complete development. The stage of invasion is short, lasting but two days as a rule. It is also severe, the fever being high, with pronounced headache and frequently with active delirium. There is no period of cessation with the appearance of the eruption, although the symptoms may remit slightly in their severity. The eruption is profuse, the pustules becoming confluent, so that whole areas, especially of the face and hands, are converted into suppurating blebs. The patient is unrecog- nizable, the distress is extreme, and the stench is penetrating and intense. The mucous membranes are usually extensively involved. The suppurative fever is apt to run high and is attended by symptoms of a septic character — irregular chills followed by exacerbations of fever, rapid and feeble pulse, diarrhoea, and extreme prostration with a low muttering delirium which at times may assume an active form. In this septic condi- tion the patient may die. Desiccation continues into the 56 MAXi'AL OF THE PRACTICE OF MEDICINE. third and fourth weeks, during which time the symptoms of the secondary fever persist with diminishing intensity. 3. The Hcmorrliagii Form. — This form is characterized by hemorrhages occurring in the pustules and the skin and from any of the free mucous surfaces — from the nose, mouth, lungs, stomach, intestines, kidneys, or uterus. This form of small-pox ma\' occur in weak, debilitated subjects, or the hemorrhages may complicate the severer forms of the disease. 4. TJie Malig)iant Form. — The invasion in malignant cases is characterized by extreme prostration and enfeebled heart- action, the initial rise of temperature not being high. In from eighteen to thirty-six hours there appears an erythema (resembling scarlet fever with large hemorrhagic blotches) which occurs extensively over the body, especially the abdomen and thighs. There are frequently hemorrhages from the mucous membranes. The regular eruption appears somewhat later, but does not run a perfectly typical course, being represented in some cases only by a few vesicles. In some cases death results in a few hours, before any eruption occurs, the patient being overwhelmed by the virulence of the disease. In other cases death does not occur until from the third to the seventh day. 5. Vanoloid. — This disease is small-pox occurring in a modified form in a person who is but partially protected by vaccination or by a previous attack. According to the extent of the protection, varioloid occurs in all grades of severity, so that the severer grades merge into true, unmodified variola, while in the lesser grades the patient may not seem to be sick at all. No matter how trifling the attack may be, it is true variola, and is capable of causing the disease in others in even the most malignant forms. Generally varioloid runs a milder course and one of shorter duration than small-pox. The stage of invasion lasts for two or three days. There may be a chill, with moderate fever, headache, pains in the back and bones, and vomiting, while in very light cases these symptoms may not be severe SMALL- POX. 57 enough to prevent the patient from bein^^ at work and out of doors. The eruption is that of variola, but it is less abundant, the pustules do not reach the same size nor penetrate so deeply, and the areola of inflamed skin is frequently absent. Many of the vesicles dry up and are not converted into pus- tules. With the appearance of the eruption the fever falls to normal and the other symptoms of the invasion disap- pear and frequently do not return. In more severe cases the symptoms of the secondary fever are slight and last but a day or so, so that there is a striking lack of proportion between the appearance of the patient and the degree of his constitutional symptoms. Desiccation begins from the fifth to the seventh day, and the resulting cicatrices are small or are absent. Complications and Sequelae of small-pox are numerous, and are due not only to the severe infectious nature of the disease, but also to the suppurative foci. There may be laryngitis, oedema of the glottis, or necrosis of the carti- lages, resulting in stenosis, necessitating intubation or tracheotomy. Broncho-pneumonia is a common complication, especially in the severer cases. There may be pleurisy. Nephritis is rare, although the urine usually contains a small amount of albumin. There may be orchitis. During the suppurative stage there may be developed septicaemia or pyaemia or arthritis. In rare cases a disseminated myelitis has been observed. Convalescence may be interrupted by boils, by gangrene of the skin, or by erysipelas. Ulceration of the cornea is but rarely seen. During convalescence there may be a post-febrile insanity or paralyses from peripheral neuritis. Prognosis. — The prognosis depends upon the degree of protection afforded the patient by vaccination. Varioloid is very seldom fatal in those protected by vaccination, while in those totally unprotected the mortality ranges from 30 to 40 per cent. The prognosis depends also upon the severity of the attack, the hemorrhagic and malignant forms being almost certainly fatal, the confluent form being very 58 MAXi'AL OF THE PRACTICE OF MEDICI.XE. dangerous, while the discrete form affords a large percent- age of recoveries. It depends also upon the age and the condition of the patient, being most fatal in children and old people, in the debilitated, and in drunkards. The prognosis is affected also by the presence of compli- cations. Treatment. — If vaccination and revaccination could be performed thoroughly, variola would become extinct. After exposure to variola, revaccination should be resorted to, and it is probable that vaccination even in the earliest stages of the disease itself, if done before the fourth day, greatly mod- ifies its severity. Patients with variola should properly be treated in con- tagious hospitals, as few private houses afford sufficient means for thorough isolation and disinfection. When this cannot be done, quarantine should be conducted on the •strictest principles, and should be continued until the skin and the hair are absolutely free from crusts and scales. All articles that come in contact with the patient should be sterilized or be destroyed. The room should be kept moderately cool and well ven- tilated. Patients are rendered worse by being kept too hot. The occurrence of mania should be anticipated by careful watching and by having the windows barred. The diet should be of milk. The fever is best treated on hydropathic principles ; the headache and backache are to be combated by opium or phenacetine. Sleep may be procured by sulphonal, chloral- amide, or codeia. The patient should, if possible, be prevented from scratch- ing. Great care should be exercised in the strictest cleans- ing of the eyes and in preventing them from being infected by their being rubbed with pus-stained hands. P'or the cleansing a saturated solution of boric acid is to be pre- ferred. As the extent of the pitting depends entirely upon the depth of the pustules, there is no method of treatment known by which pitting can be prevented. It seems, how- ever, that the intensity of the pustules is modified by ex- VACCINATION. 59 eluding the light and by keeping them covered with strips of gauze constantly wet with weak solutions of bichloride or of carbolic acid. This application also relieves the pain and itching. Isolated pustules may be painted twice a day with lo per cent, carbolic acid in alcohol. When crusts form they are to be softened by applications of lard or of vaseline to prevent them from floating in the air and thus carrying the infection. The other symptoms and compli- cations should be treated on general principles. VACCINIA; VACCINATION. Vaccination was first performed in 1798 by Jenner, and its value is now universally acknowledged. The vaccine may be procured by means of the scabs of patients vacci- nated (humanized virus), or be taken direct from the calf (bovine virus). If the humanized virus be used, it is of the utmost importance that it be taken from a healthy subject free from every trace of syphilitic and tubercular taint. As a rule, bovine virus obtained fresh from reliable sources should be used. In a primary vaccination there appears in from twenty- four to thirty-six hours a papule which on the fifth or sixth day becomes an umbilicated vesicle surrounded by an indu- rated inflammatory zone. This papule on the eighth or ninth day changes to a pustule, which dries up, and the brownish scab resulting falls off on the twentieth to the twenty-fifth day, leaving the characteristic scar. In patients who have already been vaccinated successfully there may be either no result, or an irregular atypical vesicle, or a local ulceration on an inflammatory base. About the third day of vaccination there begins a moder- ate fever, often preceded by chilly feelings, with malaise, restlessness, and irritability, these symptoms being espe- cially marked in children. These symptoms increase mod- erately until pustulation is completed ; then they subside. The neighboring lymphatic glands become swollen, painful, and tender. The protection afforded varies with the completeness of the vaccination and with the time that has elapsed since it 6o M.-lXr.lL OF THE PRACTICE OF MEDICIXE. was last performed. Every bab\- sliould be wiccinated, preferably between the second and third months, and thereafter every seven years — oftener, however, if exposed to small-pox or during an epidemic. Should, under these latter circumstances, a revaccination be unsuccessful, it should be repeated. Complications of vaccination are due either to lack of cleanliness or to impure virus employed, and should not occur if proper precautions be taken. There may be slough- ing ulcers, gangrene of the skin, or erysipelas. Septicaemia may develop in neglected cases. Impetigo contagiosa has been known to result. The patient may be inoculated with syphilis from humanized virus taken from diseased patients, the double infection resulting in the primary lesion at the site of inoculation. There ma}- be observed vesicles about the inoculation, or a general eruption of vesicles from absorption of the virus. VARICELLA. Definition and Synonym. — Varicella is a contagious dis- ease especially of childhood, and is characterized by a vesic- ular eruption. Synonym: Chicken-pox. Etiology, — Varicella occurs in sporadic, endemic, and epi- demic forms. It is contagious throughout its course, but the contagious principle is of a low grade of intensitx'. It is almost exclusively a disease of children, but it ma}' occur in young adults. One attack does not afford absolute im- munity from subsequent attacks. The exact virus has not been determined definitely. There is no connection, immediate or remote, between this disease and variola or varioloid. Symptoms. — The period of incubation is from eight to seventeen days, and it is unattended by symptoms. The invasion is marked by chilly feelings in some patients and by feverishness, the temperature rarely being higher than 102° F. except in very young children, in whom a fever of 104° F. is not unusual Convulsions are rare at the onset. There is apt to be vomiting, and the child complains of lassitude and of pains in the back and legs. These symptoms last SCARLET FEVER. 6 1 for but a few days. In some cases the constitutional symp- toms are so slight that except for the eruption the child may seem well. The eruption appears in about twenty-four hours, first on the chest and back or on the foreliead and face, and con- sists of small raised spots which in a few hours become vesicles. These vesicles vary greatly in size, the larger ones usually appearing on the forehead ; they are rarely umbili- cated ; they collapse, as a rule, by a single puncture ; they ap- pear superficial, and not deeply seated ; and they are but rarely surrounded by an inflammatory halo. A few vesicles become pustular, but the majority in a day or so simply shrivel up, leaving crusts which fall off, usually leaving no cicatrices, although circular scars may result from the larger and deeper vesicles. Fresh crops of eruption appear during the first two or three days, so that the eruption can be seen in all stages of development. The eruption also appears in any of the mucous membranes ; the vesicles, becoming macerated, leave superficial ulcers. In a few cases there appears a scarlatinal rash before the regular eruption. In rare cases, in debilitated children, there may be gangrene of the skin, or hemorrhages into the eruption and skin and from mucous membranes. The prog-nosis is regularly good except for the severer forms in very puny, weakly children. Treatment. — The patient should be kept in bed during the febrile stage, and in the house until the skin is free and clear. A child should be isolated from other children, but may associate with adults. SCARLET FEVER. Definition and Synonym. — Scarlet fever is an acute in- fectious, contagious disease with an eruption, fever, and pharyngitis, and with a tendency to cause an inflammation of the kidneys. Synonym : Scarlatina. Etiology. — The disease is contagious from the invasion until the end of desquamation. The poison is conveyed b}' the exhalations of the patient, by personal contact, or through the medium of a third person, and is spread by the scales of 62 MAXL'AL OF THE PRACTICE OF MEDICLXE. the desquamation; these scales, which float in the air and are deposited in clothing, bedding, and rooms, may remain in the hair long after convalescence. The poison possesses extra- ordinary vitality, so that contaminated fomites may convey the contagion even after months or years. The poison may be carried great distances and ma\' be convcjed also in milk. The exact nature of the poison has not definitely been determined. The disease occurs both in isolated cases, due always to contagion of some previous case, and in epidemics, which vary greatly in their virulence. It is most common in the fall and winter months. Susceptibility to the disease varies, some people being exempt. This exemption may run in families. The disease usually attacks children, 50 per cent, of all cases occurring before the fifth year, 90 per cent, before the tenth year. Young infants are rarely attacked. Adults become less and less susceptible with advancing years. One attack, with but the rarest exception, procures future immunity. The disease is said to occur with special frequency in puerperal women and after surgical operations, but it is now supposed that these cases are really septicaemia with a septic erythema, which often desquamates, as docs any long- continued hyperaemia of the skin. The relation between scarlet fever and diphtheria is at present unsettled. A patient may have the two diseases together from a mixed infection, or a scarlatina may occur with membrane in the throat, or a diphtheria may occur with a septic erythema. Careful bacterial investigations are required to settle the relationship of the two diseases. Pathology. — The characteristic lesions consist in the eruption and the pharyngitis. No traces of the eruption are observed after death, except in the hemorrhagic form. The pharynx usually presents the appearance of a catarrhal inflammation. The complicating inflammations are exceedingly numer- ous and important. There may be follicular tonsillitis or pseudo-membranous inflammation of the tonsils, pharynx, or larynx. There may be cellulitis of the neck that may SCARLET FEVER. 63 go on to gangrene or suppuration, the pus containing strep- tococci. There may be infection of the middle ear with otitis media, perforation, and deafness. Respiratory complications are not common, although broncho-pneumonia may occur. In rare cases there may be pericarditis or endocarditis, and less frequently menin- gitis. The spleen is usually found enlarged during the height of the disease. In nearly all cases there is found a parenchymatous degeneration of the kidney, but there may be either acute exudative or acute diffuse nephritis. These renal changes are the most important and formidable of all the complica- tions of the disease, constituting the so-called " scarlatinal nephritis." Symptoms. — Incubation. — This period is pretty con- stantly seven days, although its extreme limits are between twenty-four hours and two weeks. During this period there are no symptoms. Invasio7i. — The invasion is sudden and striking, being marked by fever, sore throat, and vomiting. This trinity of symptoms occurring suddenly should always excite the suspicion of scarlatina. There may be initial chilly feelings, or convulsions in young children. An actual chill is rare. The vomiting, which is usually severe and apparently uncalled for, may be projectile. The fever mounts rapidly, and reaches 103° to 105° F. within a few hours, few diseases showing such a rapid rise. There is pain on swallowing; the throat is dryish ; the glands at the angle of the jaw are swollen and tender. On inspection there may be only the appearance of a catarrhal pharyngitis either mild or severe, or there may be added a follicular tonsillitis. The pulse becomes rapid and is usually of high tension. The face is flushed, and the child at once looks seriously ill. There may be repeated convulsions or talkative delirium, according to the severity of the disease and the nervous constitution of the patient. There is usually some nocturnal wandering of the mind. In rare cases either the vomiting, the fever, or the sore throat may be absent. Eruption. — The eruption appears on the evening of the first 64 MAXL'AL OF THE rRACTICE OF MEDICIXE. Of on the second da)-, twelve or twenty four hours after the onset, although it may be delayed until forty-eii^ht hours ; it consists of minute red points, not elevated above the level of the skin, appearing first on the throat, breast, and back, and rapidly spreading ov^er the entire body, imparting to it the color of a boiled lobster. The chin and the mouth are usuall}' left clear, giving a highly characteristic appearance and making diagnosis easy between this disease and measles or small-pox. The face, moreover, is not usually so much involved as in measles. By stroking the rash white lines stand out with characteristic vividness. The eruption may cover the entire body, or it may appear in patches sepa- rated by areas of normal skin, giving a peculiar mottled appearance, or in rare cases the eruption may appear only on the face, the bod}-, or the extremities. There is usually considerable itching, especially during the intensity of the eruption. When the eruption is well marked the skin is often diffusely swollen and inflamed, pro- ducing an uncomfortable feeling of tension. The rash lasts for two or three days and then gradually fades. While the eruption is developing the pharyngeal symp- toms continue. After the initial vomiting of the onset there are rarely gastro-intestinal symptoms. The tongue presents the so-called " strawberry " appearance, the papillae in the tip and edges standing out like shining red pearls above the epithelial coating. The fever remains high during the development of the eruption, frequently reaching as high as 105° or 106° F., and then gradually subsides with the fading of the eruption, becoming normal about the seventh day, although there is frequently a slight afternoon rise through- out the entire period of desquamation. At the height of the fever there are apt to be nervous symptoms — restlessness, nocturnal wanderings, or even delirium with convulsions — but with its subsidence these symptoms rapidly improve, the pharnygitis disappears, and convalescence begins. Desquamation. — Desquamation begins, after the fading of the eruption, in large flakes. This desquamation is espe- cially noticeable about the hands and feet, epidermal casts of the fingers and toes being frequently thrown off entire. SCARLET FEVER. 65 These flakes are potent factors in the spread of the disease, and the patient should not return to ordinary hfe until desquamation is completed. Usually desquamation lasts into the third or fourth week, but it may last much longer. It is exceedingly rare for it to be absent altogether. Variations from the regular course of scarlatina are fre- quently observed, and are due in most part to varying inten- sity of infection. Of these variations, mention will be made only of the most common. I. Mild and Rudimentary Cases. — The invasion is marked only by a slight transitory fever and moderate angina. The eruption may be scanty, extending over a small portion of the body only, disappearing in from a few hours to a day, or it may be absent altogether. There is usually, fol- lowing the eruption, a slight though evident desquama- tion lasting into the second or third week. These cases are frequently spoken of as " sympathetic sore throats," and are usually seen in partially unsusceptible adults who have been exposed to scarlatina. They are really true cases of mild scarlatina, and are not only capable of spreading the disease, but may also be followed by com- plications, especially nephritis. To such a rudimentary scarlatina many a supposedly primary nephritis owes its origin. 2. Severe and Prolonged Cases. — The onset is usually severe, the temperature rising to 106° or 107° F. and the prostra- tion and cerebral symptoms being pronounced. The erup- tion in these cases may be scanty. The fever and the con- stitutional symptoms usually continue into the second week. These are bad cases, but they are not to be considered as hopeless. 3. Malignant Cases. — The invasion is marked by a rapid rise of temperature, frequently as high as 106° or 108° F., with cerebral symptoms of ominous gravity — restlessness, delirium, convulsions, passing into coma. There is urgent dyspnoea ; the pulse becomes increasingly rapid and feeble. In these cases the patient is overwhelmed by the virulence of the poison, and dies in coma or collapse in from eighteen to thirty-six hours. As a rule, there is no eruption, although 5 66 MANUAL OF THE PRACTICE OF MED/CEVE. a scanty at\'pical rash nia\' appear should the patient hve to the second or third da\'. 4. Hemorrhagic Cases. — These are severe cases with a disposition to bleed from the mucous membranes and into the skin, the latter hemorrhages appearing as petechias and large ecchymoses. Cerebral s\'mptoms are apt to be pro- nounced. There are usually vomiting and diarrhoea, and frequently dyspnoea. The temperature may not be high. The prognosis is bad, the patient usually dying in two or three days. 5. Angina Cases. — This type of scarlet fever is character- ized by the predominance of throat symptoms and compli- cating inflammations. The pharynx and fauces are usually intensely inflamed and their tissues much swollen, making speech and swallowing painful and difficult. There is fre- quently a membranous exudate which may spread from the pharj'nx and tonsils to involve the naso-pharynx and nose, or downward to the larynx, where the membrane may cause obstruction to the breathing and asphyxia. There may be necrosis of the throat-tissues that may lead to large sloughs, and if large arteries are involved fatal hemorrhage may result. The glands of the neck become enlarged, and frequently proceed to abscesses and cellulitis. Otitis media is apt to result by infection through the Eustachian canals. The patient rapidly passes into profound sepsis with its attendant symptoms — a condition which is rarely recovered from. Complications. — i. Sufficient mention has already been made of the important throat and car complications and of the glandular swelling and suppurations. 2. The complicating lesions of the kidneys are exceedingly common. Very few cases of scarlatina run their course without the kidneys being involved in one of three ways : (i) by acute degeneration ; (2) by acute exudative nephritis ; (3) by acute diffuse nephritis. These varieties of nephritis have been admirably differentiated by Delafield, and his classification will be followed. {a) Acute degeneration of the kidney, or parenchymatous nephritis, belongs to the first and second weeks of the dis- SCARLET FEVER. 6/ ease, and is not different from the degeneration occurring in the course of any severe infectious disease. The urine may be diminished sHghtly in quantity, and it usually contains albumin and casts in moderate amounts. The course is mild, unattended by constitutional symptoms, and ends in recovery. {b) Acute exudative nepliritis belongs to the second and third weeks, following either a mild or a severe attack of scar- latina. In severe cases the urine is scanty or suppressed ; its gravity usually is unchanged ; albumin and casts are abundant; there maybe blood. There are uraemic symp- toms — headache, nausea and vomiting, dyspnoea, convulsive twitchings. In some cases there is added contraction of the arteries with high-tension pulse and disturbed heart- action. The patient becomes anaemic and the face puffy, the oedema frequently becoming general with fluid in the serous cavities. The temperature is raised, and it remains remittingly high during the acute stage of the nephritis. In mild cases there may be only moderate changes in the urine ; ursemic symptoms may be unobserved. The fever is slight or absent. Between these two there are all grades of severity. These cases run about four weeks and usually terminate in recovery, a small proportion only being fatal. {f) Acute diffuse nephritis occurs in the third week and during convalescence. It is really a post-scarlatinal nephri- tis, and may develop after either mild or severe cases. It runs an acute or a subacute course. The acute cases begin suddenly and resemble a severe attack of exudative nephritis. The subacute cases develop gradually. There is apt to be repeated vomiting, which is always to be regarded with sus- picion in a patient convalescing from scarlatina. Anaemia and dropsy progress slowly. The urine is regularly dimin- ished in quantity, and it contains abundant albumin and casts. In some cases the primar}^ changes are the first symptom. In all cases of diffuse nephritis the disease is apt to continue with more or less rapidity, with or without re- mission, until the death of the patient. In rarer cases the lesion becomes chronic. 68 MAXi'AL OF THE PRACTICE OF MEDICINE. 3. I)ifiaininatu)n of sinnis uicmbrancs, meningitis, may occur Endocarditis and pericarditis are more frequent. The so-called " scarlatinal rheumatism " occurs usually as the eruption is fading, and involves especially the hands and feet, although the large joints may be affected as well. The joints are painful, and may be swollen and inflamed. The process is septic, and not rheumatic, in its nature. Recovery is effected in a few weeks, though suppuration or permanent deformity may result. 4. Liflaimnatioii of the vnisclcs, myositis, may occur, espe- cially in the neck-muscles, with pain, tenderness, and con- traction. The muscles may in rare cases remain perma- nently contracted. The prognosis is influenced by the character of the epi- demic (5 to 30 per cent, mortality), the age and general con- dition of the child, the severity of the attack, and the nature of the complications. A guarded prognosis must always be given, as dangerous complications, especially nephritis, may occur even during convalescence. Treatment. — The patient should be isolated strictly until the completion of desquamation. The room should be well ventilated, free from draughts, and should have a tempera-' ture of about 70° F. The patient should be kept in bed until the temperature has been normal for a week, after which time the child may be allowed about the room. The diet should be of milk during the febrile period ; broths, eggs, fruit, and light cereals may be allowed during early convalescence ; but no animal food should be taken until the fourth week. The best preventive of nephritis is a rigor- ous milk diet. There is no specific medication. Symptoms must be treated on general principles. Fever. — At the onset aconite may be given in drop doses every quarter of an hour until arterial tension is decreased, and then every two or three hours to hold the pulse at that point. Should the fever be high, it is best treated by hydro- therapy, which has the additional advantage of calming the nervous symptoms. For this purpose baths, the cold pack, sponging with water, or the ice-cap may be employed SCARLET FKl'ER. 69 without the least danger. The " driving in " of the erup- tion, with disastrous consequences, is mythical. Internal antipyretics should not, as a rule, be employed. The nervous symptoms may be controlled by hydro- therapy, by phenacetine (gr. ij-v) to a child five years of age, or by chloral. The following prescription has been proven useful : T^. Chloral hydrate, gr. ij ; Camphor-water, TTLxv ; Syrup of orange-peel, ad .5j. — M. Sig. Dose for a child four years old, repeated every three or four hours. Or, I^. Chloral hydrate, gr. ij ; Peppermint-water, §ss. — M. Sig. Dose for a child four years old, every three or four hours. This prescription is also valuable to correct the initial vomiting. The pharyngitis should always be treated. Gargles do not prove of much use in children, and rarely in adults. Po- tassium chlorate is to be avoided because of its toxic effects on the kidneys. The pain is best relieved by cloths wrung out of hot water, applied frequently to the neck and covered by oil silk. In some cases cold applications to the throat are more grateful. The mouth and throat must be kept clean to avoid the spread of the infection, they being frequently rinsed out with a saturated solution of boric acid, and sprayed every two to four hours with a solution of bichlo- ride of mercury (i : 5000) or with peroxide of hydrogen (3 per cent, solution). The daily anointing of the skin with a bland antiseptic ointment relieves the itching and the feeling of tension and prevents the dissemination of the scales. Lard, cacao butter, or olive oil may be used, to each ounce of which carbolic acid (gr. xx), thymol (gr. x), or menthol (gr. x) may be . added. Previous to the inunction the skin should be cleansed daily with soap and warm water. The temperature should be taken at times during con- /O MA.yr.lL OF THE PRACTICE OE MEDICINE. valescencc. The heart, lungs, and urine should be exam- ined every few days, even if the progress of the case seems satisfactory. Nephritis is to be treated as though it were a primary disease. The septic inflammation of the joints is best treated by hot applications and by saline laxatives. Ichthyol ointment (oSs to oj) niay be serviceable. Salicylic acid and its deriva- tives occasionally seem to do good, but they are uncertain. Cervical adenitis and cellulitis are to be treated on gen- eral rules. Before the patient returns to ordinary life desquamation must be over entirely. Several warm cleansing baths with repeated shampooing are to be employed to remove all scales from the skin and the hair. MEASLES. Definition and Synonym. — Measles is an acute conta- gious disease characterized by an initial coryza and a maculo- papular eruption. Synonym : Rubeola. Etiology. — The disease is endemic, and from time to time assumes epidemic proportions. It most frequently attacks children, especially those under eight years of age, but un- protected adults are more liable to the infection than to scarlet fever, the infection being more intense and suscepti- bility to it being much more universal. It is contagious throughout its course, especially during the eruption, and there are grounds for believing it contagious even during the period of incubation. The poison is conveyed by the breath, by the secretions, especially of the nose, and by the branny desquamation. It may be carried by the air, by fomites, or by a third person. One attack does not always procure immunity, but there may be a second, a third, or even a fourth attack, although recurrences are not so com- mon as supposed. The exact contagion has not been determined, but it is known to possess less vitality and a shorter duration of life than the poison of scarlet fever. Under ordinary circum- stances it is usually a mild disease, but epidemics in crowded CD CO CD <1 00 o CD CD o o 2 o to o 1-1 O 8 - 1 c U O TV . 'rrr 7 ..,. ••'< :>... .< v^ - W ^•^ ...•<; V^ - m • - 05 ^ > ■■"^ 5"^ - ^ ^ "--. CJ1 **>i^ — ' "S 03 •rrrr . . ^. . . ~3 ../.. .< 00 1 — ^ 1 " MEASLES. 71 tenement- houses and in armies may become serious, while epidemics occurring for the first time in savage tribes may be exceedingly fatal, the mortality being even 25 per cent, of the entire population. Patholog-y. — The eruption and the catarrhal inflammations of the conjunctivae and the upper respiratory tract constitute the essential lesions. As complicating lesions there may be found broncho-pneumonia, capillary bronchitis, swelling of the bronchial glands, and less frequently pleurisy or lobar pneumonia. There may be hyperaemia of the gastro-intes- tinal mucosa with swelling of Peyer's glands. Symptoms. — The period of incubation is from ten to fourteen days, rarely so long as twenty days. During this time there are usually no symptoms, although in some cases the child may be feverish and irritable. Invasion. — The child becomes listless and exhibits the symptoms of a feverish cold. There are usually shivering attacks, but a regular chill or an initial convulsion is rare. There are redness of and running from the eyes, with pho- tophobia, sneezing, snuffling, and running from the nose, followed by cough and hoarseness. Sore throat is some- times complained of, but is not so common nor so severe as in scarlet fever. Examination may show hyperaemia with small red spots on the hard and the soft palate. Koplik's spots consist of small bluish-white points surrounded by a red areola, and are seen on the buccal surfaces and sides of the tongue in the pre-eruptive stage. They are best ob- served by everting the cheek in the presence of strong sun- light. It is claimed that they occur in every case of measles, that by them a diagnosis can be made before the eruption appears, and that they are not present in other exanthemata. The temperature rapidly rises to 102° or 104° F., remitting somewhat on the second and third days, becoming again elevated upon the appearance of the eruption. There may be nausea or vomiting and nervous symptoms depending on the severity of the attack and the constitution of the child. In some cases these symptoms are slight, the child not feeling well, having apparently a trifling cold with but moderate 72 M.IXi'AL OF THE PR.IC77CF. OF MEDICINE. feverishness. The stage of iinasion lasts for three or four days, TJic Stage of Enipiion. — The eruption usually appears on the fourth day, being seen first on the face and neck, and then rapidly spreading over the chest and body. It consists of small round spots, slightly elevated, so that they may impart a shotty feeling to the finger ; these spots increase in size and assume a roundish or crescentic outline. The rash is hypersemic, disappearing on pressure, although in some cases there may be petechi^e. The rapiditj' of develop- ment varies, the eruption becoming characteristic in some cases in a few hours, in other cases not for several days. The eruption closely resembles that of poisoning by shell- fish or that produced by antipyrine. The eruption is fully developed by the end of two or three days, and then begins to fade, being followed by a fine branny desquamation. At the height of the eruption there may be some swelling and inflammation of the intervening skin, but usually it is nor- mal in appearance. When the eruption appears the temperature again rises, reaching its maximum at the time of the greatest development of the eruption, after which, usually in the second day of the eruption, the temperature begins to fall, frequently by crisis. Restlessness, sleeplessness, or even general convulsions and delirium, may accompany the exacerbation of the fever. The catarrhal symptoms attain their maximum while the eruption is developing, and then gradually subside. Variations in its Course. — i. In rare cases there may be no catarrhal symptoms during the period of invasion. 2. There are very light cases in which there may be no eruption. After the regular period of incubation the patient becomes indisposed, feverish, and has a coryza — as it is said, " sickens for the disease," but the eruption is not developed. 3. In some cases the eruption appears as early as thirty- six hours, or it may be deferred until the sixth day. 4. There are cases of marked severity characterized by high fever (105° or 106° F.) and cerebral symptoms, con- vulsions, delirium, and stupor. 5. In some epidemics, especially in armies and in savage tribes where measles appears for the first time, may ap- MEASLES. 73 pear malignant cases, the so-called " hemorrhagic " or " black " measles. The invasion is sudden and intense ; prostration is extreme; there arc convulsions or delirium or even coma. The eruption becomes hemorrhagic ; hem- orrhages occur in the skin and from mucous membranes, These cases are almost always fatal. Complications and Sequelae. — The most important are those of the respiratory system. A mild form of bronchitis is common to the disease, but in debilitated subjects, in asylum children, and in severe forms of the disease the in- flammation is apt to extend and to lead to broncho-pneu- monia. This complication runs a regular course, and is the cause of death in the vast majority of fatal eases. There may be a swelling of the bronchial glands that render them liable to tubercular infections, which may be the origin of acute miliary tuberculosis. Thus in asylums fatal cases of tuber- culosis frequently follow epidemics of measles after a little interval. In some cases there may be a tubercular bron- cho-pneumonia at the start from added tubercular infec- tion. Lobar pneumonia and pleurisy may less commonly occur. There may be protracted and severe conjunctivitis. Croupous laryngitis may occur. There may be otitis media. In weakly children there occurs rarely gangrene of the cheeks or of the vulva (cancrum oris or noma). In some cases there is exhausting diarrhoea, which may assume a dysenteric character with bloody, slimy passages. True nephritis is rare, although albuminuria is common in the height of the disease. The disease may be complicated by whooping-cough. Prognosis. — The prognosis is generally good except when severe epidemics occur in tenements, armies, and among savage races in virgin soil. Death seldom occurs from the disease itself, but from pulmonary complications. The prognosis is not good in children under the age of two years. The possibility of subsequent tuberculosis must be considered. Treatment. — The patient should be isolated until desqua- mation is completed. Especial care should be exercised to to prevent delicate children with weak lungs or a tubercu- 74 M.lXr.AL OF THE PRACTICE OF MEDICIXE. lar predjsposition from being exposed to the disease. The room should be of an even temperature (about 70° F.) and well ventilated. There is no advantage in keeping the room too hot. The patient should remain in bed until three or four days after the fever has gone, and during the febrile period should be kept on a milk diet. Water may be given freely. The majority of uncomplicated cases need no further treatment, though special symptoms may be treated as they arise. The fever rarely needs treatment. Should it be high (over 104° F.), it may be reduced by sponging with water. Cool baths may be employed with benefit. Conjunctivitis is best treated by careful cleansing of the eyes with a saturated boric-acid solution ; or a few drops of a solution of atropia (gr. j : Sj) or of alumnol (gr. v : oj) may be employed. For the redness of the eyelids the un- guentum hydrargyri oxidi flavi (U. S. P.) may be used. In severe cases the room may be darkened slightly by blinds or by screens to relieve the photophobia. Restlessness, delirium, and sleeplessness are best con- trolled by sodium bromide or phenacetine. The cough, if troublesome, is best treated by paregoric and syrup of ipecac in small doses. The itching of the skin may be relieved by washing with a solution of bicarbonate of soda or by oiling the skin with lard or with cacao butter. Other symptoms as they arise are to be treated on general principles. During desquamation the skin should be oiled daily to prevent dissemination of the branny scales. During convalescence great care should be taken to build the child up and to avoid most especially the least possi- bility of tubercular infection. Too much care cannot be taken in this reeard. RUBELLA. Etiology and Synonyms. — Rubella is rather rare, occur- ring chiefly as epidemics, which are frequently extensive. RUBELLA. 75 Sporadic and endemic cases are exceedingly infrequent. It is a disease entirely distinct from measles, although closely resembling it in many of its clinical features. It is conta- gious to both adults and children, and one attack procures future immunity. Synonyms: German measles; Roseola; Rotheln. Symptoms. — Incubatioji. — The period of incubation is usually two weeks. Invasion. — The symptoms of the invasion resemble those of measles, but are much milder and are of shorter duration. There is a slight fever, rarely over ioo° F., with headache, nausea and vomiting, 'coryza, sore throat, and swelling of the glands at the back of the neck that is almost charac- teristic. These symptoms rarely continue longer than twenty-four hours. In many cases they are so slight as to be unnoticed. The eruption, which appears in from twenty-four to forty- eight hours, is first seen on the face and chest, thence spread- ing generally. It consists of small round, raised spots, of a pinkish rose-color, which are usually discrete and which frequently are seen on the palate. They are rarely crescentic. They may become confluent, the consequent reddening of the skin closely resembling the scarlatina rash ; but the eruption is more erythematous, is not punctiform, and in places shows a papular character. In a certain number of cases there are developed from the papules a few vesicles which may become pustules. This is never the case with scarlatina nor with measles. The eruption lasts for two or three days and then fades. There may be a slight branny desquamation. During the eruption there may be some feverishness, an aggravation of the pharyngitis, and swelling of the glands at the back of the neck. In many cases, however, the only .symptom is the eruption. The prognosis is perfectly good. Treatment. — Few diseases need so little treatment as rubella. The case should be isolated to avoid the spread of the disease. y^ MAXi'AL OF THE PRACTICE OF MEDICIXE. EPIDEMIC PAROTITIS. Definition and Synonym. — Epidemic parotitis is an acute contagious disease characterized b}- inllaniniation of the saHvary glands. Sj'iiofijnn : Mumps. Etiology. — Parotitis occurs both as an endemic and an epidemic disease, epidemics being usually extensive. It is a disease of childhood and adolescence, attacking in- fants and elderly people but rarely. It is more frequent among males than among females. It is personally con- tagious from the last few da}'s of the period of incubation until the subsidence of the symptoms. The exact poison has not been absolutel}'' proven, although a bacillus paro- tidis has been described. Lesion. — The lesion consists in the swelling and conges- tion of one or of both parotid glands, and occasionally of the submaxillary glands as well. Symptoms. — The period of incubation is between two and three weeks and is unattended by symptoms. The disease begins with fever — usually not over ioi° F., but it may be as high as 103° or 104° F. — and at- tendant febrile symptoms, nausea, restlessness, and pros- tration. The local symptoms become noticeable in from twenty-four to thirty-six hours, although in some cases they may precede the fever. The patient complains of a feeling of tension, more rarely of actual pain with tender- ness, referred to the parotid gland of one side. The gland is swollen, giving the patient a characteristically comical appearance. Deglutition and speaking aggravate the pain. There may be pharyngitis or earache. The inflammation reaches its height in from three to six days and then subsides. It is usual for the inflammation to start on one side, the other parotid gland becoming affected in a day or so. More rarely both glands may be affected simultaneously, or the inflammation may be sub- siding on the side first affected before the involvement of the other side, so that the duration of the disease is doubled. The lesion is rarel)' unilateral throughout. In some cases the submaxillary glands may secondarily be EPIDEMIC PAR OTITIS. yy involved. With the subsidence of the inflammation the fever and the constitutional symptoms disappear. While the course is generally mild, there are cases which run a severe course, with high fever, rapid and feeble heart- action, and delirium. Orchitis occurs more frequently in some epidemics than in others. It is rarely seen before puberty, and double orchitis is infrequent. The orchitis gives rise to pain and tenderness ; the testicle is hard and swollen ; there may be fluid in the tunica vaginalis. The temperature rises, frequently to 103° or 104° F., and remains high until the orchitis begins to subside, which is usually in from five to ten days. Subsequent involvement of the other testicle may prolong the disease for another week. In females there may be vulvo-vaginitis, or the breasts may be enlarged and tender. Inflammation of the ovaries is rare. Complications and Sequelae. — There may be meningitis, mania, or post-febrile insanity. There may be suppuration or gangrene of the parotid glands. Severe orchitis may be followed by atrophy. In some cases arthritis has been ob- served. There may be deafness, which frequently is per- manent. Treatment. — The patient should be isolated until the dis- appearance of acute symptoms, and during the febrile period should be kept in bed and on a light diet. The parotiditis is best treated locally by applications of cold ; should, how- ever, heat be more grateful, poultices, applications of hot cloths, or dry cotton covered with oiled silk may be em- ployed. Resolution may be hastened by applications of ichthyol ointment (3ss : sj) or of iodine ointment. Orchitis is to be treated by rest in bed, elevation of the testicle, and applications of cold. In the latter stages ich- thyol ointment or unguentum plumbi iodidi may be em- ployed with benefit. Other symptoms should be treated on general principles. 78 MJXi'AL OF THE PRACTICE OF MEDICLXE. WHOOPING-COUGH. Definition and Synonym. — Whooping-cough is an acute contagious disease with inflammation of the respiratory tract, a paroxysmal cough, and a characteristic " whoop." Syu- oiiyui : Pertussis. Etiolog-y. — Whooping-cough occurs in endemic and epi- demic cases, the epidemics being most frequent in the winter and early spring months, and often being associated with epidemics of measles. The disease is personally contagious, though concentrated and prolonged exposure is usually required. One attack procures immunity. The actual cause is probably due to a short bacillus growing in cultures with well-marked characteristics, first described in 1887 by Afanassjew. The majority of cases occur in children under six years of age, though no age is exempt. In negroes it runs a more severe course. Lesion. — The lesion consists in a catarrhal inflammation of the nose, lar)-nx, trachea, and bronchi. As complicating lesions there ma\- be found extensive bronchitis of the smaller tubes, broncho-pneumonia, inflammation of the bronchial glands, and emphysema of the vesicular or interlobular variety. Symptoms. — The inaibation period of the disease is about two weeks, although this is difficult to determine owing to the insidious onset. The symptoms begin with bronchitis and coryza similar to those of an ordinary severe cold; these symptoms continue without improvement for from one to three weeks. Then appear the characteristic coughing attacks from which the disease is named. The attack be- gins with a series (fifteen to twenty) of coughs so rapid and spasmodic that the child cannot breathe. Suffocation seems imminent; the face is suffused; the eyes run; the tongue is cyanotic and protruding. The child is terrified and sits up in bed or runs to the nurse or the mother. After this series of coughs there is a long, deep inspiration with the sound of the characteristic whoop, immediately after which the convulsive coughs may be repeated. In some cases the whoop is the first indication of a coughing attack. In rare WHOOPING-COUGH. 79 cases there is only the paroxysmal cough without any whoop. The attack is often followed by the raising of a little tenacious mucus, which gives relief Very severe attacks may be accompanied by vomiting or regurgitation of food, by relaxation of the sphincters, by convulsions, or by hemorrhages from the nose, mouth, stomach, or under the conjunctiva. In rare cases there may be symptoms of cerebral or subdural hemorrhage. The number of separate attacks varies from three to eighty during the twenty-four hours. The attacks are frequently induced by emotions, by crying, by attempts at swallowing, by close, dusty air, and by changes in temperature, and they are usually more frequent at night than during the day-time. The general health suffers. Severe cases are accompanied by fever and prostration. The vomiting and the induce- ment of an attack by swallowing interfere with proper nutri- tion, while the child is nervous and fretful from loss of sleep. There is usually found superficial ulceration on each side of the frenum of the tongue, and between the attacks the face is frequently swollen, the lower lids are puffy, and the tongue is enlarged and of a bluish color. After the paroxysmal stage has lasted for from three to six weeks the attacks become less severe, the whoop ceases, and there remains only a terminal bronchitis which slowly declines. The whole duration of the disease is in this w^ay protracted for from six to twelve weeks. In adults the disease runs a more severe and energetic course, with marked depreciation in general health. Complications and Sequelae. — The pulmonary complica- tions have been mentioned under the heading of Lesions. Their association with whooping-cough renders the prog- nosis much worse than if they occurred primarily. Paralysis from cerebral or intradural hemorrhage is a rare sequela. Whooping-cough is frequently followed by acute tuber- culosis or by tubercular broncho-pneumonia, from an added infection of the inflamed lung or the bronchial glands. Qui- escent tubercular deposits may also be called into activity. In some cases there will be a return of the Avhoop at inter- 80 MAXr.lI. OF THE PRACTICE OF MEDICLXE. vals for months whenever bronchitis is contracted. This is not a recurrence, but is merely a " habit-spasm." Treatment. — Ex'cry possible care should be emplo)'ed to keep children, especially if delicate, from being exposed. Negligence in this regard is criminal. The contagion is most marked during the paroxysmal stage, and declines with the terminal bronchitis, but does not persist after the second month. Isolation and quarantine cannot be insi.sted upon to their full limits, and a final disinfection of the rooms and the clothing is not necessary, as the contagion is conveyed by the breath alone. The room should be sunny and well ventilated. In mild cases without pulmonary complications the child can go out in favorable weather. The proper feeding of the child is important, especially if there be vomiting during the attacks. Drug treatment is largely emplo)'ed, and many alleged " specifics " are lauded from time to time. No one form of treatment is of service in all cases, but one drug after another has to be tried. During the catarrhal stage the treatment is that of the bronchitis. During the paroxysmal stage treatment is directed not only toward the bronchitis, but also toward the mitigation of the paroxysms. For the latter purpose internal sedatives and local applications are employed. Internal Sedatives. — The doses given are those suitable for a child two years old. Belladonna, frequently to tolerance. Initial dose, 2 min- ims of tincture every three hours. Quinine, in full doses, gr. j every two hours. Chloral, gr. ij-iv every four hours : efficient in many cases, especially to secure sleep ; may advantageously be combined with sodium bromide (gr. iij-v), especially in children with convulsive tendencies. Opium or codeia is to be used only in the severest cases. Asafcetida mixture is often of service in mild cases. Antipyrine (gr. i-iij every two or three hours) is often attended by most brilliant results. Phcnacctiiie (gr. ij-iij every three hours) has been found useful. EPIDEMIC INELUENZA. 51 Bromoform (3 drops in simple elixir three times a clay) acts almost as a specific in some cases. The disinfection of the sleeping-room with sulphur, the child sleeping there in clean clothes after the room has been aired, often cuts short the paroxysmal stage. Local treatment may be employed if not resisted by the child — inhalation of the vapor of carbolic acid, of creosote, atomized sprays of wine of ipecac, i per cent, solutions of resorcin, peroxide of hydrogen, or solutions of quinine. Insufflations of quinine, i per cent, solutions of resorcin, or a powder of salicylic acid gr. x. to boric acid §ij, may be tried. In many cases, during the decline of the paroxysmal stage a change of climate may hasten recovery. In severe and protracted cases it should always be tried. EPIDEMIC INFLUENZA. Definition and Ssnionym. — Epidemic influenza is an acute infectious disease, occurring principally in pandemics, characterized by fever, pains, prostration, and by inflamma- tion of the mucous membranes. Synonym : La Grippe. Etiology. — The disease occurs in epidemics which spread over whole countries or quarters of the globe with great rapidity, attacking large numbers of people. The epidemics usually start in the East, the majority arising in Russia. Until 1870, ninety such epidemics had been described. The last pandemic occurred in 1889-90. The disease is not affected by sex, age, condition of life, climate, or atmospheric changes. Sporadic cases occur in the wake of the epidemics. One attack does not procure immunity. The disease is probably slightly contagious by personal contact, and possi- bly through fomites, but in the large epidemics infection cannot be traced with any certainty. The actual cause of the disease appears to be a bacillus first described in 1892 by Pfeiffer. This is a short bacillus with bulbous ends that is found in the sputum, in the tissue of the lungs, and in the blood. This bacillus is never found in other diseases, is constant in grippe, and it causes the disease in monkeys and apes by inoculation. 6 82 MAXr.lL OF THE rRACTICE OF MEDICINE. Lesions. — The regular lesion is a catarrhal inllamniation of the respiratory passages, from the nose to the bronchi ; frequently there are also swelling and hypera^mia of the mucosa of the stomach and intestines. Complicating lesions are numerous. The most import- ant are those of the respiratory organs. There may be lobar pneumonia, broncho-pneumonia, pleurisy, or empyema. Less frequently are noted abscess of the lung, abscess of the brain, meningitis, purulent pericarditis, and nephritis. Symptoms. — The symptoms arc exceedingly varied, de- pending on the severity of the infection, the reaction on the nervous centres, and the var\-ing intensit}' of the catarrhal inflammations of the respiratory and gastro-intestinal tracts. Complicating lesions also add their symptoms. 1. Syniptonis of Infection. — The onset is usually abrupt, being initiated by a chill or by chilly feelings. In some cases the chill is absent. Rarely there are prodromata, as evinced by lassitude of body and mind for several days. The temperature rapidly rises to ioi° to 104° F. accord- ing to the severity of the attack. There is marked prostra- tion from the first. The pulse is rapid and full. It may become feeble and intermittent, especially in the old and the debilitated, and may lead to heart failure. The liver and spleen in some cases are enlarged. 2. Ncrvojis Symptoms. — At the onset there is severe, agonizing headache, usually frontal, less frequently general or occipital. This headache is often as severe as in men- ingitis, persisting for hours or days, and it may be obsti- nately present during convalescence. Pain and tenderness of the muscles of the body, especially of the legs and the back, are constant symptoms. The patients feel bruised, and shift their position, trying to find one more endurable. There are great depression of spirits and an inability to concentrate the mind which may last long into convalescence. In severe cases there maybe delirium of an active type with hallucinations. There may be herpes labialis or urticaria. 3. Catarrhal Symptoms. — There are conjunctivitis, redness and oedema of the lids, and increased lacrymation. Coryza EPIDEMIC INEEUENZA. 83 appears, with snuffling and sneezing. Laryngitis is attended by hoarseness, pain, and a severe paroxysmal cough which often continues for weeks after the attack without being im- proved materially by medication. Pharyngitis and tonsil- litis are usually present. The bronchitis may be mild or severe, and is marked by harassing cough, muco-purulent sputa, which may contain blood, pain in the chest, and the ordinary physical signs. 4. Gastro-i)itcstiiial symptoms consist in a heavily-coated tongue, persistent vomiting, diarrhoea, tympanites, and pain and tenderness over the abdomen. Course of the Disease. — The relative predominance of the above .symptoms varies in different people and in differ- ent epidemics. In all cases the symptoms of general infec- tion are present, but the nervous, catarrhal, or gastro-intes- tinal symptoms vary so much in their relative intensity as to present three principal types of the disease — a nervous form, a catarrhal form, and a gastro-intestinal form. No strict line of demarcation between these different types can be made. Complications and Sequelae. — Pneumonia is by far the most frequent and fatal complication. There may be either broncho-pneumonia, especially in children, or lobar pneu- monia. The latter, which involves one or more lobes, with complete or incomplete consolidation, and which is always associated with an intense general bronchitis, differs from the ordinary course of lobar pneumonia in the following particulars : The onset may not be so abrupt, being insidious and of slow development. The expectoration is that of bronchitis, rusty sputum being usually absent. The bron- chitis is a marked feature, adding its symptoms and physi- cal signs. The temperature is lower than that of a primary pneumonia, and is frequently remittent. Cyanosis and heart failure are more frequent. The duration is longer and reso- lution is more tardy. The temperature falls gradually, as a rule, and not by crisis, and frequently persists after resolu- tion. The pneumonia is often " wandering," creeping from place to place until a considerable part of the lung has become involved. Empyema, pleurisy, abscess of the lung. 84 MAXrAL OF THE PRACTICE OF MEDICINE. mening^itis. purulent pericarditis, and acute nephritis may occur during or after the attack, and give their regular symptoms. Convalescence is usually slow and tedious, and is at- tended often by weakness of body and of mind. There may remain obstinate insomnia or cough. Facial neuralgia or headache may persist, and in some cases is due to compli- cating empyema of the antrum of Highmore. There may be post-grippal insanity or peripheral neuritis. Deafness may result from otitis media. During and after epidemics of grippe the mortalit)' from tuberculosis is manifesth- increased, quiescent and chronic tubercular processes being stirred into activity. The duration of an uncomplicated attack varies between three and seven days. It may be protracted by reason of the complications. Convalescence may be either rapid or slow and tedious. Prognosis. — Grippe itself is rarely fatal except in elderly or debilitated people or in those suffering from advanced pulmonary, nephritic, or cardiac disease. In these cases the disease may terminate fatally from weakness or from cardiac failure. The prognosis is largely influenced by the nature and severity of the complications. Treatment. — It certainh' seems that the severity of the attack can be modified by the administration of large doses of quinine at the onset. At least gr. xx-.xxx should be given within the first twenty-four hours, cinchonism being controlled by phenacetine or by sodium bromide. Aside from this the treatment is entirely symptomatic. The headache and the pains in the bones and muscles are best relieved by repeated small doses of phenacetine, prefer- ably combined with salol (each 5 grains every two hours), Antipyrine and antifebrine are to be avoided if possible, be- cause of their depressing effect. Bromides may be useful in controlling restlessness, and a hot bath followed by a lO-grain dose of Dover's powder is often of great comfort. Morphine or codeine may be employed in severe cases. If headache depends upon congestion of the frontal sinuses, inhalations of steam, creosote, or menthol are of service. DENGUE. 85 The following prescription is most satisfactory for the purpose : Y^^. Menthol, gr. x; Tinct. benzoin, comp., 5j. — M. Sig. A teaspoonful gradually added to a pitcherful of boil- ing water, to be inhaled three times a day. Sleep is best procured by sulphonal, chloralamide, or codeia. The vomiting is to be treated by regulating the feedings, by bismuth, or by morphine. Diarrhoea is to be checked by opium combined with astringents. The bronchitis is to be treated after the ordinary methods — by sedatives, by expectorants, and by counter-irritation applied to the chest. Pneumonia requires its appropriate treatment, especial care being taken to avert heart failure by the timely admin- istration of stimulants ; alcohol, digitalis, and strychnine are most usually employed for this purpose. The depressing and enfeebling influence of the disease during convalescence requires most careful attention. The patient should not return too soon to business ; the diet should be supporting ; all depressing influences should be avoided ; and appropriate tonics should be administered. A change of air is often required. This supporting treat- ment is especially indicated in those who present evidences of tubercular disease. DENGUE. Definition and Synonyms. — Dengue is an infectious epi- demic disease of warm latitudes, characterized by febrile paroxysms, pain in the muscles and bones, and anomalous eruptions. Sjnonyjns : Dandy fever ; Breakbone fever. Etiology. — The disease appears in extensive epidemics confined to the tropics and the sub-tropics. It has occurred in the Southern United States. Large numbers of people are attacked, susceptibility being almost universal. One attack does not secure immunity. The disease is supposed SG MA.VrAL OF THE PRACTICE OF MEDICINE. to be contagious by personal contact and through fomitcs. Epidemics occur in the summer months, and are checked by colder weather. The exact poison has not been deter- mined. Patholog-y. — But little is known about the disease, as fatal cases are rare. There appear to be no essential lesions. Sjanptoms. — The period of incubation is about four days. The onset is abrupt, beginning with a chill or chilly feel- ings, or with convulsions in children. The temperature rapidly rises to 102° to 106° F. according to the severity of the attack, and is accompanied by ordinary febrile .symp- toms. Cerebral symptoms are frequent in the cases with high temperature. At the onset are developed agonizing headache and backache. The muscles are sore and tender. The joints become painful, tender, and frequently red and swollen. The large and the small joints are equally affected. Prostration and depression are marked. In some cases there may appear a transitory erythematous rash. In rare cases there may be severe vomiting and purging. There may be hemorrhages from any of the mucous membranes in severe cases. Lymphatic enlargements are not uncommon. The febrile paroxysm lasts from three to five days and terminates by crisis, the fall of temperature frequently reaching the sub- normal, although in most cases a moderate fever remains. At the crisis there may be sweating or diarrhoea. As the fever falls the general symptoms disappear, the patient feel- ing better, though often prostrated and sore. The period of remission lasts from two to five days, and during it may appear a variety of eruptions which are not distinctive. There may be urticaria, erythematous eruptions of all kinds, or herpes. The severer forms may be followed by desquamation. After the period of remission there occurs a second par- oxysm of fever with a return of all the previous symptoms. This paroxysm, however, is mild and lasts only for two or three days, terminating again by crisis, after which conva- lescence is established. Convalescence is usually slow and tedious from mental and physical incapacity. EPIDEMIC CEREBRO-SPINyif. MENfNGIT/S. 8/ The prognosis is almost uniformly favorable. Treatment. — There being no specific treatment, the symptoms must be treated on general principles. EPIDEMIC CEREBRO-SPINAL MENINGITIS. Definition and Synonym. — Epidemic cerebro-spinal men- ingitis is an acute infectious disease characterized by inflam- mation of the cerebral and spinal meninges. Synonym: Cerebro-spinal fever. Etiology. — This disease, which has been recognized only since the early part of the present century, occurs chiefly in epidemics, although sporadic cases are frequently seen. The epidemics are most frequent and severe in the cold winter months, and are favored by poor hygiene and by the crowding together of people, as in garrisons and barracks. Children are more susceptible than adults. There is no evidence that the disease may be transmitted by food or by drinking-water. The disease is not considered contagious by either personal contact or through fomites, although rare cases have been reported which render it imprudent to make too dogmatic an assertion in this regard. In almost all the recently-studied cases there is found in the exudate a lance-shaped diplococcus which appears identical with the diplococcus of pneumonia, and it appears most likely that this is the specific micro-organism of the disease. It is frequently found associated with the ordinary pus organisms. Pathology. — The brain is usually congested. The veins and sinuses are engorged with blood. The pia mater is infil- trated with an exudate of fibrin, serum, and pus to a greater or lesser degree. The infiltration may be confined to the base or it may be more generally distributed. It is more abundant along the course of the blood-vessels and in the sulci. The lateral ventricles are filled \vith serum, which may be turbid from admixture of pus. In children, as a rule, and occasionally in adults, this fluid may distend and dilate the ventricles, and in chronic cases after the meningitis has subsided the distention of the ventricles may continue as a chronic hydrocephalus. 88 M.iXCAL OF THE PRACTICE OF MEDICIiXE. The pia mater covering the spinal cord shows similar inflammatory changes, especially on the posterior aspect. The brain-cortex is often infiltrated with pus, which may form small abscesses. The cerebro-spinal fluid, which is usually increased, may be turbid. In the exudate the lance- shaped cocci are found frequently with ordinary pus cocci. The lesions may involve the sheaths of the cranial nerves, leading to neuritis and perineuritis. In very malignant cases there may be no time for the lesion to develop before death. In rare cases the meningitis is of the cellular variety. The pia may appear normal or lustreless or congested. There is neither fibrin, serum, nor pus, but there is a marked pro- liferation of the connective-tissue cells of the pia. These cases usually run a different clinical course. The remaining lesions are not distinctive, being those common to all severe infectious diseases. There may be hemorrhages in the skin, in the serous membranes, and into the viscera. There is granular and fatty degeneration of the liver- and kidney-cells and of the heart-muscle. The spleen is usually enlarged and soft. Symptoms. — The period of incubation is usually short, varying from a few hours to several days. During this time the patients may complain of headache, slight feverish- ness, and lassitude. The onset is usually abrupt, being marked by a chill, fever, headache, and vomiting. The fever may reach to I02° or 104° F., and does not run any typical course. While high fever belongs to the severe cases, the reverse is not always true. In some cases the fever may not be marked. The headache is usually frontal, but it may be parietal, occipital, or general. It is a severe headache, persisting during sleep and periods of stupor, as evinced by moaning, clasping the head with the hands, or by the facial aspects of pain. There may be general pains in the bones and muscles. The vomiting is frequently severe and distressing, and EPIDEMIC CEREBROSPINAL MENINGITIS. 89 does not depend upon the giving of food or of drink. It may assume a projectile character. During the earher stages of the disease there are nervous symptoms of irritation. The headache has already been mentioned. There are frequently psychical disturbances, as shown by delirium, which may be maniacal. Some patients show morbid erotic desires. There may be from time to time a sudden sharp cry, the so-called " hydrocephalic cry." The functions of the cranial nerves are exalted. There are photophobia, usually with some amount of conjunctivitis, intolerance to sounds, facial neuralgia, and muscular twitching. The irritation of the spinal nerves is shown by pain, ten- derness, and contraction of the muscles of the back of the neck that may amount to opisthotonos if the muscles of the trunk are similarly involved. The skin is hypersesthetic, the least touch causing exqui- site pain. General exaggerated reflexes are highly charac- teristic. There are twitchings and spasms, and frequently automatic movements of the muscles of the arms or legs.. The attitude is one of flexion. Kernig's sign consists in the inability to extend the leg on the thigh when the thigh is flexed on the abdomen. It is a good, but not an invariable sign. The pulse is, at first increased in proportion to the fever, becoming slowed and full when the brain begins to be com- pressed by the effusion and distention of the ventricles. It is often remarkably variable in its rapidity. Various atypical eruptions may be seen on the skin. Herpes on the lips or the face occurs in half the cases. As the herpetic vesicles frequently contain the characteristic micrococci of the disease, bacterial examinations ma}^ be serviceable in confirming the diagnosis. There may be erythematous blotches or urticaria or petechial spots, which may be so grouped as to suggest a nervous origin. The urine usually contains small amounts of albumin and casts. There may be polyuria. Glycosuria has been observed in a certain number of cases. Digestive symptoms are not pronounced, .with the excep- 90 j/.i.vr.iL OF THE practke of medicine. tion of tlie initial vomiting. The bowels are usually obsti- nately constipated. In a few cases a coniplicatins; dysentery has been observed. The abdominal wall may be markedly retracted, presenting a "boat-shaped" appearance. There may be severe abdominal pain. /// tlic latter stages of the disease the symptoms of nervous excitation give way to those of nervous depression, and symptoms of cerebral compression make their appearance. The patient usually makes no more actual complaint of headache, although it is evident that there is still some pain experienced. There are increasing dulness and apathy, which may proceed to stupor and coma. There may be pe- riods of delirium, usually now of the low, muttering variety. Photophobia is succeeded by lack of perception of light ; the pupils are usually dilated and do not react. Noises are not objectionable. The muscular twitchings and spasms give way to weakness and paralysis, which are most marked in the face and in the eye-muscles, producing strabismus. The temperature continues to be irregular. The respiration may be irregular, or even of the " Cheyne-Stokes" variety. The pulse is usually slower than would be expected from the prostration and the fever, becoming rapid and feeble, however, toward the close of the disease. The combination of fever, headache, slow pulse, and constipation is exceed- ingly characteristic of meningitis in any of its forms. At the close of the disease there may be diarrhoea and loss of the sphincter control. In fatal cases there may be ante- mortem hyperpyrexia. In cases that recover the fever gradually disappears, while other symptoms depart more slowly. Lumbar puncture is of importance in the differential diag- nosis of the various bacterial forms of meningitis, but it pos- sesses no therapeutic value. The puncture should be made under strict antiseptic precautions. The patient lying on the right side with the knees drawn up, the needle, preferably an antitoxine needle, 6 centimeters long, should be passed between the third and fourth lumbar vertebrae, the point being entered i centimeter to the right of the median line, and directed upward and slightly inward. Aspiration EPIDEMIC CEREBRO-SPINAL MENINGITIS. 9I is not necessary, as the fluid flows easily through the needle. No ill effects are to be expected. There should be made a bacterial examination of the exudate to determine what bacteria are present. In epidemic cerebro-spinal meningitis the diplococci can be demonstrated in two-thirds of the cases, the fluid in the remaining third being sterile. The duration of ordinary cases is between one and three weeks, although more protracted cases are not uncommon. Anomalous cases are met with, especially in certain epi- demics. 1. Course in Young Babies. — Convulsions are frequent at the outset and throughout the disease ; the fever is high ; the pulse is rapid throughout ; the child passes into stupor alter- nating with restlessness, and death in coma ensues. 2. Mild Cases. — There are headache, nausea, vertigo, and a little fever. There may be stiffness of the neck and vom- iting. The diagnosis of these cases is difficult except dur- ing epidemics. 3. Intermittent Cases. — The regular course of the disease in these cases is marked by periods of improvement and remission of fever lasting for a few hours or days, the remis- sions recurring at regular intervals. The case may be mis- taken for malaria or pyaemia. 4. Abortive Cases. — Here the disease begins in the regular way, but recovery is rapid after a few days. 5. Malignant Cases. — The patient is suddenly attacked by a chill, headache, and high fever. The pulse is feeble and frequently is slow, and hemorrhagic spots usually appear on the skin. Cerebral symptoms develop rapidly, and death from toxsemia occurs in a few hours or days, before lesions or characteristic symptoms have time to develop. These cases are usually seen only in the most severe epidemics. Complications. — There may be bronchitis or broncho- pneumonia. Lobar pneumonia is frequently observed. There may be pericarditis, endocarditis, or pleurisy. There is usually conjunctivitis, but more serious lesions may de- velop, such as purulent keratitis or choroiditis with loss of sight, or optic neuritis with atrophy. Arthritis occurs in some epidemics, the joints being painful, red, and swollen 92 MAXCAL OF THE PRACTICE OE MEDICIA'E. from effusion in and around the joint-cavities, the effusion in some cases being purulent. Sequelae. — Convalescence, which is apt to be slow and tedious from prolonged muscular and mental weakness, may be complicated by relapses. In some cases the lesion in the lateral ventricles continues as a chronic h\-droccphalus. The patient recovers partially from the acute attack, but a little fever remains, the pulse is feeble, and there is great gastric irritability. The pupils are usually dilated. Ema- ciation becomes extreme. The patient lies in apathy or stupor varied by periods of restlessness and moaning. These cases last for weeks, and final recovery is rare. Some patients are left in a condition of bodily and mental weakness. They become ansemic, irritable, forgetful, and hysterical, usually recovering after a lapse of months. There may be paralysis from post-febrile neuritis. There may be sequelae from involvement of special senses. There may be partial or complete blindness from corneal ulcerations, from choroiditis, or from atrophy of the optic nerve. Permanent deafness may result from perineuritis of the auditory nerve or from labyrinthine disease, many cases of deaf-mutism being due to this disease. The prognosis, which is bad, but not hopeless, depends not only on the severity of the symptoms, especially those of cerebral origin, but also on the general character of the epidemic, the mortality ranging from 20 to 75 per cent, in different epidemics. The average mortality is about 40 per cent. Endemic cases are usually less severe than those occurring during epidemics. Treatment. — The treatment is entirely symptomatic. In robust patients, if seen early at the outset, local bleeding by leeches applied to the temples or behind the ears, or the application of wet cups to the nape of the neck, is frequently of much benefit. Relief is usually afforded by the contin- uous application of cold, by the cold coil, or by ice-bags applied to the head or the spine. Large doses of ergot are frequently given in the earlier stages to diminish cerebral congestion, and iodide of potassium in 20-grain doses three D/rirrj/ERiA. 93 times a day is warmly recommended throut^hout for its sup- posed " absorbent " action. Blistering is now considered injudicious, as it docs no good and adds to the discomfort of the patient. AppHca- tions to the shaven scalp of iodoform ointment and mercu- rial inunctions have not seemed to exert a favorable effect. For the nervous symptoms sedatives and even narcotics are required. Bromide of sodium, hyoscyamine, phenacetine, or small doses of atropine may be enough in mild cases, but the severer forms demand morphine, preferably by hypo- dermatic administration. ■• High temperatures are to be combated by hydrotherapy, and every indication of heart weakness must be met by the free and judicious use of heart stimulants. DIPHTHERIA. Definition. — Diphtheria is an acute contagious disease due to infection by the Klebs-Loeffler bacillus, and charac- terized by an exudative inflammation of mucous membranes or of abraded cutaneous surfaces, with constitutional symp- toms. Etiolog-y. — The disease is endemic in all large cities, and frequently becomes epidemic, the most characteristic epi- demics occurring in summer hotels, in institutions, and in small villages. The spread of the disease is greatly favored by poor hygiene, bad plumbing, and the crowding together of people. It is contagious by personal contact, and may be transmitted by clothing, toys, bedding, etc., even after the lapse of months or of years, the germ having intense vital- ity and duration of life. Cases, however, in which the con- tagious property of the bacillus has been retained for more than one year, though reported in medical literature, are of questionable authenticity. It is doubtful whether the disease is communicable by the breath alone. It is known, however, that the greatest con- tagion is conveyed by the secretions and by loosened bits of membrane from the infected site coughed into the faces of the attendants or sucked from the tracheotomy wound 94 M.lXr.lL OF THE PRACTICE OF MEDICIXE. b\' an over-zealous operator. The disease nia\' be trans- mitted by kissing. Cases are reported in which the disease has been taken from diphtheritic animals, especially cats. The disease is usually one of childhood, one-half the cases occurring before the fifth >'ear, although it is common enough in those under fift}-. It may occur in young babies. One attack does not procure immunity. The exciting cause is now known to be a bacillus desci'ibed in 1883 by Klebs and in 1884 by Loeffler, and bearing their combined names. Its length is a trifle less than the tubercle bacillus, but it is broader, with clubbed extremities. It is readily stained, shows a characteristic growth in nutritive media, and is capable of causing the disease in animals. Cultures are best made in blood-serum, colonies in agar-agar. It is destro}-ed by aqueous solutions of bichloride of mercury (I : 8000), salicylic acid (i : 2000), and carbolic acid (i : 50). It is destroyed also by boiling. The bacilli are usually found only in the pseudo-membrane, though exceptionally they may be present in the blood and in the viscera. They may persist in the throat for so long as three weeks after the attack, and are found in the throats of 25 per cent, of those who have been exposed to diphtheria. They are never found in other diseases. Infection usually occurs through slight abrasions of the mucous membranes, and is favored by diseased conditions of the upper air-passages. The diphtheritic ptomaine has been isolated, and its injection in animals has been followed by all the symptoms of diphtheria except the membrane. Immunity. — By the inoculation of attenuated cultures in some animals immunity has been secured ; and, what is more important, infected guinea-pigs have been cured by inocu- lating them with the blood of the animals rendered thus immune. At the present time diphtheria in the human sub- ject is being treated by this method, with the result of reducing the mortality one-half If these inoculations are begun by the second day of the disease, the patient almost invariably recovers. Pathology. — The essential lesion consists of a croupous inflammation of mucous membranes, more rarely of abraded jj/pirniER/A. 95 cutaneous surfaces. The most frequent sites are the tonsils, pharynx, palate, nares, larynx, trachea, or bronchi, and less frequently the mouth, gums, lips, oesophagus, stomach, and vagina. The mucous membrane is congested, swollen, and infil- trated with fibrin-serum and pus, which appear on its free surface. The epithelial cells and the exuded leucocytes die and undergo hyaline degeneration, losing their nuclei — the so-called " coagulation-necrosis " of Weigert. There may be necrosis of the false membrane, and of the stroma of the underlying mucous membrane as well, which may be- come gangrenous in some cases. Erosion of large arteries with even fatal hemorrhage may result. If the patient recovers, the false membrane sloughs o^ en masse or by gradual disintegration, superficial ulcers being usually left. If the ulcers be deep, evident cicatrization may result. Successive crops of membrane form if the false membrane be forcibly detached. In the false membrane are found the characteristic bacilli associated with a variety of other organisms, especially streptococci and staphylococci, which, as a rule, penetrate more deeply than does the Klebs-Loeffler bacillus. The appearance of the membrane varies. It may be ad- herent, a bleeding surface being left after its forcible removal, or it may be shreddy and readily detached. It may be thick, soft, and yellow, or it may be thin and so transparent that it can hardly be seen by the naked eye, and in some cases there may be evident only a localized hyper£emia. It may be of a dirty-green color, or it may be putrid and gangren- ous. The surrounding mucous membrane is congested and inflamed. These appearances are identical with those of pseudo-diphtheritic membranes, the only point of difference being the presence of the Klebs-Loeffler bacilli in the true cases. Complicating lesions are variable. There may be adenitis of the lymphatic glands near the infected area, which may proceed to suppuration from mixed streptococcus infection. The periglandular tissues, and even the salivary glands, may become in like manner affected. Bronchitis, either catarrhal 96 M.tXrAL OF THE FKACTICE OF MEDICIXE. or diphtheritic, areas of atelectasis, and patches of broncho- pneumonia are usually present in fatal cases. There may- be endocarditis in rare cases, but an acute degeneration of the heart-muscle is not uncommon and may lead to sudden death. The kidneys may be the seat of an acute degeneration or of an exudative or a diffuse nephritis. The spleen may be found large and soft. In cases fatal from asphyxia the viscera are usually congested. Incubation may occupy from one to fourteen days, the average duration being from two to five days. The symptoms may be divided into two groups : i. Gen- eral SN^mptoms due to the ptomaine-poisoning, and which are the same in all cases ; 2. Local svi/iptoiiis, which vary according to the localization of the lesion. I. General Symptoms. — In some cases the disease begins abruptly with a chill or, in children, with convulsions. Usu- ally, however, the onset is insidious, being marked by pros- tration, fever, and often by digestive disturbances. The fever does not run a typical course ; it may be as high as 104° F., but a temperature of from 101° to 103° F. is more common. It is often irregular or intermittent, and possibly is altogether absent even in fatal cases. Prostration is an early and constant symptom, and is proportioned more to the actual gravity of the case than to the height of the fever or to the local lesion. In mild cases prostration may be slight or absent. The pulse is rapid, with a tendency to become feeble according to the severity of the disease. In some cases the pulse may be slow (50 to 60) ; this is not usually a favorable sign. At any time sudden or gradual heart failure may develop, even during advanced convalescence. This makes the prognosis uncertain in every case. Sudden heart failure will be followed by almost instanta- neous death. Gradual heart failure will be shown by increas- ing rapidity and weakness of the pulse, dyspnoea, cyanosis, and congestion of the different viscera, with death in a itv^ hours or days. Cerebral symptoms comprise stupor, often alternating with DirnrHERfA. 97 restlessness, or mild delirium or convulsions, semi-coma, and coma. These symptoms are rather rare considering the severely toxic character of the disease. They may appear early, from the toxic action of the ptomaines on the nervous centres, or they may appear late, as the result of asphyxia. In some cases there appears an erythematous eruption resembling that of scarlatina. It is, however, evanescent, fading usually in a few hours. Bacterial examination of the pseudo-membrane or the exudate may be necessary to differentiate between this disease and those cases of scar- latina complicated with pseudo-diphtheritic pharyngitis. In malignant cases there may be purpura. Albuminuria occurs in the majority of severe cases, from parenchj'ma- tous degeneration of the kidney. The occurrence of a true nephritis must be considered as a complication. 2. Local Symptoms. — (a) Tonsillar Diphtheria. — This is the commonest form of diphtheria, and at the same time the least serious. There are three clinical forms : (i) There is a pseudo-membrane on one or both tonsils, having no relation to the crypts. (2) The crypts of the tonsils are filled with a pseudo-membranous exudate which appears on the surface as white points, resembling in every way the appearances presented by ordinary follicular tonsil- litis, and from which it can be differentiated only by bacterial examination. These white points in some cases may so coalesce that the tonsils are covered with irregular white patches. (3) The tonsil swells ; there are swelling and oedema of the surrounding structures, resembling the ap- pearances of ordinary suppurative peritonsillitis or quin.sy. No membrane is visible until after thirty-six to forty-eight hours. These cases, which seem to be due to bacterial invasion of the deeper structures, are apt to do badly. The local symptoms of the first two varieties are apt to be mild, lasting but a few days. There may be moderate fever; prostration is slight or absent ; the voice is muffled ; there are pain and soreness, which are increased by talking or SAval- lowing. However mild the case, the disease may spread and become severe, or it may be followed by any of the com- 98 MA.VL-JL OF THE PRACTICE OF MEDICIXE. plications or sequel.x, and it may be the cause of infecting^ others even with the most severe forms. (/;) P]iarvngcal DiplitJicria. — (i) There may only be an area of local hyper^emia without any pseudo-membrane. This condition is seen in those exposed to diphtheria, and is commonly called " sympathetic sore throat." It is really diphtheritic, however, and may not only be followed by sequelae or the spread of the disease, but may even be the source of contagion to others. (2) There may be a pseudo-membrane evident, usually associated with membrane on the tonsils. Symptoms. — In mild cases there may only be malaise, slight fever, and a raw feeling in the throat. In severer cases there may be pain, increased b\' talking or by swallow- ing, muffled voice, fetid breath, and in some cases ptyalism. (3) Nasal diphtheria is rare as a primary form, being usu- ally secondary to membrane in the pharynx. From the for- mation of pseudo-membrane in the nasal cavities and the attendant swelling of their mucous membranes the nostrils become more or less occluded. There is usually a dis- charge from the nose of muco-pus or sero-pus, which may be stained with blood. In some cases there is a brown, watery discharge which stains the pillow and excoriates the hps. The glands of the neck are more often involved in naso- pharyngeal diphtheria than in any other form, considerable deformity usually resulting from their tumefaction. If the nose be involved, the patient is apt to do badly. Death usually results from sepsis with cerebral symptoms or from heart failure. Small babies either asphyxiate or starve Trom their inability to breathe if they are nursed, unless they are fed by the stomach-tube. (4) Laijngcal diphtheria is a common form, and is greatly dreaded for the following reasons : {a) There is apt to be asphyxia from the occlusion of the glottis by pseudo-membranes, by the swelling and oedema of the vocal cords, and in some cases by their paralysis, from the projection of little tongues or tags of loose pseudo- DJPI/'l'JJKRfA. 99 membrane into the rima glottidis, and by the spasm from time to time of the laryngeal muscles. {J}) As the larynx is seldom infected primarily, but is affected from the spread of the disease from the pharynx, the pseudo-membrane is apt to be extensive and toxaemia severe. (c) The pseudo-membrane is apt to spread downward and to involve the trachea and the bronchi. id) There is apt to be developed either septic broncho- pneum.onia or " deglutition-pneumonia " or areas of atelec- tasis. {e) Because the larynx is affected usually in children, who do not stand the disease well. Symptoms. — The voice is hoarse and croupy, and may be reduced to a faint whisper. There is a hoarse, croupy cough. The breathing is rapid and inefficient, and there is obstructive dyspnoea which may be either obvious or masked. In obvious dyspnoea the child sits up with the neck craned forward, to bring into play all the accessory muscles of respiration. The alae nasi dilate; inspiration is prolonged and stridulous. There is inspiratory sinking of the spaces above and below the clavicles. The face is anxious and distressed, and may be semi-cyanotic. From time to time there occur paroxysms of increased dyspnoea that are often relieved by coughing up pieces of pseudo-membrane. Unless the con- dition is relieved by the casting off of the pseudo-mem- brane or by operative interference, the child passes into the condition of masked dyspnoea. In masked dyspnoea the child no longer struggles for breath, but lies flaccid or in a stupor which may deepen into coma. The skin becomes cold and livid, the pulse becomes more rapid and feeble. In this condition the patient may remain for from one to four days, and recovery from this stage is exceedingly rare. All cases, however, do not pass into this stage, but after a time the pseudo-membrane be- comes loosened and is coughed up either in large pieces or by gradual disintegration. Glandular swellings are not seen jn diphtheria of the larynx alone. lOO MA.VL'AL OF THE PKACTICE OF MEDICINE. Complications and Sequelae. — Local complications have already been alluded to. They are sloughing, erosion of arteries with hemorrhage, and swelling of the neighboring glands. Pulmonary complications occur in almost all fatal cases, and present their ordinary symptoms and physical signs. Should pneumonia occur in very sick patients, its symptoms are frequently masked by those of the primary disease. There may be gastritis or enteritis. Renal complications are common. Acute parenchymatous degeneration shows itself by changes in the urine alone. Acute exudative or acute dif- fuse nephritis may occur during the disease or during con- valescence. There are the changes in the urine common to such lesions ; there may be suppression with uraemic symp- toms. In some patients much exhausted by the disease uraemic symptoms may not appear. Of the sequelae, peripheral neuritis is the most important. It is seen in from lo to 40 per cent, of all cases, according to the epidemic, and usually occurs in the second or third week of convalescence. It may follow either mild or severe cases. The muscles most frequently paralyzed are those of the soft palate. The voice becomes nasal, there is inability to clear the throat, and deglutition is interfered with, fluids regurgitating through the nose. This may be the only symptom. The patient may have to be fed through the stomach-tube, especially if the paralysis extend to the con- strictors of the pharynx. The next most common forms are paralyses of the eye- muscles. The intrinsic muscles may be affected, causing dilatation of the pupil and loss of power of accommodation. The involvement of the extrinsic muscles produces ptosis and strabismus. If the nmscles of the larynx be affected, there will result dysimoea, aphonia, and a croupy cough. More rarely the muscles of one or more extremities may become paralyzed, or there may only be some weakness in the legs with loss of tendon-reflex. Dfi'irrifF.k'iA. loi Diphtheritic paralysis usually lasts but a few weeks or months, terminating in recovery, although in some cases it may become permanent. The nephritis may become chronic and lead to the death of the patient. There may be resulting endocarditis. If the conjunctivae be the seat of a pseudo-membrane, ulcers of the cornea with opacities usually result. The prognosis is always serious, and must in all cases be made guardedly, because, however mild the attack may be, it may at anytime spread and become severe. The dan- ger of heart failure must always be regarded. The progno- sis depends upon the character of the prevailing epidemic and also upon the age of the child, 42 per cent, of cases being fatal before the fourth year, 35 per cent, between the fourth and tenth years, and 10 per cent, between the tenth and twentieth years. The average mortality is about 25 per Cent. The prognosis depends not only upon the severity of the general infection, but also upon the locality and extent of the lesions, being worse in nasal, laryngeal, pharyngeal, and tonsillar cases in the order mentioned. The prognosis also depends upon the presence of complications and upon possible sequelae. As a rule, a good prognosis may be given to cases of tonsillar diphtheria that do not spread within two days. The mortality has been reduced within the past year, under the antitoxine treatment, to just one-half the former death-rate. If cases can be treated by antitoxine within the first thirty-six hours, the mortality will still further be reduced. Treatment. — Prophylactic Treatment. — Careful isolation should be enforced, not only for the patient, but also, as far as possible, for the attendants. " The members of a household in which a case of diphtheria exists should be regarded as sources of danger unless cultures from their throats show the absence of virulent diphtheria bacteria " (Park). Attendants on the sick should receive immunizing doses of antitoxine. Isolation should be continued until the bacilli are proved to be absent. In one-half the cases the bacilli disappear within three days after the disappearance of I02 MA.VL'AL OF THE PKACT/CE OF .VFD/CIXE. the pseudo-membrane ; in one-third of the cases, in seven days ; in one-tenth of the cases, in fourteen days ; while the bacilli max- remain in a small percentage of cases as late as the sixty-third day. After isolation is relaxed, the room, with the bedding, toys, etc., should be fumigated thoroughly with sulphur, and the linen should be boiled in 2 per cent, carbolic solution. The w^alls and the floors should be scrubbed with i : lO.OOO bichloride solution. General Treatment. — The child should be put to bed and be kept on a milk diet. The temperature of the room should be 70° F., and the air should be kept moist. The use of the steam-tent will be alluded to. Careful attention should be paid to the heart, and stimulants should be given freely when required. Especially are alcoholic stimulants to be recommended. The danger of heart failure during early convalescence should not be forgotten. The temperature may be controlled, if necessary, by hydrotherapy. Internal antipyretics should be avoided. Large repeated doses of the tincture of the chloride of iron (4 to 5 drops hourly to a child of three years) and the use of corrosive sublimate in small doses (gr. -^ every four hours as a limit, or gr. -gL. every hour) have been recommended warmly. The former is recommended, with alcoholic stimulants, as a routine treat- ment. Chlorate of potash should not be emplo}xd, because of its evil effect upon the kidneys. Local Treatment. — As diphtheria is a local disease at first, the bacilli growing in the pseudo-membrane and elaborating there the toxalbumins that poison the system, local treat- ment becomes of the first importance in destroying the activ- ity of the germ and in removing the toxalbumins when formed. Rough treatment and the mechanical tearing off of the pseudo-membrane are of actual harm. The best treatment consists in the thorough irrigation of the throat and nose with a neutral salt-solution (3j to Oj) or with boric-acid solution, a tablespoonful to the pint. A foun- tain syringe should be used, and the fluid should be at a temperature of 85° F. The patient lying on the side (as in Plate 9), the nozzle of the irrigator should be inserted in the upper nostril until the fluid runs out of the other DiprrniERiA. Pl.A'l K 9. Irrigation of naso-pharynx (Berg). DIPIITUERIA. 103 nostril and the mouth. Then the process is repeated with the lower nostril. The tip of the irrigator should then be passed well back over the dorsum of the tongue, and the pharynx well flushed out. In case the nostrils be occlud- ed with membrane, the fountain syringe may be elevated six or eight feet. Such irrigation should be done every two hours. In septic cases irrigation with bichloride (i : 4000 to I : 8000) may be employed every four to eight hours in addition. If the membrane be thick, insufflations of papoid powder may be used to advantage. Other local remedies have been recommended, but are not now as much used as formerly. Among these remedies are insufflations of powdered sulphur, applications of tincture of the chlo- ride of iron, iodine, peroxide of hydrogen, trypsin, and lactic acid. So high an authority as Loeffler recommends the follow- ing method of local treatment : After cleansing the surface of the pseudo-membrane the following solution is to be ap- plied on cotton swabs for ten seconds every three hours, later three times a day : 3^. Alcohol, 60 volumes ; Toluol, 36 volumes ; Liq. ferri sesquichlorati, 4 volumes ; Menthol, 20 volumes. In laryngeal diphtheria with dyspnoea two additional rem- edies are warmly recommended — the steam-tent and calo- mel fumigation. The steam-tent should be used upon the first appearance of dyspnoea, but it may be used in any case as a routine measure. A good way to form the tent is to throw sheets over clothes-horses arranged about the bed, or to suspend from the ceiling an open umbrella about which the sheets can be draped. The nozzle of a steam-kettle should be in- serted within the tent, so that the air is kept constantly moist. Calomel inhalations have been employed in laryngeal diph- theria, especially with dyspnoea : 10 to 20 grains may be used 104 MAXr.lL OF THE PRACTICE OF MEDICLXE. evci")- two to four hours without dant^cr of salivation to a child, although the nurses may suffer from sore gums ; mer- curic diarrhoea may, however, occur. The calomel should be piled on a piece of tin resting upon the sides of a small pail or chamber utensil, un- der the centre of the tin be- ing the alcohol lamp (Fig. i)_ The whole apparatus is to be placed inside the croup-tent, and care must be exercised that the child does not kick the lamp over and set fire to the bedding. When the laryngeal pseudo- membrane is being loosened, Fig. I.— Method of fumigating with caio- its Separation may be hast- mel : a, pail (section); b, alcohol; c, strip „ j u >.• u i.i f, ,, , ., Y , , , ened by emetics; but these of bent tin ; a, pile of calomel powder. -' ' are not to be recommended except in robust cases with good heart-action, in whom dyspnoea appears due to the obstruction caused by the loose membrane and the mucous secretion. When actual obstructive dyspnoea begins the question of operative interference comes into consideration. For the details of intubation and tracheotomy the reader is referred to works on surgeiy. It seems that intubation should be our first choice, and it should be done as soon as cyanosis, restlessness, and sinking of the intercostal spaces are noticed Serum-therapy. — The growth of the Klebs-Loefifler bacillus (Plate lo) in the body-tissues develops the peculiar toxalbu- min to the poisoning from which the constitutional symptoms are due. Nature in some unknown way elaborates in the body an antidotal poison, the antitoxine, and when the two poisons balance in effect the constitutional symptoms cease and the patient recovers. If antitoxine can be made outside the body, and injected when needed, in sufficient doses, without waiting for the system to elaborate it, the disease, it was thought, might be stamped out at the onset. The growing experiences of the past year tend more and more to prove the correctness of this assumption. DIl'inilERIA. ri.ATF, lO. ~M_:! M... A.J I. Klebs-Loeffler bacillus (photographed by Dr. W. H. Park). 2. Hutchinson teeth. DIPJJ'J'JIKRfA. loi; We may obtain the toxine of the Klebs-Locffler bacillus by growing it in a suitable culture-medium, and by injecting it in increasing amounts into an animal susceptible to diph- theria, such as the horse. The serum of the horse's blood will gradually become saturated with the newly developed substance, which is antidotal to the toxine. This may be withdrawn, separated as far as possible from the rest of the blood, preserved by the addition of certain substances, or DATE 12 13 14 1 15 16 17 18 I NOV PM AM PM AM PM |flM|PM am|pm flM|PM P.M PM L « a. iatic Injluoiccs. — Heat is most important. " Malaria rarely extends bej'ond 64° of North latitude and 57° of South latitude " (Hertz). As we near the equator the disease increases steadily in severity and persistence. Altitude. — People living in the upper stories of a house are not so apt to contract the disease as those living on the ground floor. (The mosquito does not fl}' a great distance from the ground.) Telluric Conditions. — Anything that results in the forma- tion of pools of stagnant water may be productive of a malarial endemic, as this condition favors the growth of the larvae of the mosquitoes. Immunity. — No race is absolutely immune. Negroes are less subject than the whites to the pernicious forms, and, having once become infected, they acquire relative immunity more easily than do the whites. Congenital and in some instances " family " immunity undoubtedly exists. Acquired immunity after several attacks is not so very rare. Patholog-y. — Within the organs of persons who have died of malaria there are found, first of all, the malarial parasites containing pigment and lying more or less intravascularly. In the aestivo-autumnal variety the organism is found princi- pally in the spleen, bone-marrow, and liver. The character- istic lesions in all cases are certain changes in the blood, spleen, and liver. In the more intense and acute forms numerous pigment particles are found in the blood. These particles are either free in the blood, or imbedded in the leucocytes or in the endothelium of the blood-vessels. This melannsmia results directly from the destruction of the red cells by the parasites. The pigment is most abundant in the blood-vessels of the spleen and the liver. In acute cases MALARIA. 143 the spleen is regularly enlarged, the capsule is tense, the parenchyma chocolate colored or brown, very much softened, and sometimes diffluent, and in such a condition it may be lacerated, especially when there are adhesions. The liver is usually somewhat enlarged, and assumes a brownish or blackish color. In the severer forms extravasation of blood from the mucous membranes and into their substance may take place. There may be jaundice. Focal necroses in the viscera, similar to those seen in other acute infectious dis- eases, have been described. Acute exudative nephritis is not infrequently seen. Thromboses of internal vessels have been reported, at times the greater part of the thrombus consisting of malarial organisms. In thd protracted cases the liver and spleen frequently show cirrhotic changes. At times the hypertrophy of the spleen is enormous — " ague- cake " — and may extend to the umbilicus and even beyond. The blood regularly becomes markedly anaemic. As a rule, the corpuscles and haemoglobin are diminished pro- portionately (secondary ansemia). At times it may be so severe as to resemble pernicious anaemia. In convalescence the restitution of haemoglobin is often incomplete. There is usually a leucopenia. The differential count shows a lympho- cytosis. Symptoms. — hiaibation. — As in the other infectious dis- eases, there is a period of incubation from the moment of entrance of the parasite into the system to the development of the disease. The disease is frequently so mild that it is unobserved by the patient. In some instances the disease manifests itself only after the patient has left the very mala- rious district and moved to another locality. According to recent experiments, the periods of incubation of the various types are as follows : Quartan, about fourteen days ; tertian, eleven days ; aestivo-autumnal, six days. During the period of incubation the patient may suffer from headache, consti- pation, a coated tongue, and malaise. A. Regular Malarial Fevers ; Intermittents. — There are two important types, the tertian and the quartan. The tertian is common in temperate climates. Single tertian implies that there is a paroxysm every forty-eight 144 .V.-iXr.lL OF THE PRACTICE OF MEDICINE. hours. In double tertian or pseudo-quotidian there is a paroxysm every twenty-four hours. The quartan is very rare in this latitude. The paroxysms come every seventy-two hours. In double quartan there are paroxysms occurring on two succeding days, followed by a third day which is free from an}' paroxysm. In triple quartan or pseudo-quotidian there is a paroxysm eveiy day. PlioiODicna of t)ic Attack. — The ordinary paro.xysm is divided into three stages — /. c, the chill, the fever, and the sweating. CJiill. Marked by chilly sensations, especially along the spine, yawning, and the development of "goose- flesh " ; nausea, vomiting, and headache may be present. The pulse is rapid. At this stage the temperature has already risen, and then a violent shaking chill sets in. The face becomes pale ; the teeth chatter ; the whole body feels icy cold and looks bluish. The patient seeks extra bed- clothing or huddles up near the fire. The surface ther- mometer indicates a reduction of the temperature. The rectal temperature may reach 107° F. This stage lasts from fifteen minutes to two hours. Fever. The surface cold- ness gradually disappears ; the skin becomes hot and dry ; the entire body becomes flushed ; the heart-action becomes forcible ; the pulse full and strong. The headache becomes aggravated and throbbing. The temperature during this stage may be higher than during the chill, but it usually begins to decline. Delirium sometimes occurs. This stage lasts for from one to four hours. Szt'cathi^s^. This stage begins with the appearance of moisture on the skin ; gradu- ally the whole body becomes bathed in a profuse perspira- tion. All the untoward symptoms abate and the patient sinks into a refreshing sleep. The uniformity in the dura- tion of the paroxysms is remarkable. Albuminuria may be present. The spleen may enlarge, and in children convul- sions may occur. Tune of Recurrence. — The recurrence of the paroxysm is usually at the same hour. As the disease progresses there is frequently a tendency to " anticipation ; " in some cases there may be "retardation." B. Irregular Malarial Fevers. — .Spring and early summer w ■d CD CD • •• ^^^ --^ 00 \ ^ ..'"^ CO 1 — .,-, — ■ ■ .^. . ~ ^ . ■ "" s V- .... y 1_ '^^-^ TTTT- *• • • r^ ._-^ ,— -rrrr =i= M ^ ...^ ~r -- M \ 107° 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° rr-r-r^ , .... ~ :::z — — -♦■ — — ■ — ..... i ~~r l^ .... .... — _^_»_ _— — — *'*'l"" — r" , 1 1 107° 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° •- ■— ~ — ^ -^ — ■ ■1 - .... s: y —^ gart ^ _ — « . -— ~" .... , ■"— =5rt ■ — ' '"*" ■s: >•• ■^. i m m CD CO o CD CD CD -< O M O to o w o g St) a ....!.... M ~*-^^^ • * 1 > f '^ t>2 > ^--^ 03 i> P- ^2 :>- -^•""'^ •<: 01 •^••^-^ "^>» < ^ 05 ^ .^ <:' -a --^ ^>- r^ •c" 00 Kij^. > ^ -sr CO • rf^ ■ "^ ^ > ^ < •^ > ^ / ■ — .... c -J c o a o < -1 ► o i c o % o -J h D C Jl ( o - 1- i MALARIA. 145 infections are usually intermittent. Late summer and autumn cases are characterized by a large number of irregu- larly intermittent, of continuous and remittent, and of the pernicious fevers. {a) Irregular bitermittenis. — Autumnal are less definite than the spring agues. The paroxysms are longer and tend to approach each other ; by coalescence we may get a pseudo-crisis. In very mild cases either the chill, the fever, or the sweating may be absent. {F) Continuous and Re^nittent Malarial Fevers. — In the beginning there is usually general malaise, and occasionally nausea and vomiting. The disease may set in with a violent chill, and chilly sensations may recur for several days. Gastric symptoms may be marked. The fever may be con- tinuous, with daily remissions, or there may be remissions or intermissions at short intervals. There may be jaundice. The general appearance maybe suggestive of typhoid fever. The cases vary greatly in severity. The fever may subside in a few days, or persist for two weeks or more. Delirium, coma, and hemorrhage are not very uncommon. {c) Pernicious Malarial Fevers. — These are rare in tem- perate climates. The following are the most important forms: (i) TJic comatose form. Complete unconsciousness following delirium or coming on suddenly. Unconscious- ness may persist for from twelve to twenty-four hours, and the patient may die in coma, or he may recover conscious- ness and die in a second attack. This is seen most fre- quently in the neglected cases, and is not confined to the sestivo-autumnal, but is seen also in tertian and quartan infections. Few parasites are found in the circulation in many cases (Ewing). (2) Algid form. Complete collapse, usually with gastro-intestinal s^^mptoms, with or without delirium or stupor. (3) HemorrJiagic form. Characterized by bleeding, usually from the kidneys. (4) Gastro-enteric form. Has for its prominent symptoms gastro-intestinal symptoms with moderate collapse, resembling the third week of typhoid fever. C. Malarial Cachexias. — Its two distinguishing features are anaemia and enlarged spleen. The spleen is usually 10 146 J/.-l.Vr.lL OF THE PRACTICE OF MEDICI.VE. liard, smooth, and not tender. Tlie an?emia is secondan- and may be ven' marked. It occurs especially in those who have li\ed for a time in malarious districts or have been imi)roperly treated. They may not have had typical malarial attacks. The principal symptoms are headache, constipation, bilious attacks, increasinij anaemia (skin " muddy yellow "), tendency to hemorrhages, irregular fever, paroxysmal neuralgias, especialh- supra-orbital, jaun- dice, and mental depression. Complications and Sequelae. — Acute catarrhal colitis. Acute degenerative or exudative nephritis, occasionally spontaneous rupture of the spleen, and very rarely acute lobar pneumonia, ha\-e been found to complicate malaria. Whether or not typhoid can run concurrently with malaria is still in doubt. Cases of so-called " typho-malaria " are usually " enterica." According to Ewing, malarial parasites are never found during typhoid except at the beginning of the disease or during convalescence. This author also says that typhoid fever is to a large extent incompatible with malaria, and that during the course of the former the latter infection is usually suppressed. This opinion, however, is not generally held, for some {&\\ cases have been reported by competent observers in which the malarial organism was found in the process of sporulation while the typhoid fever was at its height. Diagnosis. — The diagnosis of all forms of malaria is simplified by finding in the blood the plasmodium, and by the subsidence of the disease upon the administration of quinine. It has been asserted that splenic puncture is occasionally needed for diagnostic purposes. This pro- cedure, however, is not alone very dangerous, but also unnecessar}\ " In every case in which pigment-bearing leucocytes are observed in the blood, malaria should be suspected, as a melanaemia has so far only been observed in this disease, relapsing fever, and in connection with rare melanotic tumors " (Simon). It is important to bear in mind that malaria, typhoid, and tuberculosis are the only febrile diseases that are regularly accompanied by a leucopenia. Septicaemic fever, such as that of advanced tuberculosis, MALARIA. 147 puerperal fever, empyema, and ulcerative endocarditis are frequently mistaken for malaria. Here also we get re- curring chills with fever and sweating, but the attacks are not as regularly periodical and intermittent, the chills are not so regular and less violent. Sometimes the fever is in- termittent, sometimes remittent. Septicaemia almost always gives a hyperleucocytosis, and such fevers do not respond to quinine. The malarial organism is not present. The search for a local cause for the septicaemia should not be neglected. Typhoid is to be differentiated from severe malaria by the history, blood-examination, serum test, diazo reaction of the urine, the continuous temperature, which is usually absent in malaria, and by the general symptom- atology. Marked splenic hypertrophy in chronic malaria (the so-called " ague-cake ") may have to be differentiated from Splenic Leukaemia. The history of malarial cachexia, the absence of lymphatic enlargements, and the blood- examination, showing a leucopenia as contrasted with the marked hyperleucocytosis of the latter disease, are usually sufficient to make a diagnosis. Method of Examination of the Blood. — If made purely for diagnostic purposes, the fresh specimen is to be preferred to all others. In looking for the malarial organism it is well to bear in mind that if the iris diaphragm is kept well open, the moving pigment particles are more easily recog- nized. These moving pigment particles resemble nothing else in the blood, and when once recognized can never be forgotten. Movement of the pigment can occasionally be seen an hour after the preparation of the fresh specimen. If the examination cannot be made within this time, the slide must be fixed and stained. After allowing the slide to dry thoroughly in the air, it is fixed according to the stain employed. For the methods of preparation of a slide the reader is referred to Cabot's book on The Blood. For rapid work the best results are to be obtained with the thionin and Jenner stains. In staining with the former the dry smears are fixed in a mixture of 25 per cent, of formal- dehyde and strong alcohol. This mixture can most easily be made by adding 5 drops of a 4 per cent, formaldehyde 148 MAXfAL OF THE PRACTICE OF MEDICINE. solution to 10 c.c. of alcohol and using immediately, as It does -not keep. Fixation is complete in one minute. The stain is made by adding 20 c.c. of thionin in 50 per cent, alcohol to 100 c.c. of a 2 per cent, carbolic-acid solution. Stain the smears in this mixture for fifteen to thirty seconds. Wash off in water, dry, and examine with an oil immersion lens. By this method only the plasmodia and the nuclei are stained, while the red cells are a faint greenish yellow which contrasts sharply with the purple of the plasmodia. The Jcnncr stain is prepared as follows : Equal parts of a 1.2 per cent, to a 1.25 per cent, aqueous solution of Grijbler's eosine, yellow shade, and of a i per cent, aqueous solution of methylene-blue are mixed in an open basin, thoroughly stirred, and set aside for twenty-four hours. The resulting precipitate is filtered off, dried, powdered, washed with water, and again filtered and dried. Of the dye which has thus been prepared, a 5 per cent, solution in pure methyl alcohol is made, to which 10 per cent, of glycerine is added. After the specimens are dried in the air, without further fixation, they are well covered with the stain and then covered with a Petri dish (to prevent evaporation) for from one to four minutes, depending upon the freshness of the stain. They are next washed thoroughly in water until the purple stain has changed to a mahogany color (about thirty seconds). The specimen is then dried, and is ready for examination. The advantage of this stain is that one is thereby enabled to stain rapidly without previous fixing. At the same time it allows of a differential count and an examination for bacteria to be made. For the demonstration of the chromatin of the nucleus of the plasmodium the modification of the Roman- owsky stain suggested by Nocht is the simplest. For details of this and other stains the reader is referred to the recent book by Dr. Wood, and to the latest edition of C. E. Simons' work on Clinical Diagnosis. Prognosis. — Here we have to consider the nature of the infection, the locality and season in which it was contracted, as well as individual conditions. In the mild fevers the prognosis is usually good. In these fevers the number of MALARIA. 149 organisms found in the circulating blood gives us in most instances an index of the severity of the infection. We must bear in mind that relapses may occur for a long time, and if a patient continues to live under bad hygienic condi- tions, cachexia may follow. Spontaneous recovery occasion- ally occurs, but these cases, if untreated, almost always have relapses within a month or two. In the aestivo-autumnal infection the prognosis is not so bad as older writers would lead us to suppose, more especially in those cases where the progress of the disease is checked before the crescents have developed. In the pernicious forms the prognosis is usually grave. Here the occurrence of previous attacks must be taken into consideration, for in this event the prognosis is always bad, although there are reported recoveries from a second and even a third attack. In these cases the number of parasites in the circulating blood is not a fair index of the severity of the disease. The pernicious fevers arranged in the order of their relative gravity would be : Cerebral, hemorrhagic, gastro-intestinal, and algid. The prognosis of malarial cachexia depends upon the time it has existed, the severity of the anaemia, and the hygienic conditions existing. Prophylaxis. — Means adopted in this direction depend to a great extent upon the location dealt with. In the tropical climates the problem is a most serious one, for here the disease appears to be gaining rather than losing in both extent and severity. Fortunately, in the vicinity of New York the problem is much more hopeful. It has been suggested that all cases of malaria be reported to the Board of Health and isolated. This measure, however, appears as yet to be somewhat too radical, and would hardly meet with general approval. It seems practical, however, to appoint inspectors, to instruct the occupants of infected houses or districts in the measures to be employed for the destruction of the Anopheles, to provide proper screening of houses, and to supervise in the filling up, draining, stock- ing with fish, or petrolizing of all stagnant pools in the vicinity. Quinine should be insisted upon, and furnished I50 MAXr.lL OF THE PKACTICE OF MFDIChVE. gratis when necessary. Proper food and water are essential. The season and the hours for work in malarious districts should be carefully selected. Houses should be built in as elevated a position as possible. They should be exposed to the wind, and be as far from stagnant pools as is practical. For further information about this most important measure the reader is referred to the articles of Dr. Berkeley in the Nciv York Medical Record of January 26, 1 901, and also the recent books of Celli and Bignami and Marchiafava. Treatment. — Iiitcniiittcnt Cases. — During the paroxysm measures are employed to combat the symptoms from which the patient is suffering. During the chill external heat is em- ployed, and, if the stomach will bear it, hot drinks are given. In some cases small doses of the tincture of capsicum or gin- ger are useful. In the hot stage exactly opposite remedies are employed. Cold sponging is frequently comforting to the patient. If necessary, stimulation is employed. Anti- pyretics should not be used. As to the time of the admin- istration of quinine, opinions differ, but this seems to make very little difference, so long as the dose is large enough and is kept up for a sufficient length of time. Good results have been obtained from the administration of quinine sul- phate or hydrochlorate, in capsule or preferably in solution, in doses of 5 grains three or four times in twenty-four hours for one or two weeks, followed by doses of 2 grains three times a day continued for two months. Larger doses than this are usually not necessary. Quinine sometimes acts more efficaciously if preceded by a mercurial purge. The mixture of quinine and aromatic sulphuric acid is very satis- factory. In some few rebellious cases evaporated tincture of Warburg is useful. In children quinine-chocolate tablets or some other palatable form may have to be employed. /;/ the continuous fevers it is occasionally necessary to give somewhat larger doses, and to continue the drug for a greater length of time. Warburg's tincture sometimes helps these cases when all other remedies have failed. The fol- lowing prescription sometimes gives good results : AN71IRAX. I^. Quininae sulphatis, gr. v; Tincturae opii, mv; Tincturse capsici, mv.— M, Si?, t. i. d. 151 In the pernicious types the patient should be thoroughly and rapidly cinchonized. It is usually impossible to do this by mouth, owing to the incessant vomiting, so that hypodermic administration of one of the soluble forms of quinine is necessary. Stimulation and feeding per rectum in severe cases is also essential at times. Malarial Cachexia. — In many of these cases the parasites are no longer present in the blood, so quinine is of little use. Mild cases do well under proper hygienic and tonic treat- ment, such as iron, arsenic, and strychnine. The very chronic cases, with marked enlargement of the spleen and liver, are usually very troublesome. These cases occasion- ally resist all treatment and die with the symptoms of per- nicious anemia. Numerous other remedies have been introduced as substitutes for quinine in the treatment of malaria. All of these, however, have been proven inferior, ANTHRAX. Definition and Synonyms. — Anthrax is an infectious disease caused by the anthrax bacillus. Syiionyms : Malig- nant pustule ; Malignant oedema ; Splenic fever ; Charbon ; Milzbrand ; Woolsorter's disease. Etiology. — Anthrax which is primarily a disease of cattle, sheep, and horses, is occasionally communicated to man. It is especially frequent in Russia, Siberia, in parts of Europe, and in South America. The bacillus of anthrax was the first specific micro-organism ever described. It is a rod bacillus two to ten times longer than the diameter of a red blood-cell, non-mobile, with abundant spore-growth. The rods are often jointed together, forming long filaments. The bacilli are readily destroyed, but the spores are ex- ceedingly resistant, and live for a long time in the grass or on the surface of pasture-land. Cattle acquire the disease by eating the infected grass or by inhaling the spores. 152 MAA'UAL OF THE PRACTICE OE MEniCLYE. . In man the disease may be acquired by inoculation, by inhalation, or by the alimentary canal. Inoculation results from handling infected hides, wool, hair, or instruments, or b\' bites of flies or of mosquitoes. The disease may be ac- quired by inhalations from infected skins or wool, or the alimentary canal may be infected from diseased meat. Symptoms. — The disease occurs in an external and an internal form. I. Externa/ Form. — {ci) Malig>ia]it pustule is the most common form, and it occurs from inoculation of an ex- posed surface, usually the face. Symptoms begin from a few hours to four days after inoculation, with itching, pricking, or burning like the sting of an insect. A papule is formed, developing into a vesicle which ruptures, dis- charges bloody serum, and leaves a spot of brown dry gangrene surrounded by a zone of red swollen skin which may be covered by vesicles and which resembles a carbun- cle. There is brawny oedema of the subcutaneous tissues that may involve the whole of an arm or the side of the neck within thirty- six hours. There are usually lymphan- gitis and phlebitis starting from the infected areas. Constitutional symptoms occur if the infection becomes general. These symptoms are usually delirium or a tran- quil mind, fever, sweating, vomiting, collapse, and death, from heart failure or in the typhoid condition, in from five to eight days. If general infection does not 'occur, the constitutional symptoms are those which ordinarily accom- pany a local inflammation. The prognosis is exceedingly grave, although in a large number of patients who recover the slough separates and the wound heals. The mortality is greatly reduced if rad- ical treatment be resorted to at the onset. {b) Maligna]it CEelema. — This form occurs in regions where the connective tissue is loose, as the eyelids, neck, and forearm. The skin may not be discolored, but there is a flat infiltration with ill-defined borders and a rapidly-spreading oedema which may be of sufficient intensity to cause gan- grene. Constitutional symptoms occur early, and the disease is almost invariably fatal, although recovery is possible. ANTHRAX. I'l.AlK 14. i Bacillus anthracis : cover-glass preparation from spleen of white mouse {American Text- Book of Surge?-}'). JIYDROJ'IIO/UA. 153 2. Internal Form. — {a) Intestinal Form (Mycosis Intesti- nalis). — This form of anthrax is caused by eating infected meat, and it may affect a number of people at the same time. The attack begins as an acute infection with a chill, fever, pain in the head and back, with severe gastro-intestinal symptoms, vomiting, and diarrhoea. There is a tendency to hemorrhages, and metastatic malignant pustules may occur on the skin. There may be delirium or convulsions. Dyspnoea and cyanosis are common, and death from heart failure occurs in a few days. These cases are invariably fatal. {b) Woolsoriers' Disease. — These cases result from sorting and picking infected hair and wool. There is a chill, fol- lowed by fever, pains in the head and chest, dyspnoea, and cough. Vomiting and diarrhoea are common. There may be a clear and tranquil mind, although delirium and uncon- sciousness are frequent. There is increasing heart weak- ness, and death results, in collapse and extreme prostration, in from one to seven days. Treatment. — Preventive treatment should be directed to cattle and sheep. Diseased animals should be killed and buried deeply or cremated ; suspected animals should be isolated. Inoculations with attenuated virus are being em- ployed with considerable success in securing immunity. In man the only form amenable to treatment is the exter- nal pustule. The mass should be excised thoroughly or be penetrated by deep crucial incisions into which powdered bichloride of mercury is to be sprinkled. Subcutaneous injections of a solution of carbolic acid or of a bichloride-of- mercury solution may be made about the pustule and be repeated two or three times a day. HYDROPHOBIA. Definition and Synonym. — Hydrophobia is an acute specific disease of animals, and is communicated to man by inoculation. Synonym : Rabies. Etiology. — All animals are susceptible, but the disease is most common in the dog, wolf, cat, skunk, and fox. There is undoubtedly a microbe of the disease, but it has not yet been demonstrated. The poison is found in the nervous 154 .V.l.vr.lL OF THE rRACriCE OF MEDICINE. system and the secretions, especially- in tlie sali\a. The affection is acquired in man b\' bites of rabid animals or by the inoculation of abraded surfaces with the saliva. It occurs more readil\' in chiUlrcn than in adults, and infection is most certain in wounds of the face and head and in cases of severe and lacerated bites affording extensive surfaces for absorption. Infection is more severe in the bites of wolves than in those of cats or dogs. Of persons bitten by rabid dogs, from 15 to 50 per cent., according to various author- ities, become affected by the disease. The infecting saliva may be absorbed by the clothing if the bite is inflicted upon a clothed part. In this case infection may not occur. The incubation period varies from six weeks to two months in ordinary cases. It may be as short as two weeks, or be protracted for several months, but never longer than eight months. Cases with incubation of from one to two years have been reported, but they are not well authenticated. Pathology. — Little or no lesion may be found at autopsy. Congestion of the blood-vessels, perivascular exudation of leucocytes, and minute hemorrhages may be found in the brain and spinal cord. These are the most characteristic lesions, and are particularly well marked in the medulla. There may be congestion of the pharynx and of the mu- cous membrane of the respiratory and gastro-intestinal tract. Symptoms. — There are three stages of the disease. 1. Premonitory Stage. — The onset is usually preceded by irritation, pain, or numbness in the cicatrix, which may be- come congested and tender. The patient passes into a con- dition of mental depression and melancholia, becomes irri- table and sleepless, and is in a condition of extreme anxiety. The special senses are keenly alert. This stage lasts about a day. 2. Spasmodic Stage. — The first characteristic symptom is inability to swallow, from spasm of the muscles of deglu- tition whenever the act is attempted. The spasm spreads to the laryngeal muscles of respiration, causing dysp- noea and the utterance of odd barking sounds. Breathing in consequence becomes painful and embarrassed. The spasms, excited at first by attempts at swallowing, finally HYDRO PI/OB LI. 1 = 5 are produced by any afferent stimulant, such as draughts of air, sounds, or even mental suggestion, and extend to involve the muscles of the body generally. During these convulsions the patient snaps with his mouth and ejects foaming saliva in every direction. Mania often accompanies the spasms, while in the intervals the mind is usually clear, though 'distressed by fearful dread of impending death. Profuse salivation is common. The temperature is usually elevated, although it may be subnormal. The pulse becomes increasingly rapid, feeble, and intermittent. Prostration be- comes more marked after each paroxysm. There may be death from asphyxia in any of the paroxysms. This stage usually lasts for from one to three days. 3. T\\Q paralytic stage \di5is for from six to eighteen hours. The patient becomes quiet, the spasms cease, and the patient may swallow with ease. Unconsciousness is gradually de- veloped, and death from cardiac failure occurs. Prog-nosis. — Much can be done by preventive inocula- tions in the stage of incubation. When the disease, how- ever, has once begun, it is invariably fatal. Treatment. — Immediately after a person has been bitten a ligature should be applied on the proximal side, and the wound be sucked energetically, provided there be no cari- ous teeth or abrasions of the mouth or lips of the operator. The best results have followed an immediate excision of the wound succeeded by thorough disinfection. Cauterization is not so certain as excision as. a method of prevention. Preventive Inoculations. — Pasteur found that the contin- uous inoculation of the virus from rabbit to rabbit increased its strength to a maximum virulence, while gradual desic- cation of the medulla containing the virus diminished its virulence so that after two weeks' desiccation the virus became innocuous. It is possible, then, to obtain the virus in any grade of virulence. Inoculations were made in dogs, beginning with injections of an emulsion of the non-virulent medulla, followed by those of increasing strength until injections of medullas of the greatest virulence could be made with impunity. Animals so treated became immune to hydrophobic infection. 156 .V.IXr.lL OF THE PRACTICE OF MEDICIXE. ■ The same series of injections are now made in the case of those who have been bitten b}' rabid animals (altliough in men the final injections used are not of the most virulent qualit)'), with the result that the occurrence of h)'drophobia in nearly all cases is prevented. The mortality of those bitten by rabid animals and treated in this manner has been reduced to 0.60 per cent. There is another method of antirabic vaccination proposed — the gradual inoculation of an innocent virus obtained by the action of gastric juice upon the cords of infected rabbits. This method has even cured the developed disease in rab- bits, but it has not yet been tried in man. Treatment of tJic Disease. — When hydrophobia develops the spasms can be relieved only by morphine hypodermics and by inhalations of chloroform. The patient in this way is made more comfortable until he dies. Pseudo-rabies is an hysterical condition occurring in persons who have been bitten by dogs supposedly rabid, and it may closely simulate true hydrophobia. The symp- toms develop frequently too long after the bite to be real rabies ; the temperature is not elevated ; the disease is of longer duration and is amenable to antihysterical treatment. The diagnosis is corroborated by the knowledge of the fact that the dog was not rabid. TETANUS. Definition and Synonyms. — Tetanus is an infectious disease due to a specific bacillus. It is characterized by painful tonic spasms of the volun- Q o^ p tary muscles with exacerbations. I / ^ ^-^ Syiioiiyms : Trismus; Lock-jaw. v^ \ Etiology. — The bacillus appears ^ ^ as a delicate rod swelling at one __ ^ extremity to contain a shining Fig. 3.-Baciiius tetani (cover- sporc, assuming thus the appear- glass preparation from culture by ^^^^^ ^^ ^ druni-Stick Or a pin. Kitasato). ^ Pure cultures are obtained with difficulty. Injections of the germs, or even of the sterilized or filtered cultures, cause tetanus convulsions. Brieger has TETANUS. 157 lately isolated from tetanus cultures their distinct toxines, tetanine, tetanotoxine, and spasmotoxine, which act on the nervous centres as does strychnine, causing convulsions and spasms. The bacilli are found in various kinds of surface soil and street dust. In warm climates the soil acts as an excellent culture medium, hence in these localities the disease is more common than in colder climates. The bacilli may thrive in some particular soil so that the disease becomes endemic in that place, as in the east end of Long Island. It may assume epidemic proportions in institutions, in hospitals, and during wars. The colored race is especially susceptible. To acquire the disease the germ must enter through an abraded or a broken cutaneous or mucous surface. It may follow wounds, especially of the hands and feet, or it may infect the umbilicus in newly-born children (tetanus neona- torum). It frequently follows frost-gangrene. In some cases the point of entrance is so slight as readily to be overlooked. These cases are designated " idiopathic tetanus." The majority of cases of late have occurred in children. The bacilli are found in the wound-secretions, in the nerves leading from the point of infection, and in the spinal cord of the patient. Pathology. — There are no distinct morbid changes. There may be seen congestion, perivascular exudation, and granular degeneration of the nerve-cells in the brain and spinal cord. There may be redness and swelling of the nerve-trunks. In tetanus of the new-born there may be inflammation of the umbilicus. Symptoms. — The period of incubation is about two weeks, although from one to twenty-one days constitute its limits. The symptoms begin insidiously with soreness about the neck and pain and stiffness in the muscles. Then develops the characteristic spasm of the muscles of masti- cation. This trismus, or lock-jaw, is almost pathogno- monic, provided local causes for spasm can be excluded. The spasm then spreads to the muscles of the back of the 158 .V.iXr.-fL OF THE PRACTICE OF .VEDICLVE. nock, of the face, and of the trunk. The head is drawn backward and held rigidl\' ; the face has a mask-Hke appearance due to immobility; the corners of the mouth are drawn back, giving the " sardonic grin." The forehead is wrinkled, the patient having a peculiarly aged appear- ance. The spasm of the spinal muscles may arch the body backward so that the patient is supported only by the head and the heels (opisthotonos), and less frequently the body may be flexed forward (emprosthotonos) or curved to either side (pleurosthotonos). In severe cases the body is entirely straight and stiffened from general muscular spasm (or- thotonos). The legs may be in a condition of spasm, but the arms more frequently can be moved freely. The affected muscles are in a condition of tonic rigidity interrupted now and then with violent clonic spasms. These spasms may be so severe as to tear the rectus ab- dominalis. The muscles are exquisitely painful and tender, especially during a paroxysm. The paroxysms are reflex, and are produced by any slight stimulus, such as a noise, a jar, or a draught of air. In some cases they may appear to be spontaneous. If the intercostal muscles are affected, there is embar- rassed respiration with dyspnoea and cyanosis. These symptoms are so aggravated, should the diaphragm be involved, that the patient rarely survives the second or third tetanic spasm. In rare cases the muscles of deglutition are involved. These cases are spoken of as " hydrophobic tetanus " or the " head- tetanus " of Rose, and follow injury of the face. Besides the trismus and the difficult deglutition there is apt to be paral- ysis of the facial nerve on the side of the injury. The temperature is always elevated in acute cases, usually running to 104° F. or even higher. There may be a marked rise of temperature after death. In the milder and more chronic cases there may be but slight fever or the tempera- ture may be normal. The pulse becomes rapid and feeble toward the close of the disease. The mind is clear through- out. There is usually profuse perspiration. The duration v^aries. The acute forms may be fatal in TETANUS. 159 from one to seven days. If the attack be mild, there may- be but Httle spasm of the muscles of the trunk, and consti- tutional disturbances are not marked. In these cases tris- mus is the principal symptom. These mild cases run a course for a number of weeks. Diagnosis. — Tetanus should not be confounded with the following conditions : 1. Stryclinine-poisoiiing. — Here the maximum symptoms are developed suddenly, the muscles not being involved in gradual order as in tetanus. Trismus is absent and the arms are involved. Between the spasms the muscles are relaxed, and not rigid as in tetanus. The course is shorter than that of tetanus. 2. HydropJiobia. — Here there are the history of the case, involvement chiefly of the muscles of deglutition, and absence of trismus. 3. Hysteria. — The convulsions are not limited to any special group of muscles ; there is no trismus ; between the spasms there is muscular relaxation ; there is no change in temperature or pulse ; other hysterical symptoms are pres- ent ; the spasms are irregular and more spontaneous than reflex. Prognosis. — The disease is fatal in 80 per cent, of trau- matic cases and in 50 per cent, of idiopathic cases. It is almost always fatal in infants. Most of the cases of hydro- phobic tetanus recover. When the incubation period is less than ten days, the mortality is 96.6 per cent. Treatment. — The patient should be kept in a darkened room from which all sounds and other causes of irritation are to be excluded absolutely. No talking or unnecessary movements are to be permitted. If the trismus prevents the patient from taking even fluid food, he may be fed through a tube or by the rectum. To relieve the spasms morphine hypodermically is the most satisfactory drug. In milder cases chloral combined with sodium bromide may be employed. In very severe cases inhalations of chloroform may be necessary. In mild cases the use of hot baths may be of service. Woorara, which has been employed fre- quently, is not recommended, because of its depressing l6o MAXrAL OF THE PRACTICE OF MEDICEYE. effect on the heart. In all cases the infected wound must be disinfected to prevent further absorption. Scars may be excised and foreii^n bodies be removed. Nerve-stretching and nerve-section have proved disappointing. The hope of successful treatment lies in the use of anti- toxines derived from the blood-serum of animals rendered immune. Immunity is procured by the injection of germ cultures treated with trichloride of iodine. The injection of the blood-serum of such immune animals into persons suffering from tetanus has frequently been followed by a prompt recovery, while in almost all cases the severity of the disease has been modified greatly. In severe cases the patient may be trephined and the antitoxine injected directly into the brain. Bacelli's treatment consists in the hypodermic injection of oj-ij of a ^ per cent, solution of carbolic acid along the spinal column every three or four hours. LEPROSY. Definition. — Leprosy is a chronic infectious disease due to the bacillus leprse and characterized by tubercular nodules of the skin and the mucous membranes and by changes in the nerves. Etiolog-y. — At present the principal centres of leprosy are India, China, and the Sandwich Islands. Other import- ant foci are Norway, the Baltic provinces of Russia, Mexico, certain parts of Central and South America, and the West India Islands. In North America it occurs in certain of the Gulf cities, especially New Orleans, in the province of New Brunswick, and along the Pacific coast, where it occurs chiefly among the Chinese. Isolated cases occur from time to time in all large cities. The disease may be called " contagious," but only in the sense that direct inoculations are necessary, as is the case with syphilis. It may be congenital or hereditary, and it may be acquired through sexual congress. The majority of cases occur from the fifteenth to the thirtieth year. The specific cause is the bacillus lepr£e, discovered in 1874 by Hansen. This bacillus, which closely resembles the LEPROSY. l6l tubercle bacillus but may be distinguished from it, can be cultivated; but while inoculations of the leprous nodules can reproduce the disease, inoculations of the pure bacillus cultures have produced only negative results. Patholog-y. — The leprous nodules consist of aggregated lymphoid, epithelioid, and giant cells in and among which are found numerous bacilli. The nodules may in rare cases become organized and encapsulated, but they have a tend- ency to break down, discharge puriform matter, and result in ulcers which may heal in one direction while spreading in another. In the nerves the bacilli cause neuritis. In the last stages of the disease leprous nodules may be found in internal organs, especially the spleen and the liver. Symptoms. — Two forms are described, which may occur separately or be combined in the same patient : 1. Tubercular Leprosy. — There appear on the skin hyper- aesthetic patches of sharply-defined erythema that become gradually darker from pigmentation. These patches which precede the nodules are designated as " macular leprosy." In some cases they subsequently become anaesthetic and lose their pigment, white spots being left, the " white leprosy." Nodules then develop in the skin of any part of the body excepting the scalp, and in the mucous mem- branes, especially of the mouth, throat, larynx, and con- junctiva. The nodules vary in size from a pea to a walnut, and coalesce. This is especially marked in the face, the term leontiasis being applied to the thickened and distorted features so caused. The skin over the nodules is tense and glistening and may become red and painful. The hairs of the affected areas drop out, the loss of the eyebrows being a suggestive symptom. From the softening and breaking down of the nodules there are caused extensive ulcerations frequently covered with crusts. The ulceration may extend to the bones, causing falling of the bridge of the nose or loss of the fingers or toes, or there may be total destruction of the eyeball. 2. AiicestJictic leprosy occurs when the nerve-trunks are involved. There are at first areas of hypersesthesia and 11 l62 .V.LVC.IL OF THE rKAC'lICE OF MEDICIXE neuralgic pains, followed by anaesthesia over more or less extensive surfaces. The an;esthetic spots following the macules have already been alluded to. If the larger nerve- trunks are involved, they may be felt as nodular cords. Suppression of sweating occurs in the affected areas. There are trophic changes. Bulhie may form at any time, and after discharging their contents may either heal or be converted to extensive ulcers. There may be perforating ulcer of the foot or loss of the phalanges of the fingers or the toes. Paralyses, contractures, and atrophy of muscles are commonly observed. The prognosis is bad, but not absolutel}' hopeless. The average duration of the tubercular cases is from eight to ten years ; of the anaesthetic cases, fifteen to twenty years. Treatment. — Patients should li\e in isolated communities and under the best hygiene. Their general health and nutri- tion must be superintended carefully. There is no specific medication. Iodide of potassium in full doses (falling short, however, of iodism) and arsenic have been recommended. Of late gurjun oil in lO-minim doses and chaulmoogra oil in 2-dram doses have been favorably regarded. The former may be given by the mouth or by inunction. GLANDERS. Definition and Synonym. — Glanders is an infectious disease of the horse, ass, and mule, communicable to man. Synonym : Farcy. Etiology. — The disease is due to a specific bacillus, the bacillus mallei, which is short and non-motile, closely resembling the tubercle bacillus. The bacillus can be cultivated, and causes the disease by inoculation. The disease is acquired in man by contact of the nasal dis- charges of the horse with an abraded mucous or cutaneous surface. In rare cases it results from inhalation of the desiccated discharges. The disease is also transmissible from man to man. It occurs chiefly in those who have to do with horses. Lesion. — The lesion consists in the formation of little GLANDERS. 1 63 tumors composed of epithelioid and lymphoid cells among and in which are found the bacilli. The lesion is really a variety of infective granuloma. The nodules tend to break down rapidly, causing ulcers when they occur in the mucous membranes (glanders), and abscesses when they occur in the skin, the muscles, or the internal viscera. The adjacent skin, lymphatics, and mucous membrane are inflamed. Symptoms. — The symptoms begin in from three to five days after inoculation, but may be delayed for three weeks. An acute and a chronic form may be recognized in man. I. Acute Glanders. — There are at the onset malaise, head- ache, fever, and pain in the limbs, resembling the onset of typhoid fever, for which it is often mistaken. In peracute cases the onset is that of a more severe general infection. The local symptoms may be of the " farcy " or of the " glanders " type. Farcy Type. — The infected part becomes red, swollen, and painful, the inflammation becoming widely diffused ; there are developed nodules which become abscesses. These latter may rupture, leaving irregular deep ulcers with a grayish infiltrated floor which may become necrotic. These suppurating nodules are frequently mistaken for small-pox. The lymphatics are early affected, and along their course are subcutaneous nodules, the so-called " farcy-buds." There may be swelling and suppuration of the joints. Abscesses may form in the muscles. Glanders Type. — There is a purulent, blood-stained, fetid discharge from the nose, with a spreading inflammation of the skin over the nose and the face somewhat resembling erysipelas. Examination shows the nasal cavities to be deeply ulcerated. The septum may be necrosed. There may be similar ulcerations in the mouth, pharynx, larynx, and bronchi. Usually in man both sets of local symptoms are found. Constitutional symptoms are those of an intense infection. The temperature rises and may assume the pyaemic type, with remissions and irregular rises accompanied by chills and sweating. The pulse becomes rapid and steady, the 164 .V.l.VC'.lL OF THE PRACrrCE OF MEDIC /XE. tongue brow n and ilr\'. Vomiting and diarrhoea are almost constant. Pneumonia is apt to develop. There are restless- ness and delirium at first, passing into stupor and coma, while death results in the t\'phoid contlition in from eight to fourteen days. IVracute cases may live but a few days. In mild cases the local symptoms are less severe and the gen- eral infection is slight and limited, so that the course is mild and recovery is possible. The cases in which the nose is extensively involved — glanders type — are invariably severe and fatal. 2. Chronic Glanders. — The disease is insidious, resembling ozasna or nasal s}'philis. There is a fetid, purulent discharge from the nose, with intractable ulcerations. There are also subcutaneous nodules, abscesses, and ulcers without much inflammatory reaction or involvement of the lymphatics. These cases may last for months or even years, and usually recover, although at any time the acute form may be de- veloped with a fatal issue. Treatment. — In the early stages the wound should be excised or cauterized and treated antiseptically. For the acute cases little can be done. The nasal passages should be kept cleansed by injections of weak antiseptic solutions. Abscesses and farcy-buds should be opened as early as possible. ACTINOMYCOSIS. Definition. — Actinomycosis is a form of chronic inflam- mation caused by the actinomyces, or ray fungus. Etiology. — Actinomycosis is a disease primarily of cattle^ pigs, or horses, acquired in man by inoculations through abrasions of the skin, of the mucous membrane of the mouth, or through carious teeth. The fungus may be taken into the alimentary canal in contaminated water, in the flesh of the pig, or in infected cereals. The ray fungus, or actinomyces, consists of threads with bulbous extremities radiating from a common centre, form- ing a globular rosette. In man the fungi appear as little round masses the size of a millet-seed, usually of a sulphur- ACT f NO. MYCOSIS. 165 yellow color. They are found in the tumors and in the purulent discharges, and can be cultivated and inoculated. Patholog-y. — The lesion consists in the transformation of mature connective tissue into embryonal or granulation- tissue composed of round and epithelioid cells sometimes containing giant-cells. The appearances are identical with those of sarcoma or tubercle, but in the tumors the cha- racteristic ray fungus is found. The tumors show a tend- Fig. 4. — Actinomyces (Von Jaksch). ency to break down and suppurate, forming abscesses and sinuous fistulse. There is a chronic inflammation of the sCirrounding structures, but the lymphatics are not involved, and the course of the disease resembles that of a malignant tumor more than that of an acute infection. Symptoms. — i. Alimentary Actinomycosis. — The upper or lower jaw is frequently involved. There is considerable swelling and enlargement of the bone resembling osteo- sarcoma ; sinuses are common, tending to invade the ad- jacent soft structures of the neck and the face. The tongue, the intestines, or the liver may be involved primarily or by metastasis. 2. Cutaneous Actinomycosis. — There may be slowly-grow- ing tumors which may suppurate and leave intractable ulcers and fistulous tracts. 3. Cerebral Actinomycosis. — This form is rare. The symp- toms are those of multiple tumors or abscesses. 4. Pulmonaiy Actinomycosis. — Three clinical forms are l66 .U.IXC.IL OF THE PKALTICE OF MED/C/XE. described by Hodenpyl : {^ CO CD \ \ ^Z* /^ , <^ y .<. <^ y O s \ y 1 ^/ •••( u.-^ s^. . M < ^ N \ \ \ ^^ ■A •1 \." .../ > N \, ^. 09 V s \ Siw^ ... ^L \ 1^ J s J > s ^ y / ^^ ;> X^W" "■ 1 ^ ^p ] / '..S- ^--<< 03 jj"^ ■■•> -*-^ ■ -„w- — »«- •^. ^v- ,r-* ....1 /^r.. ■O >• \ -^ ( .,x V CX) 7 / i ~ C o D c O ( -■ D C o 1 : i ^ -J ^ D C Ji C c -' 1- > D ACUTE ENDOCARDITIS. I99 to determine, from the tumultuous action of the heart. The presence of a murmur alone is not diagnostic, and there are cases without murmurs. The association of an over-acting tumultuous heart and a small feeble pulse is of some diagnostic valve. There may be the physical signs of dilatation of the left ventricle with accentuation of the second pulmonary sound. There may be added the physical signs of venous congestion. Course of the Disease. — i. Latent Cases. — The lesion is slight and is perfectly compensated. There are no symp- toms. Physical signs may be present. In some of these cases the valve may return to a normal condition. Em- bolism may occur, however mild the case. 2. Mild Cases. — There are present inflammatory symp- toms, but the circulation is not disturbed and there are no symptoms of valvular inefficiency. In severer cases there may be a tumultuous action of the heart and some dyspnoea. 3. Sevej^e cases result either from an extensive lesion, from a secondary myocarditis preventing compensation, or from an acute endocarditis engrafted upon a chronic pro- cess, upsetting compensation. Very rarely there may be sudden death from excessive circulatory derangement. There are developed symptoms of pulmonary congestion. If the right ventricle hold good, there will be no general venous congestions. These, however, will occur if the right ventricle fail in its work. Prognosis. — Acute endocarditis rarely proves fatal unless complicated by severe pericarditis or myocarditis. A few cases with healthy valves recover, especially those cases secondary to chorea. The liability to organic valvu- lar changes is great. The possibility of repeated attacks, especially in rheumatic cases, must be taken into considera- tion. An acute attack engrafted upon a chronic endocardi- tis may upset compensation and lead to a fatal dilatation. Sudden death is exceedingly rare. The occurrence of embolism adds an uncertain element to every case. Treatment. — The old idea that endocarditis could be prevented by curing rheumatism early has not been sus- 200 MAXCAI. OF THE PK.lCrJCK OF MhDICIXE. taincd. Still, it is best to treat every case of rheumatism and chorea energetically from the very start. Patients with rheumatism should have ever}- source of heart strain removed by as nearly absolute a rest as possible. This does not lessen the patient's liability to have endocarditis, but if it does occur it is much more apt to be less severe, less extensive, and less permanent in its results. When endocarditis is once established, care should be taken not to depress the heart by too large doses of the salicylates. Inflammatory s}'mptoms are best treated by strict bodily and mental rest, applications of cold to the heart, and small doses of opium. The action of the heart should be controlled. Stimulants should be given if indicated. Over-action of the heart may be treated by small doses of aconite or of iodide of potas- sium, or by the use of cold to the precordia. The bowels should be opened freely, and distention of the stomach is to be avoided. Venous congestions should be treated by heart stimu- lants and by depletion by diuretics, diaphoretics, and cathartics. Blood-letting may be employed in selected cases. The treatment of convalescence must be tonic and sup- porting, in order that compensation may be made per- manent. MALIGNANT ENDOCARDITIS. Synonyms. — Septic. Ulcerative, Diphtheritic, Bacterial, Mycotic endocarditis ; Arterial pya^^mia. Etiolog-y. — The disease is secondary to a number of septic conditions: (i) It may follow puerperal fever or any septic condition of the puerperal state. (2) It follows septic wounds. "(3) It may complicate certain septic diseases. Of these diseases, pneumonia is perhaps the most common. Cases have followed suppurative phlebitis from ear disease, erysipelas, diphtheria, suppurative p)'lephlebitis, osteomye- litis, dysentery, abscesses, and gonorrhoea. (4) In some cases no apparent cause can be found, but it is supposed MALIGNANT ENDOCA RDJIIS. 20I that germ infection occurs through unnoticed cracks or abrasions of the skin or the mucous membranes. The exciting cause of mah'gnant endocarditis is infection of the endocardium by bacteria. There are a variety of mi- cro-organisms capable of causing this infection, the common- est being the cocci of suppuration, the coccus of erysipelas, and the pneumococcus. Infection of the endocardium by bacteria is favored by its previous weakness or inflamma- tion, three-quarters of all cases of endocarditis occurring in hearts previously affected with chronic valvular disease. Lesion. — The lesion consists in abundant cell-growth of the endocardium, forming vegetations capped with fibrin, the base consisting of granulation-tissue; these vegetations contain colonies of bacteria. The cells are apt to become necrotic, so that by their death there are formed ulcers which may perforate or erode the valve-segments, the sep- tum, or even the heart itself, or which may so weaken the resisting power of the valve that it may become bulged, forming a little aneurysm. There may be infection of the deeper endocardial layers, with the production of small abscesses. Portions of vegetations containing bacteria are apt to be- come detached, enter the blood-current, and become emboli of a distinctly infective character. In this way distinct sec- ondary lesions are developed, (i) There may be purulent inflammation of any of the serous membranes, meningitis, pericarditis, empyema, peritonitis, or suppurative inflamma- tion of the joints. (2) There may be suppurative infarctions and abscesses of any part of the body, especially of the brain, lungs, kidney, spleen, and liver. (3) There may be subcuta- neous hemorrhages from destruction of the wall of a cuta- neous blood-vessel by an infective embolus. Ptomaines arising from the growth of the bacteria poison the general system and produce the symptoms of septicaemia. The location of the inflammation is more widespread in malignant than in simple endocarditis, the right heart and the endocardium lining the heart-cavities being more fre- quently affected. In 209 cases the aortic and mitral valves together were affected in 41 ; the aortic valves alone, in 53 ; 202 MAXr.AL OF 'fl/E PRACTICE OF MEDICINE. the mitral valve alone, in yj \ the tricuspid valves, in 19; the pulmonary valves, in 15 ; the heart- wall, in "i^y, the riy^ht heart alone, in 9. When the endocardium lining the heart- cavities is affected, the most frequent situations are the upper part of the septum of the left ventricle and the postero-ex- ternal wall of the left auricle. The spleen is large and soft. Tiie cells of the kidnc\'s and the liver show degenerative changes. Symptoms. — The symptoms may conveniently be divided into three principal groups : 1. Symptoms of a Sudden and Severe Heart-lesion. — The symptoms of this group resemble those of simple endo- carditis, but are much more sudden and severe. There are marked disturbances of circulation, as shown by venous congestion in both the pulmonary and the systemic circu- lation. The lesion, as a rule, is too sudden and severe to allow of any approach to compensation. There are usually murmurs Jieard according to the valve affected. Diastolic and right-heart murmurs are more common than in simple endocarditis. The action of the heart is often so irregular and tumultuous that the rhythm of the murmurs cannot be determined. In some cases, especially when the lesion is located in the ventricular endocardium, there ma}^ be no murmur at all. In three-fourths of the cases there are present the physical signs of antecedent valvular disease. The size of the heart is not increased in acute cases, as the patient is apt to die of sepsis before dilatation can become appreciable ; but in subacute cases dilatation may become evident and there may be an approach to a compensatory hypertrophy. 2. Symptoms of Sepsis. — There is a decided tendency for the patient to pass into the " typhoid state." There is a fever which is either stead\^ or interrupted by marked re- missions. There are frequent chills followed by sudden elevation of temperature, its decline being accompanied by sweating and prostration. Repeated erratic chills indicate septic material in circulation, and they should always cause a diligent search to be made for a septic focus in some part of the body. It should be remembered, however, that MALIGNANT ENDOCARDITIS. 203 patients walking about in a condition of fever are apt to complain of chilly feelings. The chills of suppuration are too erratic to be confounded with those of malarial infection. 3. Symptoms of Infective Emboli. — Embolic symptoms give different clinical features according to their localization. Emboli of the brain will produce paralyses of various mus- cles according to the situation of the embolus, with disturb- ance of consciousness. There may be abscess of the brain or meningitis, usually associated with furious delirium. In the lungs there may be a septic pneumonia or an abscess. There may be empyema. The spleen may become large and tender and may be the seat of abscesses. Abscesses in the liver are accompanied by their usual symptoms. Em- bolism of the kidneys is marked by lumbar pain, by hema- turia, and possibly by the presence of pus in the urine. Petechial rashes may resemble the eruption of certain cases of typhoid or of cerebro-spinal meningitis. In some cases, if associated with multiple skin abscesses, the appearance of the patient may be suggestive of hemorrhagic small-pox. The diagnosis of malignant endocarditis is made by the combination of the three groups of symptoms. Any one group, however, may be slight or even latent, and any one group may predominate and give its stamp to the disease. (i) If the symptoms of the heart-lesion predominate, the case will resemble simple endocarditis or chronic endocar- ditis with some intercurrent fever, as typhoid, malarial, etc. (2) If the septic symptoms predominate, the case may re- semble one of typhoid fever, surgical septicaemia, or pyae- mia. The disease may be mistaken for malarial fever, but the chills are too erratic, the temperature does not yield to quinine, and the blood-examination does not reveal the malarial organism. The disease may also resemble acute miliary tuberculosis, but a detailed examination of the case and the finding of the bacilli in the sputa will render the diagnosis easy. (3) If the embolic symptoms predominate, the case may resemble non-infective embolism from simple endocarditis, acute or chronic, or the secondary suppurative inflammations may resemble those of primary origin. Thus the case may 204 MAXL'AL OF THi: J'K.ICJ/CJ: OF MEDICINE. be mistaken for meningitis, for abscess of tlic brain, for empyema, etc. Duration. — Some cases run an acute course of about two weeks' duration. Death results from the derange- ment of the circulation due to the heart-lesion, from sepsis, or from the infective emboli. Other cases run a subacute course of from ten to twelve weeks, and more rarely may continue for six or eight months. In these chronic cases the infection is less severe, the damage to the heart is less extensive, and tliL-rc is usually an attempt at compensation. A few of these chronic cases recover, especially if compen- sation be perfected and if embolism does not occur. The prognosis is generall}' bad. Only a {^tw cases re- cover. These cases are those which occur most frequently after puerperal infection and which have run a chronic course without embolism. These cases, however, are left with permanently disabled valves. Treatment. — The treatment is that of both the heart in- flammation and the septic condition. For the heart inflam- mation the treatment is that of ordinary endocarditis, but carried out more vigorously, and heart stimulants are more commonly indicated. There are two ways by which the septic condition may be treated. One method is by the administration of qumine in large doses, so that the patient is kept thoroughly cin- chonized, the unpleasant effects of quinine being mitigated by adequate doses of phenacetine or sodium bromide, of which from 20 to 40 grains may be given daily. The second method consists in the giving of alcohol in large doses, so that the patient is kept continuousl}' under its influence. The secondary suppurations are to be treated on general surgical principles. CHRONIC ENDOCARDITIS; VALVULAR DISEASE. The terms " chronic endocarditis " and " valvular disease " are practically sj-nonymous, as it is the endocardium of the valves that is almost regularly affected. It is well to dis- CHRONIC ENDOCARDiriS. 20$ tinguish between two sets of cases, (i) chronic endocarditis proper and (2) atheroma. Chronic Endocarditis. Patholog-y. — The lesion consists in the thickening of the valve by increased cell-growth and the formation of firm connective tissue. In this way the valve-segments become contracted, deformed, and insufficient, producing either stenosis or insufficiency, or both. Lime-salts may be deposited in the thickened valve, so that it may become a dense calcareous mass with hardly a vestige of normal tissue. There may appear vegetations and ridges formed by irregular growth of cells and connective tissue, and upon these ridges fibrin may be deposited. Detachment of the fibrin in masses will give rise to emboli which are simple and non-infective in this disease. The proliferated cells in the valve may be the seat of fatty degeneration, producing opaque yellow spots frequently infiltrated with salts of lime, or the fatty cells may break down, so that little superficial ulcers result. To the combination of chronic connective-tissue proliferation and fatty degeneration of the cells the name "atheroma" is applied. Etiology. — Chronic endocarditis regularly follows an attack of acute endocarditis produced by any of its causes. In some cases, however, it is difficult to obtain a clear clinical history of the primary attack. About half the cases have a rheumatic origin. The disease is most fre- quent in children and young adults, and affects the mitral valve with the greatest frequency. Symptoms. — (i) There are symptoms due directly to the diseased valves — aortic stenosis or regurgitation, or mitral stenosis or regurgitation. Involvement of the valves of the right heart is exceedingly rare. (2) There is developed compensatory hypertrophy ; or (3) a dilatation with various venous congestions due to the enfeebled pumping power of the heart. (4) There may be symptoms of embolism. 206 MAXUAL OF THE PRACTICE OF MEDICEXE. Atheroma. In this class of cases the endocarditis is chronic from the start. Pathology. — The lesion in the valves is the same as that of chronic endocarditis, but is only part of a tjeneral set of lesions. There is atiieroma of the aorta, which may be dilated. The small arteries show the lesions of chronic endarteritis ; their walls are thickened by connective tissue and may be infiltrated with lime-salts ; their lumen is narrowed. In the small arteries of the brain miliary aneurysms may be formed. There may be spasm of the peripheral arteries. The lungs are frequently emphysema- tous. The kidneys usually show the lesions of the atrophic form of chronic diffuse nephritis. There is frequently cirrhosis of the liver. These changes are spoken of under the general name " arterio-capillary fibrosis," and will be described with more detail in a later heading. The aortic valv^es are the favorite seat of the lesion. The mitral valve may also be involved, but it is rareh' involved alone. Etiolog-y. — Atheroma is a disease of adult life, few cases being seen before the fiftieth year. It is more common in men than in women, and is especially frequent in those who lead a life of exposure, intemperance, and severe muscular strain. It is thus common in longshoremen. Alcoholism, syphilis, gout, chronic rheumatism, and chronic lead-poisoning are cited as causes, and there seems to be a distinct family predisposition toward this series of degenerative changes. The symptoms are in the main those of the first class, but they differ in the following respects : 1. The lesion is not only of the heart, but of other organs as well, more work being thrown on the diseased heart by reason of the increased peripheral resistance in the aorta and the peripheral arteries, and the arterial spasm due to the kidney disease. 2. The lesions occur in late adult life, when recuperative powers are on the wane and when compensatory hyper- trophy is imperfect at the best. CHRONIC ENDOCARDn^S. 20/ 3. The patients are usually persons leading an intem- perate life with severe muscular strain, and unwilling — indeed, unable — to take the proper care of themselves ; by reason of their condition of life they are poor subjects for compensatory processes, 4. The lesion is progressive. The valves arc not only deformed, as in the first class, but tend to become more and more involved. Detailed symptoms of both sets of cases will be given under the head of the individual valvular lesions. Mitral Incompetency. Etiology. — Insufficiency of the mitral valve results from one of three causes : (i) Contraction or shortening of the valve-segments from chronic endocarditis, frequently asso- ciated with changes in the chordae tendineae and with more or less narrowing of the orifice. (2) Dilatation of the mitral ring from dilatation of the left ventricle. (3) Defective mus- cular closure from myocarditis, or from the weakening of the heart muscle in anemia and prolonged fever. It is important to remember that mitral insufficiency is not always a sign of chronic endocarditis, but that the valve- segments may be normal, the incompetency being " relative." Patholog-y. — As the result of the regurgitation past the mitral valve, at each systole of the ventricle the left auricle receives blood from two sources — its regular supply from the pulmonary veins, and the abnormal supply from the left ventricle. The auricle therefore becomes dilated and to some extent hypertrophied, although the latter process is never well marked in the case of an auricle. At the time of the diastole of the left ventricle this abnormal amount of blood at high pressure pours into it, over-filling it. To ac- commodate this increased amount of blood the ventricle must necessarily dilate. Although at the time of the ven- tricular systole only part of the blood is pumped forward in the direction of the normal blood-current, the remainder being forced back into the auricle, still, to get rid of the large supply of blood, the work of the left ventricle becomes excessive, and therefore the ventricle becomes hypertrophied. 208 MAXC-il. OF THE PKACT/CE OF MEDICINE. Ouiiif^ to the over-filliiii^ of the auricle during diastole, the pulmonary veins are less readil)- emptied ; the right ventri- cle expels its contents less readily, and becomes both dilated and hypertrophied. If the hj'pertrpphy of the right ven- tricle is adequate to maintain the equilibrium of the pul- monary circulation, there are no signs of venous congestions in the systemic circulation. If compensatory hypertrophy fails, however, then general venous congestions will ensue. Congestion of the pulmonary vessels is not, as a rule, as marked in mitral regurgitation as in mitral stenosis, because the back pressure is more intermittent, occurring only dur- ing diastole, whereas in mitral stenosis it is continuous. Cases of relative incompetence due to impaired nutrition of the cardiac wall or to its dilatation are not usually well compensated. There is apt to be considerable engorgement of the pulmonary vessels, with bronchitis and often with fairly profuse haemoptysis, and, from general failure in the power of the right ventricle to work in face of the pulmon- ary back pressure, general venous congestions will ensue. Symptoms. — If compensation is good, there may be no symptoms noticed by the patient even for years. There may, however, be some palpitation and dyspnoea on exer- tion, with a bluish tinge to the lips and the ears. Attacks of bronchitis or of haemoptj^sis may occur. If compensation fails, the s}^mptoms of pulmonary en- gorgement become more marked ; there are palpitation, weak and irregular action of the heart, steady dyspnoea with developing orthopnoea, increase of cough with bloody or watery expectoration, and dropsy, first in the feet and then becoming more generally distributed. By judicious treatment compensation may again be estab- lished, and the patient will recover from the attack. Subse- quent attacks grow more frequent and severe, and recovery from them becomes less and less satisfactory, until at last a permanent condition of general dropsy and venous con- gestions results, terminating the life of the patient. Sudden death is exceedingly rare. Physical Signs. — The characteristic murmur of mitral regurgitation is systolic in rhythm, is heard with maximum CHRONIC TUBERCULOSIS. 209 intensity at the apex, and is connected into the left axilla and the back. The murmur, which may be loud enough to be heard over the whole of the chest, is usually of a blow- ing, puffing character, but it may have a musical quality. The character of the mur- mur gives no indication of the degree of the insufficiency. The murmur may come and go, and when absent it may frequently be reproduced by the upright position, by deep respirations, or by exertion. Fig. :.. -Mitral regurgitation, showing ^ ■' the area of cardiac dulness, the point or There are cases in which the maximum intensity ofthe systolic murmur, 1 •, • .„ ■ and the direction in which it is carried. murmur has its maximum in- tensity along the left border of the sternum, at the level of the second or third rib, where the dilated auricle approaches the chest-wall. There may also be heard the rumbling or purring presystolic murmur of an associated mitral stenosis. In some cases the presystolic murmur alone is heard, even if there be regurgitation as well. A. systolic thrill is often appreciable at the apex, but this sign is not of much diag- nostic value. The second pulmonary sound is accentuated in almost all the cases where there is compensatory hypertrophy of the right ventricle. This sound is best heard in the second interspace to the left of the sternum. There are present the ordinary physical signs of hyper- trophy ofthe left ventricle, and usually of the right ventricle as well, or, in case of failing compensation, the signs of their dilatation. The pulse may show nothing abnormal, or it may be irregular. There is no characteristic sphygmographic tracing. The diagnosis should be made, not from the presence of the murmur alone, but from the other signs as well — the accentuated pulmonary second sound, the enlargement of 14 2IO .U.l.vr.l/. OF THE PKACTICE OF MEDICIXE. the heart, and the cHnical history. Mitral incompetency should be distinguished in this manner from those hasmic murmurs which are heard at the apex of the heart, and from the so-called "lung heart" or the Potain-Rosenbach mur- mur. This murmur is generated in the overlying lingula of lung by the pressure of the heart's impulse against a small bronchus. Wx this compression at each systole during inspiration a swstolic puffing sound is produced. This sound, however, is not transmitted to the left, and is heard only during inspiration. The diagnosis of relative incompetence due to anaemia or to exhausting disease should be made by a careful review of the case. The diagnosis is necessary not only in point of prognosis, but also in governing the treatment. Prognosis. — Mitral incompetency is perhaps the least serious of all the valvular affections, as it usually occurs in young subjects, in whom compensatory h\-pertrophy is possi- ble. The prognosis of relative incompetence due to anjemia or to exhausting disease is good if the primar\- disease can be cured. The cases which develop in consequence of dila- tation of the left ventricle usually do badly, as the dilatation generally precludes all idea of compensation. Mitral Stenosis. Etiology. — Mitral stenosis, except for rare congenital cases, is always the result of valvular change. The affection regularly follows a previous attack of endocarditis, is usually seen in early life, and is more common in women than in men, in the proportion of 4 to i, because girls are more liable than boys to rheumatism and chorea. The onset of the disease is often so insidious that its origin cannot always be determined. Pathology. — The valve-segments may be stiffened into a rigid mass, or they may be fused together, forming a conical opening, the " funnel-shaped mitral." The orifice of the valve may be constricted to form a narrow slit, the "but- tonhole mitral," or it may be so constricted as to admit only the very tip of the little finger. A stenotic mitral valve is almost always incompetent at CHRONIC ENDOCARDITIS. 21 T the same time. The effect of the stenosis is to impede free passage of blood from the left auricle into the ventricle, causing thus steady back pressure, from which other changes in the heart result. The left auricle becomes much dilated and hypertro- phied, its muscular walls being increased from two to four times in thickness. The over-filled auricle impedes the outflow of blood from the pulmonary veins ; pulmonary engorgement results, being more marked in this than in any other valvular affection. The majority of cases of pig- ment induration of the lungs are due to this condition of engorgement. Dilatation and compensatory hypertrophy of the right ventricle result, compensating for the increased tension in the pulmonary vessels and equalizing the lesser cir- culation. In course of time, when the right ventricle fails in maintaining its power and hypertrophy, it will weaken and dilate, relative incompetence of the tricuspid valve will ensue, and general venous congestions will presage a fatal issue. In uncomplicated mitral stenosis less than the normal amount of blood enters the ventricle to be pumped into the arteries ; hence less work is required of the ventricle, and neither dilatation nor hypertrophy should occur. In cases, however, associated with incompetency of the valve, hyper- trophy or dilatation of the ventricle occurs. In rare cases the ventricle may hypertrophy without any appreciable cause. It is supposed that increased peripheral resistance from general contraction of the arteries, caused by their irritation by imperfectly-oxidized blood owing to pulmo- nary congestion and engorgement, might account for these cases. The symptoms of mitral stenosis resemble those of mitral regurgitation, both conditions producing the same results — arterial anaemia and venous congestions, first in the pulmonary system, later in the systemic veins when failure of the right ventricle occurs. S^^mptoms of pulmonary congestion are, however, more marked and constant in stenosis than in insufficiency. Children with mitral stenosis are usually poorly developed. 21. MAXC'.IL OF THE PRACTICE OF MEDICLXE. Physical Signs. — The cardiac impulse is often most appreciable in tlic region of the lower sternum ami in the fourth" and fifth left interspaces, being caused b\' the hj'per- trophied and dilated right ventricle approaching the chest- wall in these situations. Localized just above and within the apex may be felt a distinct vibratory or " cat's-purr " thrill. This thrill is presystolic and terminates with a sudden sharp shock synchronous with the cardiac impulse. When present, it is pathognomonic of mitral stenosis. Care should be taken not to mistake this apex thrill for a diastolic thrill at the base due to aortic regurgitation. The nuirmur of mitral stenosis is heard to the inner side of the apex beat over a limited area (Fig. 12), and is not trans- mitted in any direction. Its rh)thm is presystolic, or, more properly speaking, anriatlar- systolic, as the murmur is pre- systolic only as regards the ventricular systole. The mur- mur is a rough, rolling, purr- ing sound, represented by pronouncing " rup " or " r-r-r- rup," having in the latter case a rolling drum-beat character. It may terminate abruptly with the first sound, which is un- usually clear and snappy, or there may be a distinct interval between the sounds. The murmur may consume a good part of the diastole, or it may be heard only during the latter part of it. The murmur often comes and goes, usually dis- appearing if compensation fail, only to reappear should compensation again be established. It is often heard better with the ear than with the stethoscope. If regurgitation coexist w^ith stenosis, there will also be heard the murmur of the former affection ; this murmur may be so faint as to be heard only when the breath is held. Valuable evidence is afforded by the second pulmonary Fig. 12. — Mitral stenosis, showing area of cardiac diilness, location of the presys- tolic murmur, and the area over which it is heard. CHRONIC ENDOCARD/'J'fS. 213 sound. This sound, which is sharply accentuated if the right ventricle is doing its work well, is reduplicated in about one-third of all cases, and its reduplication is strong presumptive proof of mitral stenosis. The second aortic sound is weak, as the amount of blood entering the aorta is insufficient to raise its tension. Hypertrophy and dilatation of the left auricle and the right heart, and possibly of the left ventricle as well, give their customary physical signs. The pulse of mitral stenosis is small as compared with the action of the heart, the arteries being under-filled. A characteristic of mitral stenosis is the occurrence of interpolated beats in the line of the descent of the pulse- wave. These interpolated beats, which are well seen in the accompanying sphygmographic tracings (Figs. 13, 14), are Fig. 13. — Sphygmogram showing the interpolated beats of mitral stenosis. Fig. 14. — Sphygmogram showing the interpolated beats of mitral stenosis. little abortive systoles, started as extra contractions of the overloaded auricles and communicated thence to the ventri- cles. As their irregular systoles occur during the time of diastole, when the ventricle is under-filled with blood, a dis- tinct and well-marked pulse-wave cannot be formed. Diagnosis. — The murmur of mitral stenosis may be mis- taken for the diastolic murmur of aortic regurgitation, trans- mitted down to the apex and heard there late in the diastole. Examination at the base of the heart should reveal the max- 214 J/.lXr.lL OF THE PRACTICE OF .UEDICEVE. imum intensity of the aortic murmur. The character of the pulse, should assist in the differential diagnosis. The diag- nosis is more difficult if the murmur be absent. The diag- nosis must be made upon the accentuated or reduplicated second pulmonary sound, the weak second aortic sound, the sudden, snappy first sound at the apex, and the physical signs of enlargement of the right ventricle. The prognosis in mitral stenosis is not so good as that in mitral insufficiency, because the back pressure of the pulmonary veins is constant and not intermittent, and be- cause the force of the left ventricle cannot be called into requisition to aid in the compensation of the lesion. Aortic Regurgitation. Etiology. — Insufficiency of the aortic valves may be caused by the following conditions : 1 . Conge7iital lack of development. 2. Rupture of a valve-segment. A healthy valve-flap may in rare instances be caused by excessive strain, such as heavy lifting; or an ordinary strain may be the means of rupturing a valve that is weakened by ulcerative changes. 3. Stretching of the aortic ring, causing " relative incom- petence." This condition is rare, and is seen only in cases of extensive atheroma of the aorta with great dilatation just above the valves. 4. Acute endocarditis. Aortic incompetence does not re- sult during an acute attack unless the valve be eroded or ulcerated. It is more commonly seen, therefore, in malig- nant endocarditis. Slow changes, however, may result in the shrinkage, contraction, and calcification of the valve, causing it to become incompetent. Aortic incompetency may thus be seen in children with antecedent history of rheumatism and acute endocarditis, but it is not so common under these circumstances as mitral disease. 5. By far the most common cause of incompetence is the slow contraction due to atheroma, seen in able-bodied laborers who are subject to heavy muscular labors and who over-indulge in alcohol. There may be a syphilitic element which of itself is capable of causing arterial CHRONIC £NDOCAA'/)/77S. 21$ sclerosis. Occurring as the result of atheroma there are apt to be found associated lesions in the aorta, arteries, kidneys, liver, and lungs, already alluded to (see Atheroma, page 206). Patholog-y.— -As the result of the incompetency of the aortic valve, blood flows from the aorta back into the ventricle during the diastole. The left ventricle then receives blood from two sources — the normal supply from the auricle, and the regurgitated blood from the aorta. The ventricle therefore becomes greatly dilated. Dilatation is all the more extreme because the distention of the ventricle occurs during diastole, at which time the tissues are in a relaxed condition, and also because the heart-wall is often the seat of fatty degeneration, as will be shown hereafter. The increased labor of expelling this large amount of blood, part of which is to roll back again, leads to hypertrophy of the left ventricle. This hypertrophy reaches the highest degree seen in any valvular disease, and may produce a heart of enormous size and weight (from 30 to 50 ounces), to which the name " bovine heart," or cor bovimnn, has been applied. This is especially the case in children. Relative incompetence of the mitral valve is common as the result of the dilatation of the left ventricle ; when this incompetence occurs there is apt to be pulmonary conges- tion with compensatory hypertrophy of the right ventricle. There is a tendency in aortic regurgitation for the heart to undergo fatty or fibroid degeneration from poor coronary circulation, either because of the associated atheroma or calcification of the coronary arteries, diminishing their cali- bre, or because the coronary arteries, by reason of the dimin- ished tension in the aorta, are poorly filled with blood. Aortic regurgitation is often associated with aortic stenosis, but regurgitation alone is more common than stenosis alone. Aortic aneurysm may complicate the valvular disease. In advanced cases there may be changes in the cardiac nerves and ganglia that may lead to angina pectoris. Symptoms. — As long as the hypertrophy equalizes the 2l6 M.IXCAL OF THE PRACTICE OF MEDICLXE. valvular defect there are no characteristic s\niptoms. In advanced cases with myocardial degeneration or with lesions in the aorta and coronary vessels there are apt to be developed symptoms of arterial auceniia — headache, dizzi- ness, irritability of temper, faintness even to the point of syncope, palpitation, dyspnoea on exertion, with the general symptoms of anaemia. There may be dull aching pain in the precordium, or else attacks of angina pectoris. If at any time the diastole be unduly prolonged, the regurgitating blood may so empt\- the aorta and large vessels as to cause sudden cerebral anaemia. Sudden death may occur under these circumstances, and its possibilit}' must always be considered in making the prognosis. CEdema of the feet and dyspnoea with progressing symptoms of venous con- gestion usher in a fatal issue, and differ in no essential features from the venous congestions and heart failure of other valvular lesions. The physical signs of aortic regurgitation are apt to be clean-cut and distinctive. The characteristic murmur, which is diastolic in rhythm, replacing the second sound, is usually heard best in the mid-sternum, at the level of the third rib, and is convected downward toward the lower end of the sternum and the apex. It may be heard best in the second right interspace or at the lower end of the sternum, or even just within the apex. If heard in these latter localities, to which it has been convected downward, it may closely resemble the presystolic murmur of mitral stenosi.s. Aid to diagnosis in such cases is afforded by the presence of the murmur at the base of the heart as well, and by the other physical signs. Often the murmur is better heard with the ear than with the stethoscope. It may be harsh and of a " sawing " character, or it may be a soft, long-drawn bruit. It is very constant and reliable. The first sound at the apex is usually weak, and may be replaced by the murmur of relative incompetence of the mitral valve. The first sound at the base may be replaced by a mur- mur. This may mean stenosis of the aortic valve, or merely CHRONIC ENDOCARDfTfS. 21/ roughening of the surface of the valve or of the intima of the aorta just above the valve. There may be a distinct diastolic thrill over the base of the heart. This thrill may be so diffused as to reach the apex and be then mistaken for the thrill of mitral stenosis ; but it is not limited to the apex, nor does it terminate with the sharp shock of the cardiac impulse, as does the thrill of mitral stenosis. The character of the pulse gives material aid in diagnosis. There is visible pulsation of the peripheral arteries, even in the vessels in which pulsation is not normally visible. The arteries may appear tortuous, straightening themselves with a peculiar jerky motion with each systole. There may be capillary pulsation under the finger-nails or over any skin Fig. 15. — Sphygmogram of aortic regurgitation. area artificially reddened by friction. However common this sign may be in aortic regurgitation, it is also seen in profound anaemia, in neurasthenia, and in conditions asso- ciated with great relaxation of the peripheral arteries, and hence is not in any sense pathognomonic. There may be pulsation in the second right intercostal space or in the suprasternal notch that may lead to the diagnosis of aneurysm. There may be a diastolic pulsation of the liver, even if the tricuspid valve be competent. Oph- thalmoscopic examination reveals visible pulsation of the retinal arteries of a characteristic jerking quality. There is heard a to-and-fro murmur in the femoral artery. On palpation the characteristic "water-hammer" or " Cor- rigan " pulse is felt. The pulse strikes the finger with a sudden forcible impulse, and then at once collapses, leaving the artery empty. This is best appreciated at the radial artery when the hand is held above the head. The quality' 2lS MAXrAL OF THE PRACTICE OF MEDICIXE. of the pulse is plainly reco<;ni/.cd in the spln-i^niooraphic tracing (F'g- IS)- Associated with these characteristic sions of aortic re- gurf^itation are those depending- upon the increased size and muscular power of the heart. There is a wide forcible area of cardiac impulse, the apex beat often beings in the sixth or seventh interspace, and being perhaps as far dis- placed as the anterior axillary line. There may be bulging of the precordium in children. This increase of size, also determined by percussion, is due to dilatation and hyper- trophy of the left heart, and possibly of the right heart as well. ' The prognosis in aortic regurgitation is not good, for three reasons: (i) As the affection occurs usually in elderly overworked alcoholic subjects as a degenerative change frequently associated with arterial and renal lesions, compensation is neither com- plete nor sustained. (2) From the frequent complication of fatty degeneration of the heart- muscle, there is a tendency to sudden or gradual heart failure. (3) There may at any Fig. 16— Aortic ixguigitaiion, showing time bc a sudden over-dis- the area of cardiac dulness, the usual points . r i j_ • i of the maximum intensity of the diastolic tCntlOU of thC VeUtncle. CaUS- murmur, and the direction in which it is jj^^ Jj-j^ paralvsis, and the Sud- carried. ' ' . ^ den death of the patient from acute cerebral anaemia. The liabilit}' to sudden death should always be remembered in giving the prognosis. Aortic Stenosis. Etiology. — The lesion of aortic stenosis may be the re- sult of chronic endocarditis following an acute attack caus- ing thickening and rigidity of the valve. Usually, however, the disease occurs in old people as an atheromatous change, and is associated with some degree of incompetency. The CHRON/C KNDOCARDfriS. 219 latter condition is the more serious, and stamps the disease with its own characteristics. Patholog-y. — The valve-segments may be simply adherent to each other, or they may be thickened, contracted, or cal- cified. There may be a tongue of fibrin or large vegetations projecting into the orifice, further obstructing it. To over- come the obstruction to the onward passage of blood through the aortic outlet, more force is required of the left ventricle. It consequently hypertrophies. Usually there is but little dilatation. The whole force of the ventricle being thus called into requisition, compensation is usually good and the remaining parts of the heart are not affected. It is only when the left ventricle begins to fail that there is dilatation of the auricle, impeded pulmonary circulation, and increased work for the right heart. Symptonis. — There are no symptoms characteristic of aortic stenosis. The affection may last for years and be dis- covered finally by accidental examination. In advanced cases, where a lessened amount of blood enters the aorta with each systole, there may be sym.ptoms of anaemia, such as dizziness, faintness, and spots before the eyes. In more advanced cases there may be Cheyne-Stokes breathing during the latter part of the disease. When compensation fails the symptoms of pulmonary and systemic congestion do not differ in any way from those caused by other valvular affections. Physical Signs. — The characteristic m^urmur is systolic, heard best in the second right interspace, and is conducted upward along the course of the great vessels. Such a murmur is not distinctive of aortic stenosis, as it may be caused as well by simple roughening of the aortic valve or of the intima of the aorta above the valve, or by anaemia. If due to stenosis, the murmur is frequently harsher than if due to the other causes, but even then it may become faint and distant if the left ventricle begin to fail. The second sound at the aortic area is usually weak from diminished blood-pressure in the aorta at the time of the diastolic closure of the valve. This sign may be of great aid in diagnosis. In other cases the second aortic sound is 220 .y.iX[:iL OF THE PKACT/CE OF MEDICIXE. replaced by the murmur of aortic regurgitation. There is frequently at the base a systolic thrill which may be very well marked. There are the ordinary physical signs of h\-pertrophy of the left ven- tricle, and, in the later stages, of its dilatation, and with the dilatation the enlargement of the right heart from hyper- trophy or dilatation. The pulse is small in size, is regu- lar in rhythm, and may be somewhat slow. Prog-nosis. — In simple ste- nosis the prognosis is gener- ally good, as compensation is easily accomplished by hypertrophy of the left ven- tricle. If the stenosis be ac- companied by regurgitation, the prognosis will depend upon the latter condition. Flo. 17. — Aortic stenosis, showing the area of cardiac dulness, the point of maxi- mum intensity of the systolic murmur (X), and the direction in which it is carried. Tricuspid Regurgitation. This condition may result as an acquired affection in endocarditis, especially in the malignant form. Relative incompetence is far more common, and is due to dilatation of the right ventricle with stretching of the tricuspid ring, or to poor muscular contraction of the ventricle. It is thus produced by a failing left heart, and by any cause producing obstruction in the pulmonary cir- culation, such as emphysema and interstitial pneumonia. In either case it is a consequence of failure in compensation of the right ventricle. When tricuspid regurgitation occurs, the blood at the time of systole regurgitates from the right ventricle into the auricle and the veins, with the production of venous congestions. The physical sig-ns of tricuspid regurgitation are — (i) A systolic murmur, usually low and soft, heard with maxi- mum intensity at the lower part of the sternum, and trans- CHRONIC ENDOCARD/riS. 221 mitted to the right, frequently as far as to the axilla. {2) Enlargement and fulness of the jugular veins. (3) A venous pulsation in the superficial veins of the neck, and frequently a pulsation of the liver. This latter sign is be.st made out by bimanual palpation, and should not be con- founded with the apparent pulsation imparted to the liver by an over-acting right ventricle. (4) Marked increase of general venous congestions. Tricuspid Stenosis. Congenital cases of tricuspid stenosis are not uncommon. The acquired form occasionally occurs, usually associated with lesions of the left heart, especially with mitral stenosis. As the only means of compensation is by hypertrophy of the relatively weak right auricle, effectual compensation cannot occur. Marked venous congestions with great cyanosis are the inevitable result. The physical signs of tricuspid stenosis are — (i) A pre- systolic rnurmur heard at the base of the ensiform carti- lage. (2) Hypertrophy and dilatation of the right auricle. (3) Occasionally a presystolic thrill over the lower part of the sternum. Pulmonary Regurgitation. This affection, which is almost invariably the result of congenital malformation, is exceedingly rare. The regurgi- tation of blood backward into the right ventricle is followed by great dilatation, and relative incompetence of the tri- cuspid valve is very apt to result. Compensation is necessarily imperfect, and a fatal issue is not long delayed. The physical signs of pulmonary regurgitation are — (i) A diastolic murmur heard in the second left interspace, and convected downward and to the right. It is difficult to differentiate the murmur from that of aortic regurgitation. (2) Enormous hypertrophy and dilatation of the right ven- tricle. (3) The physical signs of the relative incompetence of the tricuspid valve. 222 MAXr.lL OF THE rKACTlCE OF MEDIChXE. Pulmonary Stenosis. This afifection, which is of i^^reat rarity except as the re- sult of disease or of arrested development during intra-uterine life, is one of the commonest forms of congenital malforma- tions, and is often associated with an open foramen ovale or an imperfect interventricular septum. As an acquired disease it ma\' result from malignant endocarditis. There is considerable hypertrophy of the right ventricle, with dilatation, but compensation is seldom perfect, being easily upset by intercurrent pulmonary affections. The dila- tation of the right ventricle allows of tricuspid regurgitation (relative incompetence) in the majority of cases. The physical signs of pulmonary stenosis are — (i) A systolic murmur heard in the second left interspace, and convected a short distance upward and to the left. (2) A weak or absent second pulmonary sound. (3) Marked hypertrophy and dilatation of the right heart. (4) There may be the murmur of relative incompetency of the tri- cuspid valve, with fulness and possibly pulsation of the superficial veins, especially those of the neck. Treatment of Chronic Valvular Disease. The treatment of chronic valvular disease may be divided into that of the stage of compensation and that of its failure. Stage of Compensation. — Hjpertroph}^ is in itself com- pensatory of valvular defects, and if the circulation be main- tained by it so that the arteries are kept filled and the venous flow is not obstructed, there is no medicinal treatment necessary. Much harm is done by injudiciously prescribing digitalis whenever a murmur is heard, no regard being paid to whether the lesion is compensated or not. Still, it is necessary that compensation should be maintained. The balance between the available power of the heart and the work required of it may be so delicate as to be upset easily by weakness on the one side or by increase of work on the other. Should the patient run down by reason of old age, sickness, or vicious habits, the myocardium will become degenerated and its power will be weakened, while, on the CHRONIC ENDOCAND/TIS. 223 contrary, the hypertrophy may be inadequate to meet any demand for increased work. I. The patient slioiild be kept in good health. To secure inteUigent co-operation it may be necessary to inform the patient of the lesion, although it is usually best to confide in some intimate friend or member of the family, upon whose judgment reliance can be placed. The patient should lead a quiet, orderly, and well-regulated life. The diet should be simple and wholesome, and all digestive errors are to be corrected by appropriate measures. Tobacco, tea, and stimulants should be avoided. Turkish baths should be eschewed, and the patient should not live in too high an altitude. Mental worry, over-fatigue, and severe bodily exposure should be avoided. As the prognosis of valvular disease with compensation is much better than was formerly supposed, and as sudden death occurs only with aortic re- gurgitation, the patient, if informed of his complaint, should be so encouraged and stimulated as to dispel mental depres- sion and despondency. 2. The work thrown on the heart shoidd be lessened as much as possible. In almost all cases enough exercise should be taken to keep the general health good. In fact, the heart's power may even be developed by graduated exercise. Oertel recommends ascending hills of increasing steepness and length until compensation is fully established. At no time, however, should exercise or work ever be allowed to pass to the point of excessive fatigue, nor should sudden violent exercise be permitted. Mental excitement of all kinds should be interdicted. The condition of arterial tension should always be deter- mined. Should it be raised, pointing to increased periph- eral resistance, it should be reduced and kept reduced. The diet should be simple ; over-eating and drinking are to be checked ; the bowels must be kept open and diuretics be administered. These procedures may suffice without the need of drugs. Should the latter be indicated, iodide of potassium (gr. x t. i. d.), chloral hydrate (gr. v to vii t. i. d.), and nitroglycerin (gr. -^^ q. 3 h.) are of the greatest value. 224 -V.l.Vr.l/. OF THE PKACTICE OF MEDICINE. Treatment of Failing Compensation. — The treatment naturally is to be directed to fulfil four indications : 1. To lessen the work required of the lie art. [li) By rest. This of itself may restore disturbed com- pensation, and should be resorted to in all serious cases. The patient should be put to bed and kept quiet, or, in less severe cases, confined to the room. (/;) By avoidance of over-action of the heart by emotional excitement, alcohol, tea, coffee, tobacco, or sexual excesses. {c) By diminishing peripJicral arterial resistance, should any exist, by regulating the diet, by increasing elimination of offending waste products by the skin, kidneys, and bowels, and by the administration of potassium iodide, chloral, or nitroglycerin. 2. To improve the force of the heart. The best drug for this purpose is digitalis. Digitalis is contraindicated in perfectly-balanced compensatory hypertrophy. The indi- cation for its use is broken compensation, no matter from what valvular affection. When digitalis does good the pulse becomes fuller, more regular, and of better tension, the dyspnoea and oedema diminish, and the urine usually increases in quantity. There are cases in which it does good even if the pulse continues irregular. Toxic effects may. however, be produced by its injudicious administration, and are shown by nausea and vomiting. The urine is reduced in amount. The pulse becomes irregular, and there may be two heart-beats to one of the pulse, especially in mitral stenosis. The particular preparation of digitalis to be used is of no consequence if the drug be good. Only as large doses should be given as may be required; over-stimulation should be avoided. Some patients in serious conditions may require large doses — from 15 to 20 minims of the tincture every three hours — while other cases, less aggra- vated, do well on from 3 to 4 minims two or three times a day. As a certain increase in the rapidity of the heart is one of the methods of compensation for a valvular lesion, digitalis should not be given blindly to reduce the frequency of the pulse to normal. The proper administra- CIJKONIC KNDOCANDJ'J'JS.. 22$ tion of digitalis requires the greatest judgment and the detailed watching of the patient. In aortic regurgitation digitaHs may do harm by unduly prolonging the diastole, so giving time for the ventricle to become over-distended. In such cases opium in gr. j doses three times a day is often of service. Strophanthus in the form of the tincture (gr. v to viii) may be employed instead of digitalis. It is often of service in steadying an intermittently acting heart, but it is inferior to digitalis in power. Convallaria. caffeine, and adonis vernalis are not now so extensively used as formerly. They may be given, how- ever, should digitalis disagree with the stomach. Iron and strychnine are often of great value. The timely administration of iron, with or without arsenic, often restores tone to the system and checks failing compen- sation. Strychnine is of great service, combined with digi- talis, in increasing the force of the heart. When the pulse is intermittent and irregular, iodide of potassium may be given, either alone or with digitalis. It is often of the utmost service. Nitroglycerin is a valuable heart tonic to meet temporary indications. It may be combined with digitalis. When the heart's action is rapid and tumultuous, much good is done by cold applications over the heart. When the heart-action is weak and irregular, constant irritation over the heart by a nitric-acid issue is of great service. 3. To diminisJi the venous congestions. . (a) By venesection. In cases of dilatation from whatever cause, with venous congestions, cyanosis, and dyspnoea, much relief is experienced by the withdrawal of from 15 to 25 ounces of blood. Timely venesection may save the pa- tient's life in acute cases. {b) By purgation. This is of service especially in cases with dropsy. From ^ ounce to i ]4 ounces of Epsom salt may be given in a concentrated form half an hour before breakfast. The compound jalap powder, or elaterium, or any other hydrogogue cathartic may be given, and is usually well borne. 15 226 MANUAL OF THE PRACTICE OF MEDICEXE. [c) By diuresis. For this purpose digitalis, with or with- out a saline diuretic, potassium citrate or acetate, is most efficient. In almost every case a sure indication that digi- talis is doing good is the increase in the quantity of the urine. Calomel in gr. iij doses every six hours for tliree or four days is often of the greatest service in cardiac dropsy, acting both as a diuretic and a cathartic. It should be discontinued should stomatitis develop. A favorite combination is the pill composed of a grain each of powdered digitalis, squills, and blue mass. Iodide of potassium in gr. x doses is often an efficient diuretic. If the blood-tension be abnormally high, diuresis may be in- creased by the reduction of the tension by iodide of potas- sium, nitroglycerin, or chloral hydrate. When the urine is greatly diminished, cups and poultices over the kidneys often prove of the utmost value. id) By operative iiiterfereiice. Serous accumulations in the pleural or peritoneal cavities may interfere to such an extent with the respiration and the heart's action that aspira- tion under the strictest antiseptic precautions may be re- sorted to. Frequenth', after tapping ascitic fluid, diuretics and cathartics, formerly of no avail, will succeed in prevent- ing reaccumulation. If the oedema of the legs be unrelieved by depletion through the bowels and kidneys or by elevation and band- aging of the feet and legs, scarification of the skin may be resorted to, or Southey's tubes — small silver cannulae with tubing attached — maybe inserted under the skin; but these methods are recommended only in the very severest cases. 4. To improve tlie general conditioi. While the symptoms incident to the deranged circulation are being treated, every attempt should be made to support the general health of the patient and to control all symptoms that interfere with sleep or with general nutrition. The diet should be simple, nutritious, and easily digestible. Over-distention of the stomach by food or by gas should be avoided. Iron and general tonics should be given. It is important that the patient should enjoy a restful sleep at night. For this pur- ACUTE MYOCARDrnS. 22/ pose sulphonal, chloralamide, or trional may be given. In milder cases Hoffmann's anodyne, camphor-water, valerian, or bromide of sodium may suffice. In aggravated cases of insomnia with dyspnoea and restlessness nothing acts more pleasantly than morphine, preferably given hypoder- mically. Opium by the mouth may be given to these patients in divided doses throughout the day. 3. DISEASES OF THE MYOCARDIUM. ACUTE MYOCARDITIS. This disease occurs in two forms : 1. Acute Diffuse Myocarditis. — This disease occurs in the course of infectious diseases and in septic processes of all kinds, and seems to be due to poisoning of the heart-muscle by bacterial products. It is best seen in fatal cases of diph- theria. It may complicate endocarditis or pericarditis. The heart-muscle is soft ; its color is dark red with hemor- rhagic points, or it may be yellowish-red or mottled. The heart-cavities are frequently dilated. The muscle-fibres un- dergo granular degeneration and may become fatty. The interstitial fibrous structure is infiltrated with round cells. The left ventricle is more frequently involved than the right. The disease may terminate in complete recovery or in chronic fibroid myocarditis, or it may end in suppuration. 2. Acute Circumscribed Myocarditis, or Acute Suppurative Myocarditis. — This form of myocarditis is due to infection of the heart-muscle by suppurative micro-organisms which arise from a primary focus of suppuration and reach the heart as emboli. Examination reveals small scattered foci of suppuration in the heart, in the form of grayish or of yel- low spots or streaks, usually surrounded by a hemor- rhagic zone. They are most common in the anterior wall of the left ventricle and in the septum, but they may occur in any locality. A suppurative focus may rupture into the pericardium, producing suppurative pericarditis, or into the 228 MAXr.lL OF TJIE PRACTICE OF MEDICINE. heart-cavities, produciiif^ malifi^nant endocarditis, general septica-^mia, or suppurative emboli. These complications may occur without apparent rupture. Aneurx'sm of the heart and rupture of its wall may occur. The disease is almost al\va)-s fatal, as the result of the cardiac condition or of the primary disease. Rarely the abscesses become en- capsulated, the pus becomes inspissated, or a calcareous nodule may remain. Symptonis. — The symptoms of both forms of nu'ocar- ditis are indefinite and are obscured by those of the primary disease. There is, however, a sudden increase of cardiac weakness ; the pulse becomes rapid, irregular, and feeble ; dyspnoea becomes marked. The heart-cavities usually dilate, and may occasion grave disturbances of cir- culation. Sudden death may occur, even in patients who have not been considered seriously ill. This termination is especially seen in diphtheria. The physical signs are those of weakened action of the heart, and possibly some increase in its size by dilatation. There may be the murmur of mitral regurgitation from relative insufficiency. The sounds are weak and may be equidistant, giving " tick-tack " sounds resembling those of the fetal heart. The occurrence of such " embryocardia " is always of serious import. The prognosis is always grave except in the lighter degrees of the diffuse form. Treatment. — The patient should be kept in absolute rest. Cold applications to the precordium seem to be of service, and alcohol should be administered freeh'. Digitalis does not seem to be of much service ; if given in large doses it may be the means of rupturing a heart abscess. CHRONIC MYOCARDITIS. Etiology and Synonyms. — This disease may follow acute diffuse myocarditis or areas of anaemic necrosis. It is seen in chronic poisoning by alcohol, syphilis, or gout. It may be associated with pericarditis or endocarditiSc Its most com- mon cause, however, is the narrowing of the coronary arteries, producing either low-grade tissue-changes from defective CHRONIC MYOCARDI'nS. 229 blood-supply, or thrombus-formation resulting in infarctions which gradually become converted to fibroid areas. The affection is thus commonly met with in people of ad- vanced age who have indulged freely in alcohol and high living, who have had syphilis, and who have done hard work. In such patients renal disease, endarteritis, and fibroid myocarditis are usually associated. Synonyms : Fibroid heart ; Fibroid myocarditis ; Chronic interstitial myocarditis. Pathology. — The lesion may be diffuse or circumscribed. The parts most frequently affected are the wall of the left ventricle, the papillary muscles, and the septum. The affected areas are firm, cut with resistance, and are opaque and grayish in appearance. The lesion consists in the increase of connective tissue with atrophy or degeneration of the muscle-fibres. The coronary arteries generally show obliterating endarteritis. The heart is usually enlarged and hypertrophied. Localized fibroid areas may allow of sacculated dilatation of the heart. Symptoms. — In some cases of chronic myocarditis there are no symptoms, the lesion being accidentally found post- mortem. In other cases there may be sudden death, which may occur without previous symptoms of disease. In still other cases there are symptoms of weakened power of the heart with circulatory disturbances. Palpitation and dysp- noea are common. There may be attacks of angina pectoris, which may be the only symptom. Intermis- sions and inequalities of the pulse are common, and the pulse is usually slow, being frequently reduced to 40 or 50 beats in the minute. There may be sudden syncope, coming usually after exertion, in which attack the patient may die. Attacks of coma resembling cerebral hemorrhage may occur and may prove fatal. There may finally be any of the symptoms of a dilated heart with venous congestions. The physical signs are uncertain. The heart is usually enlarged in size ; its sounds are weak. Diagnosis. — Aid is afforded by the presence of the arterial degenerative changes of nephritis and by the occurrence of symptoms of a failing heart without the signs 230 MAXr.lL OF rilE PRACTICE OF MFD/CINE. of actual dilatation or \-al\'ular lesion. The diagnosis from fatt\' degeneration is almost impossible. Prognosis. — The patient may live for years, but death may occur at any time from an attack of angina, of syn- cope, of coma, or without antecedent symptoms. Treatment. — In general terms, the treatment is that of fatt}' degeneration. Iodide of potassium is indicated in syphilitic cases. Heart stimulants are demanded by signs of cardiac weakness. Alcohol, strychnine, and nitro- glycerin are to be employed for this purpose, as digitalis is contraindicated because of the already increased blood- pressure in the sclerotic arteries. The diet should be simple ; the habits of life are to be well regulated, and exercise is to be taken regularly and sparingly, and never suddenly nor to excess. SYPHILITIC MYOCARDITIS. Two forms of syphilitic myocarditis are recognized : 1. A Diffuse Fibroid Myocarditis. — This variety cannot be distinguished from the ordinary form by either physical signs or clinical symptoms. 2. Giimniata in the Myocardium. — These gummatous tumors weaken the heart-muscle, causing symptoms of heart weakness, and may result in sudden death or in rupture of the heart. A positive diagnosis can be made only in cases where marked improvement follows the administration of large doses of potassium iodide in syphi- litic subjects with heart weakness. DEGENERATION OP THE MYOCARDIUM. I. Anemic Necrosis, or white infarct, a localized degen- eration of the myocardium, occurs as the result of the occlusion of a coronary artery or of one of its branches by thrombosis or embolism. Thrombosis is favored by sclerosis and atheroma of the wall of the vessel. The anterior coronary artery is usually the one involved, so that the resulting anaemia-necrosis is found in the left ventricle or in the septum. The patch is anaemic, whitish or grayish in color, and is usually of an irregular wedge shape. It DEGENERATION OE 7V/E MYOCARDIUM. 23 1 may soften and break down, and may even result in rupture of the heart, or it may undergo hyaline degeneration and ultimately become sclerotic, forming the lesion of fibroid myocarditis. Such a blocking of the coronary artery is one of the common causes of sudden death, and the lesion should always be looked for in these medico-legai cases. In other cases there are angina pains with feebleness of the heart's action. There may be a series of such attacks, any one of which may prove fatal. 2. Parenchymatous degeneration, or "cloudy swelling," is seen in the course of infectious diseases, especially diph- theria, typhoid, and scarlet fever. It may occur even if the temperature be but slightly elevated. The left ventricle is most markedly involved : its walls are pale, turbid, and exceedingly soft and flabby ; its cavity is usually somewhat dilated. The muscle-fibres are seen filled with numerous fine granules obscuring the striae and the nuclei. There may be some infiltration of the interstitial connective tissue with round cells, and the nuclei of the muscle-cells are usu- ally swollen and multiplied. The degeneration may merge into fatty degeneration. The symptoms are those of acute diffuse myocarditis, and a differentiation from that disease by clinical symptoms and physical signs is impossible. 3. Fatty Heart. — The term " fatty heart " is loosely applied to either of two distinct conditions, fatty infiltration and fatty degeneration. (i) Fatty Infiltration {Cor Adiposiim). — In general obesity the normal amount of fat covering the heart is much in- creased ; bands of fatty tissue may extend between the mus- cular fibres even to the endocardium and the papillary mus- cles. The muscular fibres may be normal or atrophied, or they may undergo pressure-degeneration. The heart-wall is weakened and may dilate or rupture. Such fatty infiltration occurs with general obesity, usually between the fortieth and seventieth years, and is more common in men than in women. It may more rarely be seen in the conditions of old age and cachexia. The symptoms are indefinite. There is dyspnoea on exer- tion, due either to the general obesitv or to enfeebled heart- 232 MAXUAL OF THE PRACTICE OF MEDICEVE. power. The pulse is usually weak and rapid. There may- be angina pains. Sudden death may occur from rupture of the heart. The p/iysicn/ sio)is are elicited with difficulty because of the increased thickness of the chest-wall. The area of car- diac dulness ma}- be increased by the fatty deposit. The heart-sounds are weak ; there may be a .systolic murmur at the apex, from relative insufficiency of the mitral valve. The treatment is that of general obesity, by regulated diet and systematic physical exercise. (2) Fatty Dcgoicration. — Etiology. — The heart is very subject to this form of degeneration. By reason of its incessant activit}' the heart needs an abundant supply of oxygen, and it is the most susceptible muscle in the body to show changes in nutrition. Any cause, therefore, pre- venting an abundant supply of good blood, or preventing good circulation of blood within the heart itself, will be followed by degeneration. Moreover, the heart-muscle is most susceptible to bacterial and chemical poisons. {ii) Failure of general nutrition in old age, in cachectic states, and in wasting diseases. Fatty degeneration occurs in acute and chronic anaemia, and is more common in those who lead a sedentary life. {b) Failure in local nutrition. Fatty degeneration com- plicates chronic pericarditis with adhesions ; dilatation of the heart, or heart weakness from any cause by which the circulation of blood in the coronary arteries is allowed to become sluggish by reason of feeble contractile power of the ventricular wall ; aortic regurgitation, in which the dimin- ished arterial tension does not allow of efficient filling of the coronary arteries. It may occur in the hypertrophied heart of valvular disease. It is common with disease of the coro- nary arteries. As this latter condition is usually secondary to atheroma of the aorta, fatty degeneration of the heart should always be suspected in old people with atheromatous changes of the aorta and the aoi'tic valves associated with a weakly-acting heart. {c) Poisoning of the heart-muscle. This complication may occur with severe infectious disease, especially diphtheria DEGENERATION OF TI/J: MYOCARD/UM. 233 and typhoid fever, and may be associated with fatty degen- erations in other viscera. It is seen in an intense form after poisoning by phosphorus or by arsenic. It may be caused by long-continued intemperance, or it may occur with diabetes. Fatty degeneration occurs more frequently in men than in women, and is usually a disease of adult life or of old age. In some cases no assignable cause can be found. Pathology. — The process may be general or local. The left ventricle is usually, however, affected. At first there appear yellowish striae and points under the endocardium, especially in the papillary muscles and the trabeculae, the remainder of the myocardium being healthy. In more marked cases, such as are seen in profound anaemia, the entire heart may be of a light-yellowish color and be very feeble and flabby, the heart-muscle often tearing easily. There may be areas of a brownish color — the so-called " brown atrophy." This is especially seen in cases asso- ciated with valvular disease or senility. The heart-cavi- ties may be dilated, and in extreme cases may rupture. Micro- scopically, the muscular fibres are seen to be filled with fatty granules and oil-drops ; the striae and the nuclei are indistinct. In severe cases the fibres seem completely occu- pied by the granules. The areas of brown atrophy, when present, show the color to be due to a deposit of yellow- ish-brown pigment about the nuclei. Symptoms. — In some cases sudden death occurs, with or without previous indications of cardiac trouble. Such a fatal event may follow the giving of ether or chloroform, sudden mental shocks or emotions, after exertion, or after a hearty meal. In other cases there are more definite symptoms. Usually symptoms of cardiac insufficiency appear. There may be dyspnoea on exertion, or it may be constant. The pulse is short and unsustained. Such a pulse may be a constitu- tional peculiarity in some persons, but is suspicious if met with in old people. The pulse may be regular or irregular, fre- quent or slow, falling at times even to 8 or 10 to the min- ute. A slow pulse of low tension is characteristic when it 234 MAXTAL O/-' THE PRACTICE OE MEDICLWE. occurs, but it is rather rare. The pulse may become rapid and irregular, and may " go to pieces " upon exertion, whereas the pulse of functional disease of the heart becomes stronger and more regular on exertion. Kxtreme fatt\- changes, however, may be consistent with a full regular pulse and regular heart's action, pro\-i(.led dila- tation of the heart does not occur. It seems, then, that the symptoms really depend upon the supervening dilata- tion. When dilatation occurs, there arc the ordinary .symp- toms of such condition. It can usually, however, be differ- entiated from dilatation from other causes by attention to the following points: (i)The heart is not always much increased in size. (2) The symptoms are more con- stant. (3) CEdema and anasarca are exceedingly uncommon. (4) There are frequently present symptoms of a certain diag- nostic value. They comprise symptoms of syncope, pseudo- apoplectic and epileptic seizures, and angina pectoris. The syncopal attacks are characterized rather by their duration than by their intensity. There is never entire loss of consciousness, but the attack may continue with feeble heart-action, frequently a pulse sinking to 30 or 40 to the minute, and cold, clammy skin for hours. Such an attack in an old person or in one in whom a sufficient cause for fatty degeneration is present is exceedingly significant. The pseudo-apoplectic attacks are characterized by the sud- den onset of coma with stertorous breathing, often of the Cheyne-Stokes variety. There may even be a temporary hemiplegia. Absence of raised arterial tension and of the characteristic temperature-curve differentiates this condition from cerebral hemorrhage. The attack is probably due to circulatory disturbances of the brain from a weakly-acting heart. From such an attack the patient may recover, but he is alwaj's mentally enfeebled. The epileptiform attacks resemble those of petit vial. There are convulsive movements, which are not usually severe. The patient is partially unconscious, not as in epi- lepsy, but more as in syncope. The pulse is usually slow, often as low as 20, and of low tension. There may be men- tal delusions or mania followin^r such an attack. DEGENERATION OF 'J'lIE MYOCARDIUM. 235 The angina attacks are identical with those of the true or the false angina. Physical Signs. — There are no essential physical signs in fatty degeneration. There need be no increase in the size of the heart, and no murmur unless from pre-existing valvular disease. There may, however, be evidences of dilatation consequent upon the fatty degeneration, and a systolic murmur at the apex, due to relative mitral insuffi- ciency. The heart's impulse is weak, vibratory, or absent. The first sound is short — a suspicious sign in old people ; the sounds may be equidistant, and the gallop rhythm may be present. The absence of physical signs adequate to explain the symptoms of cardiac inefficiency is of the greatest aid in diagnosis. Prognosis. — Mild cases following anaemia, wasting diseases, and fevers usually do well. The symptoms are never well marked, consisting usually only of a rapid weak pulse and some little dyspnoea on exertion, with a tendency to syncopal attacks. The heart-muscle returns to a state of health when the general health of the patient improves. The prognosis of the severer forms is bad. Fatty degeneration occurring in a hypertrophied heart with valvu- lar disease weakens the muscular wall, allows of dilatation, and upsets compensation. Sudden death may occur at any time, either unexpectedly, as during an attack of syncope, pseudo-apoplexy, epilepsy, or angina, or from rupture of the heart. The patient may die from heart weakness should he be attacked with any intercurrent disease. Treatment. — The patient should avoid every physical or mental excitement that might tax the power of the heart. Rest is of the utmost importance. The diet should be simple and nourishing. The stomach should not be over- distended by food or by gas. The strictest attention is to be paid to the general health. Anaemia should be met with iron tonics ; malnutrition, by proper feeding, cod-liver oil, and fresh air. Wine with the meals may be allowed, to stimulate digestion. Symptoms of heart feebleness should be controlled by heart stimulants and strict enforcement of rest. Digitalis 236 MAXr.lL OF TJIE PRACTICE OF MEDICI. XE. is often of great service, but any of the other cardiac tonics may be employed. Nitroghxerin is to be employed if the tension of the pulse be high from associated arterio- sclerosis. The general management of the case is that of valvular disease with broken compensation. Angina attacks are best relieved by amyl nitrite, nitroglycerin, or mor- phine given subcutaneously, while sudden attacks of heart failure require active stimulation by inhalations of amx'l nitrite or ammonia or b\' h\-podermics of ether, whiskey, or digitalis. ANEURYSM OF THE HEART. 1. AficjirjsDi of a valve results from weakening of the valve by either simple or malignant endocarditis. Aneu- rysms of the aortic valve bulge into the left ventricle; those of the mitral valve, into the auricle. The aortic valves are most frequently affected, the anterior mitral segment being more often involved than the posterior. Rupture of a valve-aneurysm produces extensive destruction and incom- petency. 2. Anc7irysni of flic licart-wall is preceded by weakening of the wall by chronic myocarditis, by endocardial ulcerations of malignant endocarditis, and by areas of anaemic necrosis. In rare cases aneurysm of the heart-wall has followed stab- wounds. The usual situation of an aneurysm is in the left ventricle near the apex. Aneurysm of the auricles or of the right ventricle is rare. The aneurysm may vary in size from that of a nut to that of the heart itself Its sac is composed of pericardium, myocardium (the muscular fibres of which are often replaced by fibrous tissue), and endocar- dium. The cavity of the aneurysm is frequently occupied by laminated fibrin. Rupture of the aneurysm has occurred in but 7 out of 90 cases. The symptoms are not distinctive, and a diagnosis is rarely made. There may be near the apex some localized bulging, which may give an expansile pulsation. If the aneurysm be large, there may be marked disproportion be- tween its pulsation and the feeble pulsation in the peripheral arteries. RUPTURE OF 77/E ///CARV. 237 The prognosis is exceedingly grave. Death may result from syncope or rupture, but more usually it occurs grad- ually from heart exhaustion due to the primary disease. The treatment is that of fatty heart. Nothing can be done directly for the aneurysm. RUPTURE OP THE HEART. Etiology. — A degenerated condition of the myocardium must in all cases precede rupture of the heart. Fatty de- generation, especially of localized areas, is the most frequent cause, occurring in "jy per cent of all cases, but anaemic necrosis following thrombosis of the coronary arteries, fatty infiltration, circumscribed myocarditis, broken-down tumors and gummata, and deep endocardial ulcerations and cardiac aneurysms may also lead to rupture. Two-thirds of all subjects of rupture of the heart are over sixty years of age. The rupture usually occurs after exertion, but it may occur while the patient is at rest. Pathology. — The usual situation of the rupture is in the anterior wall of the left ventricle, near the apex; more rarely the rupture may be situated in the posterior wall of the left ventricle, in the septum, or in the wall of the right ventricle. The rupture is usually small, and it may be either direct or indirect. Symptoms. — If the rupture be direct, the patient experi- ences agonizing cardiac pain, suffocation, and great appre- hension. The pulse becomes rapid and feeble ; the skin is cold and clammy. Death may occur in syncope in a few minutes (in 71 per cent, of cases), or it may be deferred for several hours. In the more protracted cases vomiting and purging may be noticed. The prognosis is always fatal. The treatment is entirely prophylactic. Persons known to have degeneration of the myocardium should lead tran- quil lives free from every mental or bodily strain. 238 .U.-IXC'.IL OF THE PRACTICE OF MEDIChXE. 4. NEUROSES OF THE HEART. PALPITATION. The term " palpitation " is applied to all forms of abnor- mal cardiac sensations which are unpleasantly sensible to the patient. The distinctive features are violent pulsations of an unpleasant nature, usually with throbbing of the larger arteries. The pulse may be rapid and over-forcible, but it may be normal or even weak. Tlie attack appears suddenly, lasts a few minutes or hours, and, while not serious, occa- sions considerable alarm. Various neurotic symptoms — flushing of the face, sweating, eructation of gas, and the abundant passage of limpid urine — often accompany or fol- low the attack. Palpitation is a pure neurosis, which may, of course, occur in a health}' or a diseased heart. It is to be distin- guished from the over-action of organic disease in that it is not produced by exertion — in fact, is often dispelled by exercise— appears often at night while at rest, and is not accompanied by dyspncea or other symptoms of cardiac distress. Pathology. — There is no lesion, but in long-continued cases hypertrophy or dilatation may result. Etiolog-y. — The cause of palpitation of the heart is a re- flex inhibition of the vagus action that enables the accelera- tors to run away with the heart. The affection is common in women and in young adults, and is rarer in advanced age. It occurs in weak and nervous conditions, after sickness, in hysteria and neurasthenia, in excitable subjects, and at the climacteric. It is produced by unhealthy occupations and by vicious modes of life. It is common with over-use of tea, tobacco, or coffee. Flatulent dyspepsia is a prolific cause of palpitation, and it may occur as a reflex phenom- enon from gastric, intestinal, or ovarian irritation. The effect of emotions is well known. Palpitation of the heart is a symptom of exophthalmic goitre. The " irritable heart of soldiers " (DaCosta) is a form of TREMOR CORDS — fN'J'HRAir'rfKN'J' ACT/ ON. 239 palpitation caused by excitemeriL and ovcr-cxcrtion, espe- cially if the thorax be compressed with shoulder-straps ; this condition is accompanied with some dyspnoea on exertion. TREMOR CORDIS. This condition, which is the opposite of palpitation, oc- curs occasionally in youth and more commonly in advanced life. It may occur in healthy hearts or in those enfeebled by myocardial degeneration. The attack comes without warn- ing; the heart "trembles" or "flutters," while the pulse sinks to a tremulous thread. The attack lasts for a few seconds and terminates by a forcible cardiac beat. Tremor cordis is almost always due to flatulence or car- diac distress, and is not produced by emotions. There is no accompanying faintness, although the attack occasions seri- ous alarm. The prognosis is perfectly good. INTERMITTENT ACTION. Intermittent action occurs whenever the heart misses a beat from time to time. Intermittency may be regular or irregular, habitual and constant or only occasional. It usually occurs after meals, as an evidence of flatulent dys- pepsia ; it occurs after over-use of tea, coffee, or tobacco; it is common in gout, in uric-acid diathesis, in nervous and hypochondriacal conditions, and after bodily and mental shocks. A constantly intermittent action of the heart is common to many old people, and is of no great significance. Intermittency often occurs with fatty degeneration of the heart, and is to be distinguished from reflex intermittency by getting the patient to exercise briskly. By such exer- cise the really weak heart goes to pieces, while the healthy but neurotic heart clears up. Intermittency associated with organic disease of the heart is often of serious omen, indicating that the contraction of the auricles is not sufficient to fill the ventricles, hence the ventricles wait until they are properly filled. 240 .)/.i.yr.i/ ()/•' 77//-; PhwcTfcr. of mkdicixe. TACHYCARDIA. A rapid pulse accompanies many morbid conditions, such as fevers, exhaustion, collapse, emotional conditions pro- ducing palpitation, pain, maniacal conditions, and the inges- tion of certain poisons, as alcohol, atropine, nitroghxerin, and over-doses of digitalis. A rapid pulse is physiological after exertion and in the newly-born, whose normal pulse ranges between 120 and 135. The term " tachycardia," or " heart-hurry," is more properly applied to a rapid heart-action, often reaching 200 or more in the minute, tlie action being, moreover, usually feeble. Its distinguishing feature is the very little disturb- ance it gives, in contradistinction to the rapid pulse of exoph- FiG. iS. — Sphygmogram from a case of tachycardia. Pulse-rate, 175. thalmic goitre, of palpitation, of exertion, and of cardiac failure. Tachycardia may be due to tumors pressing on the vagus trunk or to mitral stenosis. In later life it is an important sign of senile degeneration, and is an added source of danger, as the attack may terminate in syncope or in asystole. Reflex tachycardia, a pure neurosis, may occur from any source of irritation, especially from gastric distress, and in reflex tachycardia the pulse may be fairly forcible. Intcniiittoit tacJiycardia is a rare disorder in which heart- hurry comes in attacks at varying intervals, each attack lasting a few hours. The pulse is rapid and weak, fre- quently over 200 to the minute, but usually the distress to the patient is but slight. The cause for such attacks is not definitely known. A permanent cure is rare, and the dis- ease may terminate fatally at any time. BRACIIYCARDfA ; BRADYCARDIA. 24I BRACHYCARDIA ; BRADYCARDIA. Two forms of slow heart are recognized — the false and the true. False brachycardia, in which the pulse is slow but the number of heart-beats is normal, is usually due to a dilating heart with myocardial degeneration, in which the dropped beats are due to weak or abortive systole. In some cases false brachycardia seems to be due to alternating hemi- systoles, each ventricle acting independently. True brachyca7'dia occurs whenever both pulse and cardiac systole are abnormally infrequent. Infrequent pulse occurs in some people as a constitutional peculiarity ; it occurs in hunger, and it is frequent in the puerperal state. Pathologically it occurs in a number of conditions : (i) In diseases of the medulla and in compression of the brain ; for example, in basilar meningitis, tumors of the brain, and cerebral hemorrhage. It occurs also with diseases and injuries of the cervical cord. (2) In degeneration of the heart-muscle. A slow pulse in the aged is highly significant of fatty heart. The pulse may fall to even 8 in the minute in these cases. (3) After the sudden lowering of peripheral resistance, as by bleeding or by the withdrawal of effusions in the chest or the abdomen. (4) After the critical fall of temperature in acute fevers, especially in pneumonia, typhoid fever, erysipelas, and acute articular rheumatism. (5) In poisoning by digitalis, alcohol, aconite, or lead. Infrequent pulse occurs regularly with jaundice. It is com- mon in uraemia. The poison may be from auto-intoxica- tion following digestive disturbances — a very common cause for brachycardia. Thus it is frequently observed with ulcer, cancer, or dilatation of the stomach. (6) Conditions of asphyxia. (7) Various conditions of melancholia. Brachycardia is most common with advanced life. The affection is usually of serious import, as in senile hearts it is 16 242 MAXr.lL OF TJIK PKACTICE OF MEDICIXE. very often dependent upon dilatation and nn'ocardial de- generation. The treatment is that of the underlying cause. ANGINA PECTORIS. Definition and Synonyms. — .Vngina pectoris is a disease characterized by severe pain over the heart, by a sense of impending' death, and in severe cases by disturbances in the action of the heart. Sy)iony))is : Stenocardia ; Breast-pang ; Neuralgia of the heart. Etiology. — The disease, which is one of adult life, and usually of the higher classes, attacks men in over 80 per cent, of all the cases. The exciting cause of an attack may be either exertion, external cold, indigestion, or constipa- tion, subsequent attacks becoming more and more easily provoked. In some cases no exciting cause can be dis- covered. Lesion. — No one lesion is constant. Ossification or inflammation of the coronary arteries is commonly found. Fatty heart, arterial sclerosis leading to high arterial ten- sion, atheroma of the aorta or of the aortic valves, fibroid myocarditis, and chronic inflammation of the coronary plexus are also among the pathological findings. In some rare cases no lesion is discoverable. The nature of the disease is not well known. The best explanation seems to be that a sudden high tension occurs in the arteries, causing a spasm of the heart in its efforts to overcome the resistance. The same spasm occurs in an over-filled bladder or stomach when its contents cannot easily be expelled, causing often agonizing pain. As a matter of fact, extreme degrees of arterial tension occur in 96 per cent, of all cases of angina pectoris during the attack. In the 4 per cent, of cases in which the tension is not raised no explanation can be given. There being in almost all cases some form of cardiac lesion, angina pectoris affords the strongest presumptive proof of organic disease. Symptoms. — The symptoms occur in attacks lasting from a few seconds to half an hour. One or two minutes ANGINA PECTORIS. 243 is the average duration. The severer attacks occur at night. Each attack is attended by three cardinal symptoms : (i) Pain over the heart is exceedingly severe; it is neur- algic in character, with a sense of constriction. The pains may radiate up the neck and down the left arm and hand, or they may extend to the back. The face is cold, ashen-pale, and clammy ; the expression is anxious ; there may be general sweating. The patient immobilizes himself from pain. With the pain there may be a feeling of numbness or coldness in the fingers. (2) Dread of impending death coexists with the pain in an equal degree. After the attack is over the patient fre- quently exclaims that if the pain had lasted a minute longer he would have died. In attacks cut short by the use of drugs the sense of impending death may not be noted. In mild degrees the patient may complain only of uneasiness and general apprehension. (3) Disturbance in the heaj^fs action occurs in almost all attacks. The pulse becomes rapid and irregular, and in 96 per cent, of cases is of extremely high tension. In some cases, however, the pulse may be uniform and but slightly altered. There may be considerable dyspnoea, and during the attack there may be a vehement desire to pass urine, although the bladder be empty. The attack may terminate in recovery, usually with the eructation of gas, with vomiting, or with the passage of a large quantity of limpid urine; or the patient may pass into syncope, from which he may or may not recover. Some patients who have had angina suffer from time to time from attacks of faintness without either pain or dread. This condition is not really angina, but is equally as serious. There may be but one attack of angina, or there may be a number of attacks at irregular intervals of weeks, months, or years. Between the attacks the disease itself gives no symptoms, although the underlying cardiac lesions present their ordinary clinical symptoms and physical signs. 244 MA XL' A L OF TJIE PRACTICE OF MEDICINE. The prognosis is bad. The patient may die in many of the attacks, some patients not surviving the very first. Re- curring attacks, as a rule, become more frequent and more severe, although it is possible for the attacks at any time to cease recurring. Much can be done by judicious treatment. The prognosis is best in cases in which the attacks are induced by a preventable cause. The disease often runs a protracted course, and is not so serious if associated with aortic disease. Treatment. — During an Attack. — Treatment is directed toward the blood-tension and the pain. If the arterial tension be increased, amyl nitrite should at once be given by inhalation, from 2 to 5 drops being placed in cotton or on a handkerchief and applied to the nose. Patients subject to attacks of angina pectoris should carry with them constantly the pearls of amyl nitrite, and should use them at the first indication of an attack. Usually this treatment cuts short an attack, but it may fail. If relief is not afforded in a minute or two by amyl nitrite, chloroform should be given, a few inhalations often affording prompt relief In some cases a hypodermic injection of morphine must be resorted to ; its action is rendered more efficient by a hot bath. In case the arterial tension be not increased, amyl nitrite does not do much good, and the treatment consists chiefly in morphine combined with inhalations of chloroform. Between the Attacks. — The general health should be cared for in every possible way. Excitement and sudden or severe muscular effort should be avoided. Tobacco and stimulants are prohibited. Exciting causes of attacks should be found and prevented. If the blood-tension is high between the attacks, it should be reduced by regula- tion of the diet and the action of the kidneys and the bowels and by the use of drugs. For this purpose nitro- glycerin may be given in gr. y^ doses, at first three times a day, the do.se being increased gradually until the patient complains of flushing or of headache. Prolonged use of iodide of potassium is often followed by good results. From 10 to 20 grains, three times a day. PSKUDO-ANG/NA. 245 may be given for years, the close being omitted from time to time or being replaced by doses of nitroglycerin to avoid iodism. There may be good results obtained by combining chloral hydrate in 5- or 7-grain doses with the iodide. PSEUDO-ANGINA. Etiology. — Women are niore frequently affected with pseudo-angina than are men. The disease is most common in the nervous and neurasthenic, and is apt to be associated with other nervous and vaso-motor phenomena. It may occur at any age. It is common at the menopause, and may occur with especial frequency at the monthly sickness. The attacks may arise spontaneously, or they "may be precipi- tated by worry or by disturbing emotions. In some cases there is a distant reflex origin. Pathology. — Pseudo-angina is a pure neurosis, and there is no essential lesion. Symptoms. — The disease comes in attacks which last for minutes, days, or even for weeks. If the attack be pro- longed the symptoms are remittent. The average duration is one or two hours, being longer than in true angina. The attacks, which may recur with a certain periodicity, are usually more frequent than in true angina. The symptoms of an attack somewhat resemble those of true angina. There is pain over the heart, which, however, is less severe, more diffused, and often is accompanied with precordial tender- ness. The patient does not immobilize himself as in angina, but is agitated and anxious. There is not the same dread of impending death, although the patient is apprehensive. The heart's action is either feeble and irregular or tumult- uous. The arterial tension is not increased. The breath- ing is rapid and oppressed. Vomiting and pain over the stomach are common toward the close of protracted attacks. There may be various hysterical or neurotic symptoms dur- ing and between the attacks. The diagnosis is chiefly to be made from true angina. The chief points of diagnosis have already been given. The absence of arterial or cardiac lesions would be of importance in excluding the true angina. There are, however, difficult 246 J/.l.Vr.-lL OF THE PRACTICE OF MEDICIXF. cases of combined hysteria, aortic valvular disease, and an- gina pains in \-oung women, in which an absolute diagnosis cannot be made. The prog-nosis is perfectly good both for life and for recovery. Treatment. — During the attack the action of the heart should be regulated ; if the attack be prolonged, sedatives and anti-neuralgic remedies may be employed, such as phenacetine, bromide of sodium, and camphor or cannabis indica. As the arterial tension is not increased, amyl nitrite, nitroglycerin, and similarly acting drugs are not indicated. Between the attacks treatment should be directed toward the general health and the underlying nervous condition. EXOPHTHALMIC GOITRE. Definition and Synonyms. — Exophthalmic goitre is a disease characterized by enlargement of the thyroid gland, protrusion of the eyeballs, and tachycardia, together with various nervous phenomena. The disease was first de- scribed in 1786 by Parry, but a complete description was first given in 1835 by Graves of Dublin, and in 1840 by Basedow of Germany. Syno)iyuis : Graves' disease ; Base- dow's disease. Etiology. — While no age is exempt, exophthalmic goitre is most common between the ages of fifteen and thirty-five. It occurs in women in the proportion of 5 to i. When it occurs in men it seems to run a more severe course. It is most common in anaemic nervous people, and ,may run in families predisposed to nervous ailments. It may follow a blow, a shock, or a fall. It may occur after preg- nancy, although when pregnancy occurs in a patient af- fected by the disease, recovery more or less complete may ensue. Pathology. — The nature of the disease is unknown. A supposed lesion has been sought for in the sympathetic nervous system, but changes in the nerves and the ganglia are neither constant nor peculiar. The disease can be re- produced in dogs by destruction of the restiform bodies, ExonrniALMic gui'J're. 247 and a case has been reported in which hemorrhages were found in the floor of the fourth ventricle. The theory first advanced by Moebius in 1886 is now generally accejjted : that the symptoms are due to an excess of thyroid poison acting directly on the vasomotor, nervous, and muscular systems. The resemblance between the symptoms of ex- ophthalmic goitre and those produced by overdosing by thyroid extract, and the contrast between the symptoms and those of myxoedema, seem to attest the correctness of this theory. The symptoms of exophthalmic goitre may be divided into four groups : 1. Heart Symptoms. — The heart's action becomes rapid, running frequently as high as 120 to 140, or even 200, beats in the minute. The rapidity is largely controlled by the conditions of rest and exertion. The action of the heart is usually forceful and accompanied by a feeling of palpitation, but both these latter symptoms may be absent. The tachy- cardia is usually the first symptom observed, and, in fact, the disease may stop here, with this as its only symptom. There is usually marked pulsation of the carotids, and there may be a capillary pulsation. In long-continued cases there may be hypertrophy of the heart, which may in debilitated subjects merge into dilatation. Soft systolic murmurs at the base are common ; they may be heard at the apex as well. 2. Exophthalmos usually follows the tachycardia. The eyeball is protruded, and the eyelids do not cover the scler- otics, leaving a rim of white above and below the cornea, giving the patient a peculiar startled look. The protrusion may be extreme, so that the eye is dislocated from its socket. There is a lack of synchronism between the action of the eyeball and that of the upper eyelid, so that when the eyeball is moved downward the lid does not follow it as in health. This is known as " Graefe's symptom." The upper eyelid may be so retracted that it is retained near the bony wall of the orbit, and to this condition is given the name of " Stellwag's symptom." The pupils and the optic nerves are usually healthy, but pulsation of the retinal ves- sels is common. Exophthalmos may be absent in some cases. 248 M.l.yr.ll. OF THE PA'ACr/CE OE MEDICIXE. 3. Goitre develops with the exophthalmos. It may be general or in only one lobe, and the enlargement is rarely so extreme as in simple goitre. The gland is soft and pulsating at first, becoming firmer and harder in protracted cases. There is usually a thrill felt on palpation. On auscultation ma)- be heard a systolic murmur, or more commonly a venous hum. 4. Xcrvous symptoDis are common to almost all cases, but there is considerable varict)^ in the extent to which they are developed. Emotional and mental disturbances are common. There may be hysteria, neurasthenia, irritabilit}- of temper, and mental depression often passing into melancholia. There may be temporary mania. There is a tendency to general neuralgic pains. Symptoms of general paresis have been observed in a few instances. Muscular tremors comprise one of the most constant symptoms of the disease. The tremor is usually fine, generally first involving the hands, and is more marked on motion. It may become general, and may even interfere with the walking power. In rare cases the tremor may be limited to one member. There is usually insomnia. There may be attacks of precordial pain resembling pseudo-angina. The skin is persistently moist with perspiration, and the electrical resist- ance of the body is diminished. Derangements of the digestion are common. There may be intermitting attacks of diarrhoea and flatulency, with severe and distressing vomiting resembling the gastric or gastro-intestinal crises of locomotor ataxia. There may be pigmentation of the skin as in Addison's disease, or patches of leucoderma. The hair may become white or may fall out. Urticaria and angio-neurotic oedema of the skin are common. There may be slight irregular fever without known cause. Alternating flushings and pallor of the face with hot and cold flashes are common. Menstrual disorders frequently occur, amenorrhcea being the rule, although menorrhagia EXOrUTJ/.lf.MlC GOfTRE. 249 may occur. There may be paroxysmal dyspnoea occurring especially with the attacks of palpitation. Prognosis. — Exophthalmic goitre runs usually a chronic course extending over years. It is seldom fatal except from the dilatation of the heart that may be induced. A certain number of patients recover completely or in part, but when the disease is well developed recovery is rare. There are some acute cases following fright in which recovery is rapid. Treatment. — The general nervous and anaemic condition should receive efficient treatment. The diet should be nutritious and digestible. Moderate exercise in the open air is to be enforced systematically if possible. All causes for nervous irritation should be avoided, and iron with arsenic or inhalations of oxygen gas should be given, together with general nervines and tonics. The action of the heart should be regulated. Digitalis and strophanthus may succeed, but they are not reliable. Convallaria often does good when digitalis fails. Ergot may be employed with benefit, and belladonna given until dryness of the throat is obtained may be of service. Brilliant results often are obtained by iodide of potassium in 5- or lo-grain doses three times a day combined with from 10 to 15 grains of sodium bromide. This combination is especially indicated where the heart's action is rapid and forceful with subjec- tive feelings of palpitation. Good results are claimed for the use of sodium glycerophosphate in 15- to 20-grain doses three or four times a day. In cases with marked gastro- intestinal symptoms colon irrigations daily are of service, and several cases of apparently permanent cure have been reported from this procedure alone. Aconite and veratrum viride are not of much benefit. Rest in bed with cold applications (as an ice-bag or Leiter's coil) over the heart are often efficient. In less severe cases a smooth piece of ice may be rubbed briskly over the heart for fifteen minutes two or three times a day. The use of galvanism has been recommended highly, and it should always be tried as a routine measure. The cathode should be placed at the back of the neck or at the 250 MA.VL'AI. OF THE PKACTICE OF MFDICIXE. angle of the jaw, while the anode is placed over the course of the sympathetic in the neck or over the heart. An application for fifteen minutes every second day is suf- ficient. Feeding with raw thyroid glands of the sheep and hypodermic injections of thyroid extract have been em- ployed, but with unfavorable results. The results obtained with desiccated thymus gland and with suprarenal extract have not been altogether favorable. In severe cases thy- roidectomy may be resorted to with a fair percentage of cures and improvements ; but the operation is in itself a considerable source of danger. Ligation of the thyroid arteries has been recommended. 5. CONGENITAL MALFORMATIONS. Congenital malformations may be due to arrested or abnormal development or to endocarditis during fetal life. The following classification is the one generally adopted : Patency of the Foramen Ovale. — If the patency exists in but small degree, it is not of serious importance unless accompanied by other anomalies. The greater degrees of patency are not incompatible with fairly prolonged life. In these cases the diagnosis can be suspected by marked cyanosis, either without heart-murmurs (fairly diagnostic) or by systolic and presystolic murmurs heard over the mid-sternum at the level of the third and fourth ribs. Defects of the Septa. — Minor defects of the ventricular systole are not rare and are not of much importance. Major defects rarely occur alone, but usually are associated with stenosis of the pulmonary valve, forming a most serious lesion. The defect results in the propulsion of blood from the stronger left ventricle into the right heart during systole, leading to embarrassed respirations and venous congestions. The physical sign is a loud .systolic murmur heard over the whole precordium and between the shoulders, and not transmitted. Both auricular and ven- CONG EN/ TA L MAL FORMA 7 VONS. 2 5 I tricular septa may be defective, producing the cor diiocii- lare, or the reptilian heart. Stenosis or Incompetence of the Tricuspid and Mitral Valves. — These defects are rare. For physical signs see Chronic Endocarditis, pp. 204—227. Stenosis and Atresia of the Pulmonary Orifice or of the Conus Arteriosus. — These affections comprise the most important group of cases, being, moreover, relatively common. Pulmonary stenosis alone is not inconsistent with life for some years. For the physical signs see Pulmonary Stenosis, p. 222. The lesion, however, is usually associated with defects of the ventricular septum, and the prognosis is thereby rendered far more serious. Persistence of the Ductus Arteriosus. — This channel should normally be closed on the fourteenth day. If patent, there result rapid hypertrophy and dilatation of the right ventricle, dilatation of the pulmonary artery, dyspnoea, cyanosis, and congestion of the lungs, with general venous congestions. The physical signs are a long-continued systolic murmur over the pulmonary area, a systolic thrill, and a protrusion of the upper part of the sternum. Stenosis of the Aortic Orifice. — Stenosis of the aorta is rare. It is a serious lesion, incompatible with life for more than a few weeks. Stenosis of the conus arteriosus is not inconsistent with a fairly prolonged life. The circulation is carried on by anastomoses between branches of the sub- clavian with those of the epigastric and intercostal arteries. The arteries of the upper extremities are regularly larger and fuller than those of the lower. Transposition of Arterial Trunks. — This condition is necessarily fatal /;/ utcro, unless compensated by other anomalies, such as open foramen ovale or communication between the pulmonary vein and the right side of the heart. Numerical Anomalies of the Valve-segments. — Super- numerary valves are of no significance. Deficiency of valve-segments is usually associated with other and more serious anomalies. Ectopia cardis may occur with congenital fissure of the sternum and abdomen. Displacement of the heart into the 25:: MAXrAL OF THE PKACTICE OF MEDICIXE. neck or the abdomen may occur. There ma\' be acardia, double heart, bifid apex, or absence of the pericardium. Symptoms. — Radical defects are inconsistent with life, so that the child dies /// utcro or shortly after birth. In those who live cyanosis is so marked a feature that the name " morbus creruleus " has been given to the disease, and the term " blue babies " has been applied to these children. The c\-anosis, which may be constant or may be induced onh' by exertion or by crying, varies from a lead color to a purplish hue. The child shows retarded mental and physical development. The nails are clubbed. The external temperature is low, and there is a great suscepti- bility to cold. Pulmonary affections are common, dyspnoea and cough are frequently observed, and the child is apt to succumb to an attack of bronchitis or of pulmonary con- gestion, or to any of the ordinary diseases of childhood. Treatment consists in guarding the child from cold and in checking promptly intercurrent diseases. The treatment for the'heart itself is the same as that for valvular disease of adults. 6. DISEASES OF THE ARTERIES. ARTERIO-SCLEROSIS. Etiology and Synonyms. — Arterio-sclerosis occurs as a disease of advanced age, usually in those over forty. It is one of the conditions of senility. Predisposition to arterial degeneration runs in some families and may be inherited. Among the exciting causes are chronic alcoholism, lead- poisoning, gout, syphilis, diabetes, and over-eating, espe- cially with sedentary habits of life. There may be an ante- cedent history of uric-acid diathesis. The disease is common with chronic articular rheumatism, and may precede, follow, or develop simultaneously with Bright's disease, especially with the granular kidney. It may follow severe over-work of the muscles. Synonyms: Chronic endarteritis; Atheroma. Patholog-y. — The aorta is almost alwa\'s affected ; next in frequency come the larger arteries. The disease may be uniformly distributed, or it may involve some arteries and A R TE R ro- SCL E R OS/S. 253 not others ; it may be either circumscribed or diffuse. The intima is much thickened by an increase of connective tissue and by the deposit of round cells. These cells may undergo fatty degeneration, imparting a yellow color in patches to the interior of the artery. In the deeper tissues the cells may break down to form a mixture of fat, detritus, and cholesterin-crystals from which the name " atheroma," or " pulp," is derived ; or, if near the surface, an atheroma- tous ulcer is formed. Atheromatous patches and ulcers and the narrowed lumen allow of the formation of thrombi. In other cases the intima becomes markedly sclerotic and of bony hardness from the deposit in it of salts of lime. The media and the adventitia may show similar changes, even to fatty degeneration and calcification, or the media may become atrophied. Seco7idary lesions are found chiefly in the heart. The arterial lesion produces loss of elasticity, and consequently increases peripheral resistance to the work of the heart. The thickening of the intima may, moreover, cause such a narrowing of the lumen of the vessels that an added resist- ance results ; in consequence, the left ventricle becomes hypertrophied in all cases in which the nutrition of the patient is good, and compensation is effected. Should general nutrition fail, dilatation will ensue. The hypertrophied heart, pumping blood into the vessels whose outflow is impeded, raises arterial tension generally and causes an accentuation of the second aortic sound. The changes in the aorta may so weaken its wall as to allow the formation of an aneurysm. For the same reason miliary aneurysms may be formed in the cerebral arteries and may result in rupture and cerebral hemorrhage. Dry gangrene of the extremities may result from dimin- ished supply of blood from the narrowing of the arterial lumen by connective tissue or thrombi. Associated Lesions. — Contracted kidney occurs in the great majority of cases. It is often difficult to decide in a given case whether the arterial or the renal disease has been primary. Emphysema with chronic bronchitis is present in a large 254 .VAXr.-lL OF THE PKACVVCE OF MEDICINE. number of cases, and the patient is liable to have cirrhosis of the liver, as alcoholism is a common fictor in cirrhosis and in arterial sclerosis. Atheroma of the aortic valves is a frequent complication. The symptoms are exceedingly diverse, depending upon which arteries are most affected and upon the secondary and associated lesions. Arterial sclerosis with compensa- tory hypertrophy is not inconsistent with general good health. When compensation fails the general symptoms of dilatation and heart-inefficiency occur. Sclerosis of the coronary arteries may produce throm- bosis with sudden death, fibroid degeneration, aneurysm or rupture of the heart, and angina pectoris. Cerebral symptoms are those of cerebral endarteritis (which see), comprising acute and chronic degeneration, spasm of cerebral vessels with transient or permanent paralyses, and cerebral hemorrhages. Renal symptoms may be absent, or the urine may be increased in quantity and of low specific gravity, with but occasionally hyaline casts and a trace of albumin. In other cases the renal symptoms are distinctly uraemic and may terminate the life of the patient. The course of the disease may be complicated by aneur- ysm, by gangrene, or by an associated emphysema. Physical Signs. — The combination of increased arterial tension, hypertrophy of the left ventricle, accentuation of the second aortic sound, and an appreciable thickening of the arteries affords conclusive proof of the existence of arterio-sclerosis. A high-tension pulse may exist with very little sclerosis, but sclerosis and high tension usually go together except when the left ventricle fails. The pulse- wave is slow in its ascent, is felt for an appreciably long period, subsides slowly, and between the beats the pulse remains firm and full. The wave-fluctuations are compara- tively small. It is difficult, even impossible in some cases, to obliterate the pulse by firm pressure on the artery. The sphygmographic tracing (Fig. 19) shows a short slanting up- stroke, a flat or rounded summit, and a gradual descent in which the dicrotic wave is slighly marked or absent. ARTKRITIS. Platk 1 6. y^. •, r•.^*^•.•^*»-•5!J;,■ % >ri Small artery: thickening of all the coats (Delafield). ARTERITIS. I' LATE 17. ^^•' ■*^ "V "V Small artery: obliterating endarteritis (Delafi, eld). ARTERITIS. Platk 1 8. ^z ^i>-- .^X f '' I, ■■% ^^ % t I '') 4 '( Syphilitfc endarteritis fFin?p.-l ■ ! \, If ingei) . b shows thickened int SYPif/LfTic AirncNiTis. 255 The prognosis, so far as life is concerned, is not unfavor- able. The danger of renal or cardiac disease or of cerebral complications is always present. The chief question is whether compensatory hypertrophy of the left ventricle can be maintained. Sudden death may occur. Treatment. — Much can be done to limit the extension of the disease by a quiet mode of life, plain, non-.stimulating diet, and a correction of those conditions known to pro- duce the disease. The state of the bowels and of the urine Fig. 19. — Sphygmogram showing high-tension pulse. should be regarded, and the skin should be kept active by daily baths. Alcohol is to be prohibited. High blood- tension should be reduced by appropriate drugs. Of these, nitroglycerin is the most serviceable, given in doses of gr. y-^ every three or four hours, or at longer intervals if not well borne. Iodide of potassium in gr. x doses t. i. d. is of service, especially in syphilitic patients. It is advantage- ously combined with choral in gr. v-x doses. Sudden and severe muscular efforts should be avoided, especially if the aorta be extensively involved. When the heart begins to dilate, stimulants will be required. Digitalis should not be given, however, unless its effect in raising arterial tension be balanced by its combination with nitroglycerin. Should acute dilatation occur, with lividity and dyspnoea, venesec- tion may be resorted to. SYPHILITIC ARTERITIS. Besides sj'philis being a causative factor in arterio-sclerosis and aneurysm, two specific forms of arteritis are described : I. Obliteraiing endarteritis with proliferation of new tissue within the intima, obstructing the lumen. There is also a small-celled infiltration of the middle and external coats. This form of infiltration is not absolutely characteristic of 256 MA.yr.lL OF THE PRACTICE OF MEDICINE. syphilis, but should be so regarded should other syphilitic changes be found. 2. Gitvimatous Pcri-artcritis. — Guninia develop within the adventitia, forming ovoid swellings along the course of the artery. There is usually an associated obliterating endarteritis. This process is distinctive of syphilis, and occurs especially in the coronary and cerebral arteries. ANEURYSM. The following forms of aneurysm occur: 1. True aneurysm, in which the sac is formed by the arterial coats. The aneurysm may be cylindrical, fusiform, or sacculated. 2. False or dissecting aneurysm, in which, from laceration of the intima, blood makes its way between the layers and may rupture through the outer coats. 3. Arterio-ve/ious aneurysm, where a communication ex- ists between an artery and a vein. If there be an interven- ing sac, the term varicose aiie?irysin is applied ; if the com- munication be direct, the condition is termed aneurysmal varix. Etiology. — There is always some weakness of the arterial wall, so that it becomes dilated from the blood-pressure. There is almost regularly arterial sclerosis, and the con- ditions which produce this sclerosis are therefore causative factors of aneurysm. Bacterial infection of the aortic wall, producing aneurysm, has been observed with malignant endocarditis. Embolism may lead to aneurysm by causing local degen- eration or injury of the vessel-wall. The determining cause of aneurysm is high arterial pres- sure from the arterial sclerosis or from severe muscular efforts. Aneurysm is more common in men than in women, and is more frequent among the working classes, as long- shoremen, in whom alcoholism, syphilis, and over-work are important factors. It is rare before thirty and after fifty years of age, because arterial sclerosis does not appear be- fore the earlier limit, and because muscular strain is not so common after the latter age. ANEURYSM. 257 Pathology. — The cavity of the aneurysm usually contains clots of blood, frequently laminated and partly organized. There may be calcareous degeneration of the clot. The vessels leading from the artery at the site of the aneurysm may be occluded ; portions of the clot may become de- tached and carried into the circulation as emboli. Organ- isation of the clot is conservative in its nature and is more common in sacculated aneurysm. The aneurysm-wall is never composed of normal vessel- wall. The intima shows marked changes of arterial sclero- sis. The media is changed, and is often in a condition of fatty degeneration. The adventitia is thickened by inflam- matory processes, thus reinforcing the weakened arterial wall. The intima and the media may atrophy so that the wall consists of the adventitia alone. Aneurysms vary in size from microscopic miliary aneur- ysms to those the size of a child's head or larger. Aneurysms may rupture, may compress neighboring organs, and may cause pressure-erosion. The situation of aneurysms varies. In 860 cases ana- lyzed by Sibson, the situation of the aneurysm was as follows : The ascending portion of the arch, 141 ; the transverse portion of the arch, 120; the ascending and transverse portions together, 112; the sinuses of Valsalva, 87 ; the descending portions of the arch, 72 ; the transverse and descending portions together, 20 ; the whole arch, 28 ; the thoracic aorta, 71 ; the abdominal aorta at the coeliac axis, 131 ; the lower part of the abdominal aorta, 26. Symptoms. — An aneurysm, being a pulsating tumor in the course of the arterial circulation, growing in the stiff- walled thorax, and having a tendency to rupture, naturally produces four groups of symptoms : (i) The presence of a growing pulsating tumor ; (2) its pressure on surrounding parts; (3) its effect upon the circulation of the blood; (4) the symptoms due to erosion and rupture. Symptoms of Aneurysm of the Thoracic Aorta. — Pressure-symptoms are usually marked, and afford data for the localization of the aneurysm. I. Pressure on the Vena Cava or its Brajiches. — There 17 258 .)/./.\YWZ OF THE PRACTICE OF MEDJCIXE. may be congestion and oedema of the arm and the face on one side, more rarely on both ; or in old-standing cases there may be a brawny swelling of the base of the neck, termed by the French " the collar of flesh." Large aneur- ysms of the ascending aorta sacculated downward may press on the inferior vena cava, causing oedema of the feet and ascites. There may be erosion from pressure and rupture into the superior vena cava with aneurysms of the ascend- ing arch. Congestion of the chest-wall occurs from pres- sure on the azygos vein. 2. Prcssitrc on the Trachea and the Bronchi. — Moderate pressure causes symptoms of inflammation and cough with expectoration which may contain blood. More marked pressure on the trachea causes inspiratory dyspncea, either steady or paroxysmal, or orthopncea. There are developed s}'mptoms of gradual asphyxia. In some cases sudden fatal asphyxia may occur either from pressure-erosion of a tracheal ring, allowing the trachea to collapse suddenly like a membranous tube, or from the lodgement of a plug of mucus at the pressure-point, causing total obstruction. Tracheal compression is usually seen with aneurysms of the transverse arch. Compression of a bronchus causes localized bronchial catarrh with sibilant and sonorous rales, dyspnoea, and diminished breathing over that part of the lung. There may be bronchiectasis and suppuration of the lung. The left bronchus is the one more frequently compressed. With large aneurysms the lung may be par- .tially compressed. Rupture may occur into the lung, the trachea, or the bronchi. A large hemorrhage will cause death by anemia, or, filling the bronchi, cause asphyxia or septic broncho- pneumonia. Small repeated hemorrhages may occur from moderate leakage. Aneurysms of the descending arch often rupture into a pleural sac. 3. Pressure on the cesophagns occurs with aneurysms of the descending aorta, more rarely with those of the trans- verse arch. Dysphagia may be either steady or parox- ysmal, and may lead to great emaciation. The case may resemble one of oesophageal stricture, and care should ANEURYSM. 259 always be taken in such cases to exclude thoracic aneur- ysm before passing an oesophageal bougie, as otherwise instrumental rupture of the aneurysmal sac may result. Rupture into the oesophagus may occur and may be the first symptom of an unsuspected aneurysm. 4. Pressure or Traction on the Recurrent Laryngeal Nerve. — The left side is more commonly affected. There may result spasm or paralysis of one or of both vocal cords. There is dyspnoea which is steady or paroxysmal ; a brassy or clanging cough quite distinctive; husky or whis- pering voice or aphonia. Spasmodic dyspnoea of laryngeal origin is differentiated from obstructive dyspnoea of tracheal pressure by being relieved by inhalations of chloroform. 5. Pressure on the Sympathetic Nerve. — In the early stages the pupil on the affected side is dilated and the skin is paler than normal ; later occur contraction of the pupil and flushing and sweating of the skin. 6. Pressure on the brachial plexus causes neuralgic pains, twitchings, and later areas of anaesthesia. 7. Pressure on the Bones. — Pressure on the vertebrae causes the erosion of their bodies with a steady boring pain in the back that is distinctive of aneurysms of the descend- ing aorta. Complete erosion will expose the spinal cord to pressure with the symptoms of a transverse myelitis. 8. Pressure on the intercostal nerves causes neuralgic pain. Pressure on the sternum and the ribs is common with aneur- ysms of the ascending arch. Boring pain is experienced, and there is apparent a large pulsating tumor covered finally only by red shiny skin resembling that of a pointing ab- scess. External rupture is the inevitable result. 9. Aneurysms at the root of the aorta frequently cause angina pains. Physical Signs. — Inspection in many instances is negative. There may be bulging of the chest-wall, best appreciated with oblique light. This bulging occurs usually above the third rib, to the right of the sternum. Aneurysms of the ascending aorta are found projecting in the left scapular region. An external tumor may be formed by the sac approaching the surface, invading the intermediate struct- 26o MAXC.tL OJ- THE J'RACTICE 01- MEJ>JCJA'E. urcs. The heart's apex is often displaced downward and to the left. Palpation reveals an expansile pulsation of the tumor. There may be a heaving impulse without the appearance of an external tumor. There ma\' be a systolic thrill, and in some cases a diastolic shock which is highly distinctive. Fluctuation ma\- be detected when the sac has perforated the chest-v/all. Care should be taken, however, in manipu- lation to avoid rupture of the sac. There may be pulsation in the sternal notch in case of aneurysm of the transverse arch. Percussion reveals dulness or flatness whenever the aneur- ysm is large enough to approach the chest-wall. Small, deeply-seated aneurysms do not, therefore, yield dulness. Dulness on the right side of the manubrium indicates aneur- ysm of the ascending arch ; dulness in the middle line ex- tending to the left points to aneurysm of the transverse arch ; \vhile dulness to the left of the spinal column occurs with aneurysm of the descending aorta. There may be tender- ness on percussion, and a sense of abnormal resistance. Auscultation may yield negative results even with large aneurysms. There may be a continuous hum louder at each systole, or a systolic or double murmur. The aortic second sound is usually accentuated, or it may be replaced b}' the murmur of an associated regurgitation at the aortic valve. There may be a systolic murmur heard over the trachea, due to the expulsion of air at each pulsation of an overlying aneuiysm. The pulse in the arteries beyond the aneurysm is fre- quently altered, becoming slowed and the wave being partially effaced. Aneuiysms of the ascending arch alone, delay all pulses equally. Large aneurysms of the descending aorta may totally efface the pulse-wave in the abdominal aorta and femorals. When the aorta at the origin of the innominate artery is involved, the right radial pulse is more retarded and effaced than the left. When the trans\-erse arch is involved beyond the innominate, it is the left pulse that is the more affected. Tracheal tugging is a sign of much value in detecting ANEURYSM. 261 Fig. 20. — Aneurysm of the ascending aorta, showing shape of the outline and the position of the customary double murmurs. deep aneury.sms pre.ssing backward upon the trachea or the left bronchus. The patient should sit with the chin de- pressed, so as to relax the tissues of the neck. The exam- iner, standing behind the patient, raises the cricoid cartilage on the tips of the index fingers. If an aneurysm be present in the situation above noted, a characteristic down- ward tugging will occur with each pulsation This tugging is a sign of great value, al- though not absolutely path- ognomonic. The heart may be displaced downward and to the left. It is not usually enlarged unless from some coexisting lesion. Diagnosis. — Throbbing of the aorta in aortic insuffi- ciency, and displacement of the aorta forward with spinal curvature, may simulate aneurysm, but pressure-symptoms, pain, and retardation of the pulse are absent. Sacculated empyema receiving impulses from the heart may cause a pulsating tumor, but the pulsation is not expansile, there are no circulatory symptoms, and septic symptoms occur. Pulsating sarcoma and other growths of the mediastinum often present great difficulties in diagnosis. The pulsations in these growths are not expansile, as in aneur3^sm, have less force and power, and have no diastolic shock. In some cases a differential diagnosis between a pulsating tumor and an aneurysm is impossible. The prognosis is always grave. Recovery may occur, but it is not to be expected. The aneurysm may rupture at any time, and the rupture may even be the first symptom. Dissecting aneurysms just above the sinuses of Valsalva rupture usually into the pericardium, causing sudden death. Sudden heart failure is common with aneurysm without rupture, and death may result from obstructive dyspnoea. 26: M.ixr.u. oj- rnii pk.ict/ck (>/■ mkvici.xj:. myelitis, dyspha;^ia, and exhaustion, or from associated endocarditis of the aortic vaKes. Tlic course of the disease is usually about two years, although life may be prolonged in some cases for five or ten years. The treatment of aneurysm of the thoracic aorta consists in the attempt to secure coagulation within the sac. Rest is an essential feature of the treatment, and should be as nearly absolute as possible. Mental excitement of all kinds should be avoided. Tufnell's treatment consists in the enforcement of rest and a restricted diet. He allows for breakfast 2 ounces of bread and butter with 2 ounces of milk; for dinner, 2 or 3 ounces of bread and 2 or 3 Fig. 21. — Sphygmograms of the radial pulse on the right (a) and the left side (i^), from a case of aneurysm of the transverse part of the arch of the aorta, ounces of meat, with from 2 to 4 ounces of milk or claret ; for supper, 2 ounces of bread and 2 ounces of milk. This plan succeeds best in small sacculated aneurysms. Few patients, however, can stand such a radical reduction of food, so this treatment cannot be enforced rigor- ously. A more liberal supply may be given, but fluids should be restricted as much as possible. Systematic bleed- ing may prove of service in the earlier stages in robust sub- jects: 8 or 10 ounces of blood may be abstracted every ten days or two weeks, provided that excessive ansemia is not produced. Of medicines, iodide of potassium is most commonly em- ployed, the aim being to tranquillize the circulation and ANEURYSM OF "J'lIE ABDOMINAr. AORTA. 263 reduce blood-tension without increasing the frequency of the pulse. To find the proper dose the patient should be put to bed for several days, to find the rapidity of the pulse at rest. Then the iodide is to be given in 5-grain doses, well diluted, three times a day, and gradually increased as long as the pulse is not made more frequent. Rarely more than 10 or 15 grains three times a day are necessary. One marked effect of the iodide is the reduction of pain. Aconite may be used for temporary over-action of the heart, but its administration for any length of time is not recommended. Various forms of local treatment have been recommended, but with indifferent success. The insertion of horse-hair, catgut, wire, and the injection of styptics into the sac have been tried. Loreta's method has been followed in some cases by good results. This treatment consists in filling the sac with fine silver wire pushed through a hypodermic needle, combined with electrolysis. Special symptoms are to be treated as they arise. Dysp- noea and congestion may be relieved by timely venesection. Morphine is to be employed for pain. Urgent dyspnoea may seem to indicate a tracheotomy, but the operation is usually useless, as the obstruction is below the site of the operation in nearly all cases. If chloroform inhalations re- lieve the dyspnoea, and if laryngoscopic examination reveals bilateral abductor paralysis, the operation may be resorted to. External rupture is to be retarded by painting the sur- face with a solution of gutta-percha, by the use of ice-bags, or by a metal or an elastic support. ANEURYSM OF THE ABDOMINAL AORTA. The usual situation of aneurysms of the abdominal aorta is near the coeliac axis, which is frequently involved. The aneurysm maybe fusiform or sacculated, and may be multiple. It may project backward, eroding the vertebrae, or it may project forward, attaining considerable size. It may rupture into the pleura, the retroperitoneal tissues, the peritoneum, or the intestines. Symptoms. — Pain is the most prominent symptom ; it 264 .V.LVr.-l/. OF THE PRACTICE OF MFDICIXE. may be sharp, shootings, radiating down the legs, or it may be the steady boring pain of bone-erosion. Gastric symp- toms are common, especially gastralgia and vomiting. Em- bolism of the mesenteric artery may occur, producing severe colick}' pain. Para:sthesia and paraplegia may result from pressure on the cord. Physical Signs. — There may be a pulsating tumor ap- parent on inspection. By palpation a tumor of expansile pulsation is appreciated. There may be heard a systolic, diastolic, or double murmur. The pulse in the femorals is retarded and may be obliterated. To avoid mistaking a throbbing aorta for aneurysm, Osier sa\'s, " It is to be remembered that no pulsation, however forcible, nor the presence of a thrill or a systolic murmur, justifies the diagnosis of abdominal aneurysm unless there is a definite tumor wliicli can be grasped and which has an expansile pnlsationT A tumor of the pylorus with an impulse trans- mitted from the underlying aorta may be mistaken for aneur\-sm, but the impulse is not expansile and is lost when the patient assumes the knee-chest position, the tumor fall- ing forward away from the aorta. The prognosis of abdominal aneurysm is grave, although recovery is not impossible. The treatment generally is that of thoracic aneurysm. Pressure on the proximal portion of the aorta may be resorted to under chloroform. Pressure should not be too severe, as bad results have followed the bruising of the sac. m, DISEASES OF THE RESPIRATORY SYSTEM. L DISEASES OF THE LARYNX. SPASM OF THE LARYNX. Two forms of spasm of the larynx are recognized : (i) Laryngismus stridulus; (2) Spasmodic laryngitis. I. Laryngismus Stridulus (Thymic Asthma). — This form occurs in children under two and a half years of age. Rickets is found in two-thirds of the cases. It is more common in boys, in delicate, dyspeptic, and nervous chil- dren. It is less frequent in America than in England, France, or Germany. It may be a symptom of tetany. Etiology. — The attack may be induced by any reflex cause for irritation, such as dyspepsia, poor air, constipa- tion, dentition, or attacks of crying ; it is favored by inflam- mation of any part of the respiratory tract. Patholog-y. — The disease consists of a spasm of the adductors of the larynx, without inflammatory basis. Symptoms. — The attacks may come at any time, but they are most common just as the child awakes. Re.spira- tion is suddenly arrested ; the child struggles for breath ; the face is pale, cyanotic, or congested ; the pulse becomes weak and flickering; after a number of seconds the .spasm relaxes and air is inspired with a loud crowing sound. During the attack there may be spasm of the hands and feet (" carpopedal spasms "), or even general convulsions. The attack is not accompanied by cough, hoarseness, or fever. The paroxysms may be as frequent in severe cases as thirty or forty during the twenty-four hours, and they may be continued at intervals for months. Slight reflex causes may at any time bring on the paroxysms. The prognosis is generally good, but it is possible for the child to die in any of the attacks. Severe spasms may be the cause of meningeal hemorrhage. 265 266 m.i\l:u. of the pa'act/ce of medicixe. Treatment. — The spasm is of such short duration tliat there is but httle time for treatment. It seems be.st not to shake the child nor to dash water in its face, as has ,been recommended, but to keep the child quiet until the attack is over. Should the apnoea be persi.stent, a hot bath (95° F.) should be given and a cold compress be applied to the head. Intubation may be resorted to if danger be imminent. Recurrences of the paroxysms may be prevented by rectal injections of chloral hydrate (gr. ij-v) in milk of asafetida (oij), to which from 2 to 5 grains of sodium bromide may be added. Swollen gums should be lanced freely. The bowels should be regulated, and attention be paid to the proper scientific feeding of the child. Osier recom- mends warm baths two or three times a day while the back and the chest are being sponged with cool water. Any cause for reflex irritation should be discovered and properly treated. The importance of good fresh air and sunlight must be remembered in all cases. 2. Spasmodic Laryngitis (Spasmodic Croup). — This is the more common form of spasm ; it occurs regularly in children between two and five years of age, and equally in strong and in delicate subjects. Symptoms. — The attack comes regularly after the first heavy sleep, usually between i and 3 o'clock a. m. The child suddenly awakes and sits up in bed with evident d}'spnoea. The inspirations are noisy, difficult, and " croupy ;" the voice is husky ; there is a brassy " croupy " cough. The oppression and cyanosis may appear alarming, but after a time (from half an hour to an hour) the attack suddenly ceases and the child is as well as ever. During the attack there are neither constitutional nor inflammatory symptoms, and there is no fever. The attack may be repeated on sub- sequent nights, but in these cases there is usually added a mild catarrhal laryngitis, with cough, hoarseness, and possi- bly slight fever, during the day. The prognosis is perfectly good, notwithstanding the alarming appearance of the child. Treatment. — A prompt emetic should at once be admin- istered, such as wine of ipecac .oj, or mustard and water; ACUTE CATARRHAL LARYNGITIS. 26/ the yellow sulphate of mercury (gr. ij-v) has been recom- mended, but as it may cause gastro-enteritis it should not be used. If the attack persist, hot baths and hot fomenta- tions to the throat may be employed. ACUTE CATARRHAL LARYNGITIS. Etiology. — Many cases of acute catarrhal laryngitis are due to catching cold or to breathing irritating and impure air, especially in patients with catarrhal affections of the nose and the throat. An attack may be induced by over- use of the voice. Laryngitis may be one of the lesions of "the grippe " or of measles ; it may also complicate any dis- ease of the bronchi and lungs attended with cough and expectoration. It may also occur with any of the acute infectious diseases. Patholog-y. — On laryngoscopic examination the mucous membrane of the larynx is seen to be red, congested, and swollen. The inflammation may be generally distributed or it may involve only certain areas. The vocal cords are usually involved, and their mobility is impaired. There may be an over-secretion of the mucous glands, or only a slight mucoid exudation. Superficial ulcerations may re- sult in severe cases. In certain cases in adults there may be considerable oedema of the larynx, which may consti- tute a formidable complication. Symptoms. — In adults the course of the disease is somewhat different from that in children. Fever may be slight or absent, but malaise to some extent is common ; slight rigors may initiate a severe attack. The voice be- comes hoarse or is reduced to a whisper ; the cough is croupy or barking, and is usually paroxysmal and harass- ing. Pain referred to the larynx may be quite severe and steady ; it is usually increased by swallowing, talking, or coughing. In other cases a burning, irritating feeling alone is complained of Pressure over the cricoid cartilage may cause pain or a paroxysm of coughing. In severer cases with oedema of the glottis dyspnoea may be a marked symp- tom. The difficulty of breathing may be continuous or paroxysmal; it may lead to asphyxia. This complication is 268 MAXr.-lL OF THE PRACTICE OF MEDICIXE. more common in those suffering from alcoholism and Bright's disease. /// C/ii/dnu. — The peculiarit\- of laryng^itis in children is that it is often complicated b)- spasm of the larynx, consti- tuting a clinical group of symptoms to which the names " pseudo-croup " and " catarrhal croup " have been given. This complication usually occurs in the winter months and in children under three years of age, although some chil- dren continue to have attacks until their tenth or twelfth year. The symptoms resemble those in adults, but they are more marked at night. The child is usually awakened b}' severe and distressing dyspnoea, not, however, of the same explosive violence that is seen in pure spasmodic laryngitis. The attack wears itself out in an hour or so, and the child is left with only the ordinary .symptoms of laryngitis. The diagnosis must be made from spasmodic laryngitis and membranous croup. In spasmodic laryngitis the at- tack begins suddenly with explosive violence, and between the attacks the child is well and has no fever. In catarrhal laryngitis the child has been ailing, the d}*spnoea begins more gradually, and between the attacks of dyspnoea the child has a cough, the voice is hoarse, and there is some fever. In membranous laryngitis the dyspnoea is more con- tinuous, the general symptoms are more severe, and there are usually patches of membrane on the pharynx and the tonsils. The cervical glands are also swollen. In adults laryngoscopic examination will make a positive diagnosis from nervous or hysterical aphonia and from sim- ple oedema glottidis. Treatment. — The patient should breathe warm, pure, and moist air, and must avoid over-use of the voice. Cold applications to the neck are often of great service. The following prescriptions are of use in allaying the cough : !^s. Ammonii chloridi, .^iss ; Mist, glycyrrhizse comp., 5iv. — M. Sig. A teaspoonful every two hours in a wineglassful of water for an adult. CHRONIC CATARRHAL LARYNGITIS. 269 ]^. Antimonii et potassii tartrates, gr. -^^^ ; Codeiae, gr. \. — M. Ft. chart. No. j. Sig. One every two or three hours for an adult. The inhalation of menthol and compound tincture of benzoin is of great service. When the acute stage is passed astringent sprays may be employed. Attacks of dyspnoea in children are to be treated as are those of spasmodic laryngitis. CHRONIC CATARRHAL LARYNGITIS. Etiology. — This condition may result from repeated acute attacks, from breathing irritating dust or vapor, from excess- ive smoking, and from over-use of the voice ; it may com- plicate chronic bronchitis and pulmonary phthisis. The most common cause, however, is chronic nasal and pharyn- geal catarrh, especially if the nares be occluded and unfit for proper nose-breathing. Pathology. — The mucous membrane of the larynx is congested and thickened, and the proper motility of the vocal cords is impaired. Secretion is excessive or scanty and tenacious. Symptoms. — There is a tickling, irritating cough, worse at night and in damp weather. The voice is husky, has no " reaching power," and may at times be lost entirely. Tick- ling sensations in the larynx cause a constant desire to clear the throat. Treatment. — The first thing is to remove the cause of the laryngitis, and especially to direct proper treatment to nasal and pharyngeal catarrhal conditions, should they exist. Heated rooms and impure air are to be avoided, smoking is to be prohibited, and proper exercise in the open air is to be insisted upon. Mufflers and neck-handkerchiefs .should be avoided. Of great service are astringent sprays, especially nitrate of silver (gr. x : 5J). Obstinate cases should be referred to a throat specialist. 2JO M.lXrAL OF THE rKACTICE OF MEDICINE. MEMBRANOUS LARYNGITIS. Etiology and Synonym. — The occurrence of a mcm- branou.s laryngitis not diphtheritic in its nature is denied by some authors ; but cases undoubtedly occur in which the Klebs-Loefflcr bacillus cannot be demonstrated, but in which streptococci and staphylococci pla\' a causative role. Further bacterial examinations, however, are desirable to place these cases of non-diphtheritic membranous laryn- gitis upon a firm and independent basis. Syiioiiym : Mem- branous croup. The pathology is practically that of diphtheria of the lar}'nx, except that the deeper tissues are not, as a rule, so extensively infiltrated, and that the Klebs-Loeffler bacilli are not present. The exudation may be confined to the larynx, or it may spread to the trachea and bronchi, and more rarely to the pharynx, the palate, and the tonsils. In the exudate staph}^lococci and streptococci are found. The disease occurs in children between two and seven years of age almost exclusively. The symptoms of the non-diphtheritic laryngitis closdy resemble those of the diphtheritic form, but they lack the extreme prostration so characteristic of diphtheritic toxaemia. The points of differential diagnosis from diphtheria are as follows: (i) The patient is a child between two and seven years of age ; (2) there is no history of exposure to diph- theria ; (3) the patient does not act as a source of contagion to others ; (4) albumin and casts are not apt to be found in the urine; (5) the symptoms are those of laryngeal obstruc- tion and inflammation rather than those of ob.struction, pros- tration, and sepsis ; (6) the lesion occurs in a primary form in the larynx, whereas in diphtheria the membrane on the larynx is almo.st invariably secondary to membrane on the pharynx, the tonsils, or the palate; (7) cardiac failure, peripheral neuritis with paralysis, and nephritis are not observed as sequelze. Treatment. — Owing to the necessary uncertainty of diag- nosis, the case should be isolated thoroughly from the start, and be considered as diphtheria. The treatment is that of TUBERCULAR LAR YNGIT/S. 271 laryngeal diphtheria in every particular, except that pharyn- geal irrigation need not be insisted upon. TUBERCULAR LARYNGITIS. Etiology and Synonym. — Tubercular infection of the larynx is almost always secondary to pulmonary tuber- culosis, in which it complicates from 18 to 30 per cent, of all cases. The larynx may be involved early or late in the course of the pulmonary disease. The occurrence of tuber- cular laryngitis is more common in men than in women, and between the twentieth and thirtieth years. Synonym: Laryngeal phthisis. Patholog-y. — The mucosa is thickened by tubercular deposits and by oedema, especially over the arytenoid car- tilages. Tubercles appear upon the surface, and often co- alesce to form masses, which may ulcerate. The resulting ulcers are broad and shallow, having grayish bases and being surrounded by thickened mucosa. There may be a destruction of the deeper tissues by extension of the ulcera- tion. The disease may spread to the pharynx, the epiglottis, or the oesophagus. Symptoms. — Hoarseness or aphonia constitutes an early and a constant symptom, to which, however, no diagnostic Fig. 22. — Tubercular laryngitis (Brown). importance can be attached, as the change of voice may be due to muscular insufficiency of the vocal cords or to chronic catarrhal laryngitis, to which conditions phthisical patients are extremely susceptible. There is usually an annoying painful cough, which is, however, sometimes absent even in aggravated cases. Pain on talking may be severe, and neuralgic pains running to the ears may be com- -/- M.lXr.lL OF THE PRACTICE OF MEDIC/XE plained of. Pain on swallowing" may be so distressing that the patient is with difificult}- prevailed upon to take suffi- cient food ; this pain usuall>- results from tubercular involve- ment of the epiglottis or the pharynx. Dyspnoea may appear late in the disease, in either a constant or a parox- ysmal form, often necessitating tracheotomy to avert death from suffocation or to render the patient's condition a trifle more endurable. The diag-nosis is made by laryngoscopic examination. In the earlier stages of the disease the larynx is of a peculiar pallor, while the arytenoids show a characteristic club-like swelling. Later in the disease the tubercular masses and ulcerations are easily recognized. A diagnosis is aided by finding tubercular changes in the lungs, and is rendered certain by the presence of tubercle bacilli in the secretion from the base of the ulcer. The prognosis for duration of life depends largely upon the primary pulmonary disease. Death may be hastened by suffocation, inanition, or exhaustion. Treatment is often unavailing. The larynx should be kept free of secretion by cleansing sprays. Astringents may be used by spray or insufflation, and powdered iodo- form may be insufflated with benefit. Pain in swallowing may be controlled by spraying the throat with a 2 per cent, solution of cocaine. Applications of lactic acid and submucous injections of creosote have been recommended warmly, but they should be used only by skilled specialists. For the relief of the dyspnoea tracheotomy may be indicated. Surgical treatment of tubercular laryngitis consists in the scraping out of tubercular deposits, the parts being exposed by a median thyroidectomy if necessary. SYPHILITIC LARYNGITIS. The hereditary form of syphilitic laryngitis usually appears in early childhood ; it is characterized by the formation of gummata, deep ulcerations, and cicatricial deformities. The acquired form is more common. As a secondary lesion the larynx may be the seat of an erythema, imparting to it a purplish-red, mottled appear- (EDEMATOUS LARYNG/77S. 2/3 ance and giving rise to the symptoms of a simple laryngitis. Mucous patches and condylomata are rarely observed. As a tertiary lesion the disease is most common. There is a chronic catarrhal laryngitis, with an infiltration of the mucosa with gummata varying in size from a pin's head to a hazelnut. These gummata may undergo resolution if the ap- propriate treatment be effectual, or they may ulcerate, fre- quently destroying the deeper structures. The lesions may involve the larynx or may be unilateral. Cicatrices follow the ulcerations, and they may be sufficiently extensive to cause great deformity. Laryngeal stenosis from such a cause is a frequent sequela. Treatment must be prompt and energetic — mercury for the secondary form, potassium iodide in large doses for the tertiary period, under the rules laid down for the treatment of syphilis. The larynx must be kept clear by sprays, and any resulting stenosis is to be treated by cutting or by dila- tation. Should the gummata be large enough to occlude the glottis, tracheotomy may be necessary to avert fatal dyspnoea. (EDEMATOUS LARYNGITIS. Etiology and Synonym. — CEdema of the glottis may complicate severe acute inflammation, whether due to cold, to inhalation of irritant vapors, or secondary to certain of the acute infectious diseases. It may occur with perichon- dritis, as in tubercular or syphilitic laryngitis, or it may be due to the spread of intense inflammations of neighboring parts. CEdema of the glottis may suddenly occur in the course of acute or chronic Bright's disease, but this mode of occurrence is exceedingly rare. Synonym : CEdema of the glottis. Symptoms. — Dyspnoea is suddenly developed and be- comes rapidly urgent. The voice becomes husky and is finally lost. Respiration is accompanied by stridor. Symp- toms of asphyxia occur as a terminal event. The diagnosis can be made with certainty by laryngoscopic examination. The ary-epiglottidean folds are seen to be intensely oedematous, meeting in the median line in severe 18 274 MANi'AL OF TJ/E P A'. I C TICK OF MEDICINE. cases. The epiglottis may be involved by the cedema, and in rare cases the parts below the cords are also swollen. With- out the. aid of the laryngoscope the diagnosis can usually be made by feeling the oedematous parts with the finger-tip. The prognosis is exceedingly bad. Treatment. — No time should be lost in temporizing. Ice poultices should be applied to the neck, and after spraying the throat with cocaine long incisions should be made into the oedematous parts with a curved bistoury protected ex- cept at the extreme tip. Tracheotomy should be resorted to unless prompt relief is afforded by the scarifications. 2. DISEASES OF THE BRONCHI, ACUTE CATARRHAL BRONCHITIS. Etiology. — Primary bronchitis is exceedingly common as the result of " catching cold," beginning as a coryza and extending downward in the chest. It is more frequent in children and old people than in adults, and in the aged is a formidable disease. Cases are more common in the winter and spring months and in climates in which extreme and sudden changes in the weather occur. The disease is occasionally seen in localized epidemics, and it may even assume an apparently contagious nature. Those who lead an indoor life with insufficient ventilation are more suscep- tible, and those with " delicate chests " develop the disease upon the least provocation. It may be caused by the in- halation of noxious gases, such as ammonia, chlorine, or sulphurous acid, or by the breathing of smoke or of dust, especially in factories. Scco7idary bronchitis occurs with measles, influenza, whooping-cough, and any of the infectious diseases, and with diseases of the heart, lungs, or pleura. The considera- tion of these cases is referred to their respective headings. Pathology. — The lesion is bilateral, affecting the trachea and the larger and medium-sized bronchi. In severe cases, especially in children and old people, the smaller bronchi may be involved. The mucous membrane is congested, ACUTE CATARRHAL BRONCI/mS 2/5 reddened, swollen, and covered with mucus and muco-pus containing desquamated epithelial cells and leucocytes. The mucous glands are enlarged. In severe cases the sub- mucosa is oedematous and is infiltrated with leucocytes. Symptoms. — I)i Adults. — There may be chilly feelings at the onset, followed by moderate fever, which rarely rises to 103° F. even in the severest cases. Heaviness and malaise are present, with general pains in the bones, and the patient may be sick enough to be in bed. The chest symptoms set in with a feeling of tightness and oppression, a scraped feeling under the sternum, and a cough. At first the cough is dry, hoarse, and painful, com- ing in distressing paroxysms. Pain in the chest during coughing is chiefly felt along the attachments of the dia- phragm and down the sternum. When secretion is estab- lished the cough is much relieved. The sputum is at first scanty and mucous in character; it may be blood-streaked; later it becomes more abundant and muco-purulent. Dysp- noea is not a regular feature of bronchitis of adults, although in some patients there may be asthmatic breathing. Bronchitis /;/ young children is a more serious disease, from its tendency to involve the smaller tubes and to merge into broncho-pneumonia. In young babies cough, fever, and rapid breathing may be the only symptoms. The rapid breathing makes it difficult to nurse these young infants. In older children the disease may be either mild or severe. In severe cases there may be convulsions at the outset. The fever is high (102° to 103° F.) with morning remis- sions ; the pulse is rapid ; the breathing is rapid and may be insufficient, as shown by duskiness of the skin and symptoms of carbon-dioxide poisoning. There is cough, but the sputa are regularly swallowed. There are apt to be gaseous dis- tention of the stomach and vomiting. It is often hard to tell where bronchitis ends and broncho-pneumonia begins. If the symptoms be severe, if they continue for three or four days without improvement, and if the physical signs point to the involvement of the smallest bronchi, it is best to regard the case as one of pneumonia. To this class of cases the 2/6 M.-iXC.iL OF THE PRACTICE OF MEDICLYE. term " capillary broncliitis " is given, but they are more properly cases of broncho-pneumonia. Bronchitis /;/ old people is dangerous from the prostration and from the tendency of the disease to spread to the smaller tubes, and even to pass into broncho-pneumonia. There is a slight but irregular fever ; prostration is extreme, the weakness interfering with the cough and the proper clearing out of the accumulated mucus. There is no com- plaint of dyspnoea, but the breathing is rapid and often is insufficient. There may be slight delirium, especially at night. Physical Signs. — The regular physical signs of bronchitis consist of coarse large and small mucous rales. In children bronchial fremitus is usually present. In the earlier stages there may be sibilant and sonorous breathing. Subcrepi- tant rales point to the involvement of the smaller tubes. Rales may be absent (i) in mild cases with scanty secretion, (2) in inflammation of the trachea and the large bronchi alone, (3) after coughing with the expulsion of the secretion, and (4) in the feeble and aged, in whom respiration is too feeble to generate rales. The prognosis is good except in young infants and in old people, in whom broncho-pneumonia may develop. In the aged death from exhaustion may occur. The diagnosis of bronchitis is simple, but it is not to be considered complete unless it be determined whether the bronchitis is primary or is dependent upon some other disease, or whether it be an acute exacerbation of a chronic bronchitis. Bronchitis at an apex implies tubercular disease. Bronchitis of the finer tubes, worse at the apex and with continual high temperature, suggests miliary tuberculosis. Unilateral bronchitis suggests aneurysmal pressure, chronic interstitial pneumonia, or pleural adhesions. Bronchitis with dyspnoea and repeated slight hemorrhages suggests tuber- culosis or cardiac disease. Recurring attacks of bronchitis in young children suggest tuberculosis or tubercular bron- chial glands. Treatment. — In the majority of cases no treatment is re- quired. Much can be done to abort an attack by free dia- ACUTE CATARKII.lf. /i A'()XC///77S. 277 phoresis at the onset. A Dover's powder at night with a hot .mustard foot-bath often suffices. A hot lemonade contain- ing a little whiskey is a popular and efficacious remedy. Turkish baths are objectionable from the danger of catch- ing more cold on leaving the bath-house, but a hot bath at night is often useful if the patient need not leave the house afterward. The bowels should be opened by salines, and 10 grains of quinine in a single dose may be given. Delicate patients should be kept indoors or in bed. Expectorants are very useful to promote free secretion, but they are often given indiscriminately. They may be combined with seda- tives. In the dry stage tartar emetic in gr. -^ doses every two hours until slight nausea is experienced is often service- able, but preparations of squills, senega, ipecac, or ammo- nium muriate may be used. The sedatives employed are codeia and dilute hydrocyanic acid or small doses of opium. The following formula is recommended : I^. Codeiae, gr. \; Amnion, muriat., gr. ij ; Acid, hydrocyanic, dilut., 1T[ iij ; Syrup, scillae comp., TTL x ; Infus. prun. Virg., ad 3j. — M. Sig. Dose every two or three hours for an adult. When free secretion is established, ammonium muriate with mist, glycyrrhizae comp. is of much benefit. The paroxysmal cough of the earlier stages is frequentl}^ benefited by the inhalation of steam, to which maybe added compound tinc- ture of benzoin or terebene. If the disease threaten to become chronic, the patient should be put upon a support- ing tonic treatment, and, if possible, be sent away to some warm, dry, inland place. Bronchitis in children is to be treated like that in adults, except that opiates are not well borne. Severe cases are to be treated like broncho-pneumonia. If the bronchi become blocked by a too profuse secretion, interfering with free respiration, a simple emetic should be given. Bronchitis in old people frequently requires stimulation by alcohol, digi- 2/8 MAXL'.lf. OF THE FRACIICE OF MEDICINE. talis, and strychnine. Opiates are to be used with extreme caution. ACUTE CROUPOUS BRONCHITIS. Etiolog-y and Synonyms. — The disease is rare. It may occur as the result of breathing irritating \-apors and steam, but it is more often secondary to diphtheritic or croupous larj'ngitis by extension downward. Syiioin'iiis : Acute fibrinous bronchitis; Acute membranous bronchitis; Diph- theritic bronchitis. The lesion is that of a croupous inflammation of a mu- cous membrane. In cases complicating laryngeal diphtheria tlie Klebs-Loeffler bacilli are present in the membrane. Symptoms. — There may be a chill with fever and pros- tration at the onset, or there may be the previous history of membranous laryngitis. When developed, there is a cough with muco-purulent expectoration. From time to time there will be attacks of paroxysmal cough with the expectoration of rolled-up casts of a bronchus and its branches. These casts consist chiefly of coagulated fibrin which in places has undergone hj'aline degeneration, and in its meshes are leucocytes, epithelial cells, and frequently Ley- den's crystals and Curschmann's spirals. These casts readily unroll in the water. During the coughing attack suffoca- tion seems imminent, and often some blood is raised, but after the cast is expectorated the distress abates. Between the coughing attacks the symptoms resemble severe acute bronchitis, frequently with symptoms of insufificient aeration of the blood and of dyspncea. The physical signs consist of bronchial rales of all kinds, fine and coarse, with sibilant and sonorous breathing. When a bronchus is occluded, breathing sounds may be absent over that portion of lung, returning, however, when the occluding membrane is coughed up. The prognosis is bad, depending on the nature of the primary disease and the extent of the bronchi involved. Death usually occurs from suffocation. It is a most serious complication after tracheotomy. CI/RONIC CATARIUIAl. fiRONC/I/T/S. 2J<) The treatment is that of acute bronchitis, except that inhalation of steam is often of service in loosening the false membrane. For this purpose hypodermics of pilocarpine may also be employed. Inhalations of pure oxygen gas are of benefit if symptoms of asphyxia appear. CHRONIC CATARRHAL BRONCHITIS. Etiolog-y. — Chronic catarrhal bronchitis may occur after repeated acute attacks, but it is not common except in rheu- matic and gouty patients. It is most commonly secondary to emphysema, to any chronic inflammation of the lung, to pleural adhesions, and to organic heart disease. . It usually occurs in elderly people; it is more common in the winter months. Patholog-y. — The mucous membrane of the bronchi may be thinned, and the muscular and glandular coats may be either atrophied or thickened and granular. There may be superficial ulcerations. Bronchial dilatation is not uncom- mon. Emphysema is usually present. The sjrmptonis persist for years — better in summer, worse in winter. There is a cough which is worse at night. The expectoration varies greatly. In some cases it is scanty — the so-called " dry catarrh," an obstinate form with severe and paroxysmal cough. The term " bronchorrhoea " is ap- plied to cases with excessive secretion. The expectoration may be thick and yellowish or greenish, or more watery in character, depending upon the relative proportions of pus, mucus, and serum. If bronchiectatic cavities are present, the patient will often raise large quantities of secretion by any change of position which allows the cavity to drain itself Dyspnoea is not marked except from associated em- physema or cardiac disease, although some patients develop asthmatic breathing from time to time. There may be mild constitutional symptoms, especially during the winter months — emaciation, slight afternoon rise of temperature, and loss of strength. Fetid bronchitis occurs when the secretions decompose, especially in bronchiectatic cavities, in tubercular cavities, 280 MAXCAL OF THE PRACTICE OF MFDICIXE. with abscess and gangrene of the lung, and in empyema with a puhiionary fistula. Fetid expectoration may occur in chronic bronchitis ; it is likely to lead to bronchiectasis, pneumonia, or gangrene of the lung. In these cases it is often difficult to say which is the primary disease. ' The physical signs are those of bronchitis — coarse and subcrepitant rales, with sibilant and sonorous breathing. Bronchiectatic cavities yield their regular physical signs. If the bronchitis be secondary to pulmonary or cardiac dis- ease, the ph\'sical signs of such disease are present. The prognosis is bad for complete recovery, although patients live for years in comparative comfort. Treatment. — The best possible treatment is to send the patient for the winter to some warm, equable climate. In every case the primary disease should be treated, gouty and rheumatic habits corrected, the bowels regulated, the diet supervised, and every attention paid to the general nutrition. The ordinary expectorants are not of much service. Iodide of potassium in 5- or lo-grain doses three times a day often has a certain curative influence ; it should always be tried. Ammonium chloride in 10- or 15-grain doses every two or three hours does good when the secretion is abundant. If there be profuse purulent secretion, turpentine, terpin and terpin hydrate, cubebs, and oil of sandalwood should be tried. For distressing cough the syrup of tar, with or with- out the syrup of wild cherry or the fluid extract of chekan, may be used. The latter is to be given in oj doses every three hours, and the most desirable way of administering it is to evaporate it to a solid extract, which can be given in capsule, after the common method of administering War- burg's tincture. If fetid bronchitis occurs, myrtol may be used in 2- to 5-grain doses three times a day. Oil of sandalwood and terpin hydrate are also of service, while the odor may be lessened by means of sprays of carbolic acid or of thymol. BK O NCI I IE CTASIS. 2«I CHRONIC CROUPOUS BRONCHITIS. Etiology and Synonyms. — Nothing definite is known about this rare disease, except that it is more common in adults and in males, and that it is often associated with phthisis. Synonyms : Membranous bron- chitis ; Fibrinous bronchitis ; Plastic bronchitis. The symptoms of chronic bronchitis are present, and from time to time the patient has a severe coughing attack, possibly with spitting of blood, and raises a cast of a bronchus and its branches. These casts consist of an unknown albuminoid sub- stance, probably of altered fibrin. The attacks occur at varying intervals extending over years, as the disease is essentially chronic. The prognosis for life is good ; for recovery from the bronchitis, bad. The treatment is that of chronic bronchitis. Fig. 23. — Fibrinous bronchial cast. BRONCHIECTASIS. Definition. — Bronchietasis is a dilatation of the bronchial tubes. Etiology. — The disease is always secondary to some lesion weaking the bronchial wall, so that it dilates under coughing pressure. 1. There may be congenital weakness of the bronchial wall, usually unilateral, but these cases are extremely rare. 2. Inflammation of the bronchial wall leading to atrophic changes in the muscular and fibrous structures is the opera- tive cause in the large majority of cases; hence the disease occurs with chronic bronchitis, emphysema, broncho-pneu- monia of children, phthisis, foreign bodies within the bronchi, or pressure from an aneurysm or a tumor. 282 M.I.M'AL 0J-' THE PRACTICE OT MEDICIXE. 3. The bronchial wall may be weakened by traction from without, from old pleuritic adhesions, interstitial pneumonia, and fibroid phthisis. Pathology. — A cylindrical and a sacculated form of bron- chiectasis are recognized. The two forms may coexist in the same lung. The dilatation varies in size from a pea to that of a small orange. Sacculated dilatations are usually multiple, being spread along the course of a bronchus. A single sacculated bronchiectasis surrounded by non- indurated lung-tissue ma}' occur with emphysema and bronchitis in rare instances, and may resemble a single cyst without contents. The bronchial wall is thinned and its constituent elements are atrophied. The mucous mem- brane constituting the lining of the cavity may be normal or smooth and glistening, the columnar having been replaced by pavement epithelium, or it may be infiltrated and thick- ened, or it may be extensively ulcerated, especially in cases where the secretions are retained. The contents of some of the larger cavities are often exceedingly fetid, and a general fetid bronchitis may complicate the disease. Symptoms. — Moderate bronchiectasis does not, as a rule, give rise to symptoms or ph^'sical signs, and it cannot be recognized during life. The larger dilatations are diag- nosed by the cough and the expectoration. After a period of some hours free from cough a paroxysm will occur, dur- ing which large quantities of sputum are raised, frequently "by mouthfuls." These coughing attacks usually occur in the morning upon arising; they may be brought on by any position of the body that allows the secretion to flow from the dilatation into a normal tube. The sputum is abundant, frequently is foul-smelling, and separates on standing into three layers — the upper of a brownish froth, the middle of watery mucoid substance, and the lowest of a thick sediment of granular matter and cells. When ulcera- tion occurs there may be present hasmatoidin-crystals and elastic fibres. Hemorrhage may occur, but it is rare. The physical signs are not pronounced except in the well-marked cases. Large saccular " dilatations " give rise to the physical signs of cavities, associated with the evidences ASTHMA. 283 of the disease to which the bronchiectasis is secondary. The caveroLis signs vary from time to time according to the amount of accumulated secretion ; these signs are often locaHzed at the base of the lung — a point of considerable importance in the diagnosis between this lesion and a tuber- cular cavity. The physical signs may closely resemble a sacculated empyema with an opening into a bronchus, but the history of the case will usually make the diagnosis evi- dent. Prognosis. — The condition is essentially chronic, often lasting for years, during which time the patient may enjoy an active life. The prognosis is rendered worse by the primary lung conditions, by hypertrophy and dilatation of the right ventricle secondary to interstitial pneumonia, and by the possibility of an added tubercular infection or of pulmonary gangrene. Treatment is unsatisfactory, because it is inadequate to heal the dilatation. The cough is beneficial in clearing out the accumulated secretions, hence narcotics are inadmis- sible. Stimulant expectorants are useless. Some benefit may result from the administration of terpin hydrate in full doses, terebene, and turpentine. Injection of antiseptic solu- tions into the cavities has been followed by good results in some cases. In patients in good condition, with superficial cavities, incision and drainage may be resorted to. For the fever myrtol may be given internally, and inhalation of car- bolic acid (i to 3 percent, solution) and of thymol (i : looo), as described under Fetid Bronchitis ; the results, however, are never very satisfactory in extreme cases. ASTHMA. Definition. — Asthma is an affection characterized by paroxysmal dyspnoea due to contraction of the bronchi. The same name also designates the paroxysmal dyspnoea, due .to the contraction of the arteries, commonly seen with emphysema. Etiolog-y. — A number of theories have been advanced to explain the symptoms : (i) That the disease is due to spasm of the muscular tissue of the small bronchi (Biermer). (2) 2 84 .V.IXCAL OF THE PRACTICE OF MEDICINE. That it is due to spasm of the diaphragm and the accessory muscles of respiration (W'intrich-Bambcrger). (3) That it is a vaso-motor neurosis causing sudden sweUing of tiie bronchial mucous membrane (Storck, Sir Andrew Clark, Traube). (4) That it is due to the elimination of Leyden's , crystals. (5) That it is a special form of inflammation of the bronchioles — bronchiolitis exudativa (Curschmann). Of these theories, the first, that of bronchial spasm, is the one generally adopted. The causes of the disease are both predisposing and exciting. Predisposing Causes. — The disease is more common in those with high-strung nervous systems ; it may run in neurotic families associated with epilepsy or with neuralgia. Males are more frequently affected than females. As to age, of 225 cases, 71 occurred in the first decade, 30 in the second, 39 in the third, 44 in the fourth, 24 in the fifth, 12 in the sixth, 4 in the seventh, and i in the eighth. The predisposition to the disease is frequently retained through- out life. The affection is more common in those with pul- monary emphysema. Exciting Causes. — Climatic influences are very curious, some patients having asthma in some places and not in others, without apparent reason. Vegetable and terrestrial dust and irritating vapors may induce an attack. In this respect asthma closely resembles hay fever, with which dis- ease it is closely allied, and which it frequently complicates. Ipecac, sulphur, iodine, the pollen of many flowers and grasses, the irritant odor of violets, roses, and strawberries, the dust of feathers, and the emanations of certain animals afford familiar examples of personal susceptibility. Sudden mental shocks and deep emotions may induce asthma. The most frequent cause of an attack in those predisposed to asthma is bronchitis, and if in such patients bronchitis can be avoided, attacks of asthma are rare. Reflex causes arc common. Nasal polypi, hypertrophic rhinitis, naso-pharyngeal adenoids, and enlarged tonsils are frequently found, and the cure of these conditions will in many cases remove the liability to asthma. It is too much ASTHMA. 285 to claim that nasal and pharyngeal lesions comprise the only cause, however, as has been done by some. Among other reflex causes are uterine and ovarian diseases, over- loading of the stomach, and the taking of certain articles of food. Pathology. — As asthma is a functional disease, there is no regular lesion, although in old asthmatics emphysema and chronic bronchitis are often present. Symptoms. — There may be premonitions — a sense of drowsiness, depression of the mind, tightness in the chest, or peculiar feelings in individual cases that mean an impend- ing attack. The paroxysm usually begins at night with a sense of dyspnoea and with laborious efforts at breathing. The patient cannot lie down, but sits or stands, usually by an open window. Inspiration is spasmodic ; expiration is prolonged and wheezing. The accessory muscles of respi- ration are called into play ; the face is livid and distressed, and perhaps cyanotic. Limpid urine is usually passed in large quantities. There is a cough, tight at first, with ball- like gelatinous masses of sputum — the "'perks'' of Laennec. These balls can be unrolled in water; they represent mucous casts of the smaller bronchi. They frequently have a dis- tinct spiral form, and they are known as " Curschmann's spirals " (Fig. 24), in which there is frequently a central Fig. 24. — Curschmann's spirals : a, central fibre (after Curschmann). translucent filament composed of altered mucin. In addi- tion are found in the sputum the pointed octahedral crystals 286 MAXUAL OF THE PKACTICE OF MEDICINE. described by Lcyden, identical with those found in semen and in leukciemic blood (Fig. 25). Physical Signs. — The chest is fixed and enlarged — often from 6 to 8 centimeters larger in circumference than nor- mal. Expansion is poor, especially laterally, and is in strong contrast to the muscular attempts of respiration. Inspiration is short ; expiration is prolonged and wheezing. The diaphragm is low and moves but slightly. Percussion shows an increased area of pulmonary resonance. The note may be normal or hyper-resonant or tympanitic. On auscultation are heard all varieties of sibilant, sonorous, cooing, and whistling rales, especially during expiration. Fig. 25. — Charcot-Leyden's asthma-crystals (after Riegel). The expiratory murmur may be prolonged, or breathing sounds may be absent or be obscured by the rales. The duration of the attack varies from several hours to a number of days. In the more protracted cases the symp- toms are worse at night. Between the attacks there may be dyspnoea, wheezing respiration, and cough. In the long- standing cases emphysema and chronic bronchitis develop, resulting in chronic invalidism. The prognosis for life is good, death never resulting dur- ing a paroxysm. ASTJJMA. 287 Treatment. — Djiring the attack immediate treatment is required to relax the contracted bronchioles. A number of remedies maybe employed, Of these remedies amyl nitrite is the most serviceable, a perle containing from 2 to 5 minims being broken in a handkerchief and the vapor inhaled. Hot stimulants or spirits of chloroform in hot water may be given, while whiffs of chloroform may be required in aggra- vated cases. Permanent relief is often afforded, even in obstinate cases, by a hypodermic injection of morphine. Nitroglycerin, gr. j-^ every two or three hours, is of service in the more protracted cases. Choral in 10- or 15-grain doses often affords relief Antipyrine, gr. xv, or phenacetine, gr. X, may be used, repeated every three hours. Good results are claimed for the fluid extract of grindelia robusta in 3j doses every four hours. The smoke of cigarettes containing hyoscyamus, belladonna, or stramonium may be inhaled, or pastilles may be made from these drugs, with the addition of potassium chlorate or nitrate. Inhalations of cigar-smoke are frequently of great value. Paper satu- rated with a strong solution of potassium nitrate burnt in the room before retiring will often ward off a nocturnal attack. Between attacks antispasmodics should be given. Iodide of potassium in gr. v-xv doses three times a day, with or without the addition of 5 grains of chloral to each dose, is of great benefit. Nitroglycerin, gr. y^Q- every four to six hours, may be used. The systematic inhalation of com- pressed air has been recommended strongly. The diet should be such as not to induce flatulence, carbohydrates being used in great moderation. The patient should not retire to bed on a full stomach, and it is usually best for the heavy meal of the day to be taken at noon. If nasal polypi or hypertrophies are present, they should be removed. For every asthmatic there are localities in which he has little or no asthma. The particular locality of exemption should be found by each patient to suit his individual case, as no regular rule can be laid down to suit all patients. 2S8 M.-IXCAL OF THE PRACTICE OF MEDICINE. 3. DISEASES OF THE LUNGS. {(.i) Circulatory Disturhances. CONGESTION OF THE LUNGS. Congestion may be either active or passive. Active congestion occurs with acute inflammation of the lungs, with over-action of the heart, and from the inhalation of hot or irritating vapors. It may cause increase of dysp- noea, cough, and expectoration, with a moderate degree of fever, but about its symptomatology not much is accurately known. Most authors describe a rapidly fatal form of congestion occurring after exposure to cold or after over-exertion. Passiz'c Congestion. — Two distinct forms of passive con- gestion are recognized — mechanical and hypostatic. 1. Mechanical congestion is known as " brown induration " or the " pneumonia of heart disease " ; it is described under the heading of Chronic Venous Congestions of Heart Disease, page 192. 2. Hypostatic congestion of the posterior portions of the lungs is often found as the result of post-mortem changes. It is common in those confined to bed for a long time in a weakly condition, as the combined result of feeble circula- tion and the effect of gravity. In coma and in cerebral injuries, such as cerebral hemorrhage, it is often seen in its most pronounced degree. The affected portions of lung are congested, cedematous, heavy, and imperfectly aerated. The congestion may be complicated by patches of con- solidation resembling either broncho-pneumonia or a lobar pneumonia, being due to the passage into the bronchi of food or air containing streptococci. The symptoms are usually obscured by those of the primary disease, so that a diagnosis is to be made by phys- ical signs. There is dulness over the congested portions, with feeble breathing and liquid rales. In more advanced cases there may be bronchial breathing and bronchophony. (KDJiMA OJ< TI/E LUNGS. 289 CEDBMA OP THE LUNGS. Localized oedema of the lung.s occurs with congestion, inflammation, and new growths ; it is known as " collateral oedema." General pulmonary oedema occurs from weakness of the left side of the heart, the force of the right heart being unimpaired, or it may occur in pronounced conditions of hydra^mia. Either cause alone may suffice for its produc- tion, although in extreme cases both factors are usually present. It is often present during the death agony, being a symptom of approaching death. It is seen in the final stages of cachexias, profound anaemia, acute and chronic Bright's disease, pneumonia, cerebral diseases, and diseases of the heart. The lungs are heavy, pit on pressure, and from their cut section exudes a frothy serous or sero-sanguinolent fluid in abundance. This fluid is also present in the trachea and the bronchi. The oedema interferes with the proper degree of aeration, although cut pieces of the lung still float in water. There is usually associated congestion of the lungs, espe- cially of the posterior portions. The symptoms are increasing frequency of respirations, dyspnoea with cough, and the expectoration of serum which may be blood-tinged. The respirations are bubbling and rattling, and cyanosis, increasing coma, and cold, clammy extremities precede the fatal issue. The percussion-note over the oedematous portions is more or less dull ; the respi- ratory murmur is feeble or is obscured by large liquid rales and bubbling sounds usually first heard at the bases. The treatment is that of the primary condition. The heart should be stimulated energetically ; cups and poultices are to be applied to the chest, and the bowels should be moved freely. Venesection should be resorted to in acute cases with cyanosis ; it frequently affords relief 19 390 MAXCJL OF THE PRACTICE OF MEDICIXE. PULMONARY HEMORRHAGE. Two forms of pulnionar)' hemorrhage are recognized: I. Broncho-puhiionary hemorrhage, or bronchorrhagia, in which condition the blood is poured into the bronchi and is expectorated; 2. Puhiionar\' apoplexy, or pneumorrhagia, in which disease the hemorrhage occurs into the substance of the lung. Broncho-Pulmonary Hemorrhage, or Hemoptysis. There is a variety of causes giving rise to this condition. {a) Pulmonary tuberculosis is the most common cause, and it should always be suspected, even if neither symptoms nor ph)-sical signs be present. Small repeated hemorrhages in the earlier stages are due to bronchial congestion or ulceration. Large hemorrhages in the later stages arise in cavities from erosion of a branch of the pulmonary artery or from rupture of an aneurysmal dilatation of the same. {B) Hemorrhages may occur in young people without assignable cause, although in some cases they may follow excitement or severe muscular exertion, especially in high altitudes. (c) Anaemic hysterical women may raise a little blood from time to time without apparent reason. Deception must always be suspected in such cases, however. {d) Severe injuries and contusions of the chest are often followed by hemorrhage. (r) Patients with emphysema and bronchitis may occa- sionally raise small quantities of blood. (/") Hemorrhage may result from certain diseases of the lung, the initial stage of pneumonia, cancer, gangrene, abscess, or bronchiectatic cavities. (^) Vicarious haemoptysis may occur with interrupted menstruation. It has been known to follow removal of both ovaries. (//) Small repeated hemorrhages are common with the pulmonary congestion of heart disease, especially with lesions of the mitral valve. (z) With aneurysms small quantities of blood may be raised PULMONARY IfKMOR R IJAG E. 2Cj] from congestion of the bronchi from pressure or by leakage through a small perforation. Large and fatal hemorrhage results from rupture of the sac into the trachea or into a bronchus. (y) Any ulcerative process in the larynx, the trachea, or the bronchus may cause small repeated hemorrhages. (/') Sir Andrew Clark describes a form of haemoptysis, seen in elderly people, which he calls " arthritic haemop- tysis." It occurs in those of the arthritic diathesis ; it is due to minute structural alterations in the terminal blood- vessels of the lung. The prognosis in these cases is usually good. (/) Haemoptysis occurs with extensive blood-alterations of malignant fevers, as hemorrhagic variola, and with pur- pura haemorrhagica. (pi) In Japan and China occurs an endemic haemoptysis due to the presence of the Distoma Ringeri in the bronchi. Symptoms. — There may be a preceding feeling of oppres- sion in the chest, but usually the first symptoms are a warm, mawkish taste in the mouth, nausea and faintness, and the appearance of the blood. The quantity of blood ejected varies from a dram to a pint or more. Anaemic symptoms — faintness, syncope, dyspnoea, " air- hunger," and pallor — depend on the quantity of blood lost. Large hemorrhages may be fatal from anaemia or from the filling of the bronchi with blood, but usually danger is not imminent. There is generally but little effort in raising the blood. Should the quantity be large, a certain amount may be swallowed, to be vomited later or passed with the stools. Blood from the lungs has certain characteristics which distinguish it from blood from the stomach. It is scarlet in color, of an alkaline reaction, frothy, and mixed with mucus. In the clots air-bubbles can usually be seen. After a hemorrhage the sputa are usually blood-stained, of a dark crimson or brown color, and frequently clots like bronchial casts are raised. Vomited blood is dark brown- ish, contains no air, but is mixed with stomach-contents and is of an acid reaction. Blood coming from the pharynx or the nares is usually hawked up, and on inspection blood- 292 .U.I. VI . I/. OF THE PR.ICTICE OF .MF.D/CLXK. streaks can almost al\va\-s be scon descendini^ from tlie naso-pharynx. Lar^ hemorrhages, leading; even to a fatal issue, can take place into extensive pulmonary cavities without blood being coughed up at all. The hemorrhage may continue for several hours or even days, and attacks may be repeated from time to time. They may be induced by exertion, by over-indulgence in stimulants, or by excitement, but in some cases they occur without apparent cause, even while the patient is resting quietly at night. Anaemic symptoms follow large hemorrhages, but after small hemoptyses the patients frequently feel much relieved in their pulmonary or cardiac symptoms. Treatment. — For the large hemorrhages arising from erosion of an artery or from rupture of an aneurysm treat- ment is unavailing. The patient should be kept absolutely quiet and secluded, and small doses of opium should be given to relieve the restlessness and steady the heart. Fainting is nature's measure of tranquillizing the circulation and inducing firm thrombosis. Anaemic symptoms are treated by elevation of the foot of the bed, by ligating the extremities, and by hypodermic injections (hypodermoclysis) or arterial transfusion of ster- ilized saline solutions, which may also be given by the rectum. Internal haemostatics are useless. In less serious hemorrhages the patient may be given ice to swallow and may drink small quantities of aromatic sul- phuric acid in water. Theoretically, measures to reduce the frequency of the heart-beats and reduce the blood-pressure in the pulmonary circulation are indicated, but our know- ledge as to how this latter indication can be fulfilled is very meagre. Rest should be enforced, and opium be given to quiet the patient. The diet should be light, and stimulants should not be employed. Digitalis is contraindicated. Aco- nite may be given with benefit if there be vascular excite- ment. Acid drinks and cracked ice may be given. Ergot, gallic acid, acetate of lead, hydrastis, and krameria are used as routine measures, but are of doubtful utility. Ice applied to the chest is recommended, and in some cases it seems PULMONARY HEMORRHAGE. 293 to do good. Free purgation is indicated to reduce blood- pressure ; it should be resorted to in all protracted cases. Pulmonary Apoplexy ; Hemorrhagic Infarct. Hemorrhage into the substance of the lung, with rupture of its tissue, may occur with severe contusions, with pene- trating wounds, and with rupture of an aneurysm. Aside from these cases, so-called " hemorrhagic infarct.^ " result from embolism or thombosis of a branch of the pulmonary artery, resulting in the stoppage of its circulation. As these are " terminal " arteries, without anastomotic branches, the blood in the vessels beyond the obstruction is in a condition of stasis, and congestion occurs from a backward pressure into the shut-off region. The vascular walls lose their con- sistency and allow the escape of blood into the surrounding structures. The hemorrhagic area is red and solid, resembling a blood- clot, becoming reddish-brown in time from pigment-changes. It is of a wedge shape with the base out ; the pleura covering it is usually inflamed. It is usually situated toward the base, and it varies in size from a walnut to that of an orange. There may be a surrounding zone of pneumonia. Such an infarction may be absorbed if small, but it usually becomes changed to a pigmented, puckered cicatrix. In rarer cases it may undergo sloughing or gangrene. Abscess results if the cause be an infectious embolus containing suppurative micrococci, as may occur in pyaemia or in malignant endo- carditis. Symptoms. — There is usually pain in the side, sudden dyspnoea, oppression in the chest, and bloody expectora- tion, in some cases amounting to a fair-sized haemoptysis. Physical examination yields over the hemorrhagic area, if it be of sufficient size, dulness, bronchial voice and breathing, and pleuritic and bronchial rales. Large hemorrhagic in- farcts may be followed by sudden death. It must be remem- bered that obstruction of a large branch of the pulmonary artery can occur without the formation of a hemorrhagic infarct. The treatment is practically that of pneumonia. 294 .y-l\L:t/. OF THE PRACTICr. OF MEDJC/XE. LOBAR PNEUMONIA. Definition and Synonyms. — Lobar pneumonia is an in- fectious disease due to the diplococcus pneumoniae ; it is characterized by an inflammation of the lung with consti- tutional symptoms. Synonyms: Croupous or Fibrinous Pneumonia ; Pneumonitis. Etiology. — The diplococcus pneumoniae of Frankel, commonly known as the " pneumococcus," is the specific germ of the disease. It is an ovoid coccus, or, more prop- erly speaking, a bacillus, usually occurring in pairs, and more often encapsulated. It is found in the nasal and buccal secretions of 20 per cent, of healthy people, anil after an attack of pneumonia it is often found in the mouth for months ; hence there must be conditions giving the germ at times more intense pathogenic properties, or conditions ren- ■^- Fig. 26. — Fraiikel's pneumonia coccus, bred from the expectoration. (Prepared by Prof. Gartner. Oil-immersion lens j'j ; eye-piece No. 4.) daring the individual susceptible to the infection. Among these causes may be mentioned exposure to hardship and cold ; consequently the disease is more frequent in men than in women. It frequently follows immersion in cold water. Traumatisms of the chest-wall produce the so-called "contusion-pneumonia." Alcoholism, chronic Bright's disease, and any condition of bodily weakness predispose to the disease. Repeated attacks may occur; they are ex- plained by auto-infection from the persistence of diplococci in the buccal and nasal secretions. The disease is more common in the months from February to May, although it may occur at any time. It occurs in all temperate climates, but it is unknown north of Labrador. It is more frequent in LOBAR PNEUMONIA. 2g$ the Southern than in the Northern States. The influence of age is important. Liability to the disease increases up to the twentieth year, then decreases until liability is again increased in old age. Children under five years of age usually have broncho-pneumonia; those between five and fifteen years of age have either lobar pneumonia or broncho- pneumonia; adults usually have lobar pneumonia. The diplococci are found not only in the exudate in the inflamed lung, but also in many of the complicating lesions, as in the meninges, the pleura, or the pericardium ; they may even involve these parts without there being any inflamma- tion of the lung at all. Pathology. — The lesion involves a whole lobe, a part of a lobe, or the entire lung. The lower lobes are more frequently involved than the upper ; the right lung is more often involved than the left. The process is divided into four stages : congestion, red hepatization, gray hepatization, and resolution. Congestion. — The lung is congested and heavy ; its cut surface is bathed with bloody serum. Microscopic exami- nation shows congestion of the blood-vessels and swelling and proliferation of the alveolar epithelium, while the air- cells are partially filled by an exudate of fibrin pus-cells, red blood-corpuscles, and epithelial cells. The stage of congestion usually lasts for several hours, but it may be protracted for several days. Red Hepatization. — The lung is large, often showing in- dentations of the ribs, and is remarkably friable. It is hard and airless, cut pieces sinking in water. There is fibrin on the pulmonary pleura. The cut surface is dry, reddish, and dis- tinctly granular, due to the protrusion of inflammatory exu- date from the air-cells. The microscope shows the air-cells, and frequently the small bronchi as well, filled with an exu- date of fibrin, pus-cells, red blood-cells, and epithelium. The blood-vessels are congested but pervious. The inter- stitial connective tissue of the lung may be infiltrated with inflammatory exudate. Diplococci, and occasionally staph- ylococci and streptococci as well, are seen in the exudate. 296 M.LXlilL OF THE PRACTICE OF MEDICIXE. One-fourth of the flital cases occur in rod hepatization from the first to the eleventh da)- of the disease. Gra\'^ HcpatiacJtioii. — Tlie color changes from reddish- brown to ijray, at first in spots, so that the luntj has a mot- tled appearance. The lung still remains solid, but the exudate is decolorized and begins to soften and degenerate. One-half the fatal cases occur in the mottled condition, between the second and the eighteenth day, and one-fourth in the completed gray stage, between the fourth and the twenty- fifth day. Rt'solittion occurs in spots at first. Fatty degeneration and liquefaction of the exudate occur, allowing of its absorp- tion and expectoration. Resolution should begin soon after defervescence, but it may be delayed. The unaffected portion of the lung ma}- be congested and oedematous, especially the portions near the affected area. The bronchi of the pneumonic lobe show catarrhal inflam- mation, and they may be filled by fibrinous plugs. Modifications of tlic Lesion. — Resolution may be delayed, the lung remaining in dry gray hepatization for weeks. The exudate may be so excessive that the blood-vessels are compressed, leading to necrotic changes of portions of the lungs. There may be an excessive production of pus-ccUs, which infiltrate the connective-tissue septa, forming small abscesses or a diffused suppuration. Gangrene of the lung may occur. Instead of resolution the exudation may be- come organized into connective tissue, so that the air-cells are obliterated and rendered permanently unfit for use. The bronchitis may be general and excessive, especially in cases accompanying epidemic influenza. Complicating lesions result from infection of other parts by diploccoci. Pleuri.sy is only to be considered a compli- cation if it extend beyond the pneumonic area or if serous or purulent effusion occur. Pericarditis is not infrequent. It occurs more commonly with double or left-lung pneumonias and in children. It is due to diplococcus infection, producing plastic inflammation or serous or purulent effusion. The prognosis of pleurisy LOIJAR PNEUMONIA. I'l.AlK 19 Day of Disease 2 3 4 5 6 7 R D 10 Pillae ; 120 104° / A ^ i / '. Resp. *^0 110 103^ / \ V f si/ ;^ ^ /^ w 50 100 102*^ :\ \j 7 ^ T f: V r\ • I \ 40 90 101^ < 1 / A I •, ^ • •, \; i '■ 30 80 100"^ ■\ \- > y /> s/ V Vl s-S ^ 20 70 99' y ;\ ^ ^: 10 60 98'' '■ \ y / Lobfir pneumonia terminating by crisis on the seventh day: temperature (black), pulse (blue), and respiration (red). Day of Disease 2 3 4 5 G 7 Pulse 150 107° ; t- 140 106° A \ ED, 130 105° :; /; 120 104° '■ \ •( t\ I ^ Resp. 60 110 103° ■/ \ /i ^ •4 c^ 1/ r ; • : 50 100 102° 40 90 101° 30 80 100° V \/ ■ 1 A A \ ) /:N J : ■> '■/ Sv ^ s / \ h : Temperature chart of a fatal case of pneumonia : temperature (blaclc), pulse (blue), and respiration (red). /, DBA R PNE UMON/A. 297 ;ind pericarditis of pneumonic origin is better tlian thjit of the other forms. Endocarditis is more common tlian pericarditis. It may be either simple or malignant ; it occurs as an acute exacer- bation not infrequently in those who have old valvular disease. Meningitis may occur, and it is usually associated with malignant endocarditis. It is often difficult to tell whether pneumonia or meningitis be the primary disease. Croupous gastritis or colitis may occur. The liver and the kidney usually show parenchymatous changes. Symptoms. — Prodromal symptoms, consisting of malaise, dull pain in the back and the bones, and some soreness in the chest, are present in about one-fourth of the cases. Day of Disease 5 6 7 8 9 10 11 12 ... 1 1 105° 104° :l : :i : ; A ; 103° 102° V ^ ^ I • K V \ A 101° 100° 99° : ^ > \ : • ■ :1 \> ^ vj/ \ : i V :i : 98° . . ■ 1 ■ • ■ • i • •1 '■ Fig. 27. — Temperature chart of pneumonia terminating by lysis. They last for a day or so, and probably are due to a pro- tracted stage of congestion. The actual onset of the disease is marked by one or more cliills in about 90 per cent, of the cases, and from the chill the duration of the disease is reckoned. In children convul- sions or vomiting may replace the chill. In old people a shivering attack and pain in the side may be the only symptoms. The temperaUirc rises rapidly and attains its maximum in 298 MAXi'AL OF THE PRACTICE OF MEDICINE. from twenty-four to thirty-six hours, although in some cases the height of the fever is not reached until the da\' before defervescence. The fe\'er remains high with slight evening exacerbations, which in uncomplicated cases should not ex- ceed 104° F. Dcfcii'csccncc may occur at an\' time between the second and the eighteenth day, the seventh, fifth, eighth, sixth, and ninth davs being the favorites, in the order named. The tern- Day of Disease 3 4 5 7 8 9 10 1 106'^ : / im. 105= 104*^ :• ^■.\ '/^ /" i \v''' / ^ V' '^y ^cl h V- ■J . \ 103° : v V '■ r : Fig. 28. — Temperature chart of pneumonia with purulent inflammation terminating fatally. perature ma\' fall in from six to forty-eight hours by crisis, or in from three to five days by lysis. In some cases the temperature is markedly remittent at any time in its course, especially in children. In other cases a pseudo-crisis occurs about the fifth day. At the time of the crisis the tempera- ture may fall to subnormal, and after the crisis a slight rise Fig. 29. — Lobar pneumonia in child, with remittent temperature (Holt). of fever is noticeable for two or three days, especially in the evening. A high temperature persisting for ten days suggests purulent infiltration or empyema. A sudden rise LOBAR PNEUMONIA. 299 of temperature at any time indicates a complication or an extension of the disease. In old people the temperature may be normal or even subnormal. In the pneumonias complicating epidemic influenza the temperature does not become normal for days, and it may even persist after reso- lution. The character of tJie heart's action is of the utmost import- ance, as heart failure constitutes th-e greatest danger of pneumonia. The pulse should be full and about lOO in a favorable case. A pulse over 120 passes the safety limit and gives cause for anxiety. The most critical time is just before defervescence, at which time liability to sudden or gradual heart failure is the greatest. The possibility of sudden death must always be considered. Day of Disease 4 6 6 7 8 9 10 11 12 105° 104° ; .;/ \: / V /"k • ^ : f :/ 103° ■J t; '■ V y \ ^ 1 V 102° :\ S: ; V /; DI !I). 101° ; \ / >* \ '■■ Fig. 30- -L Obc I-p nei imc nia; defe rve see nee : i an jre le ( 3f lur g- In old people rigidity of the arterial walls may give a fictitious tension to the pulse, and it is best to note the character of the action of the heart itself Of equal import- ance with a rapid pulse in old people is an irregular and intermittent heart-action. A fall in the pulse even to 50 may be noticed before crisis. In case of rapid defervescence there may be extreme prostration and heart failure. A pulse running up rapidly to 140 indicates paresis of the medulla and often precedes the fatal issue. In children, however, a rapid pulse is not of so much importance, recovery being possible even with a pulse of 150 to 200. 300 .UAXC'AL OF THE PKACTICE OF MEDICINE. The breathing is rapid and oppressed. Its rapidity varies with the amount of fever, tlie extent of lunLj involved, the severity of pleuritic pain, and the presence of complications. The respirations should be below 40 to the minute, a tem- perature of 104° F., respiration of 40, and a pulse of 1 20 being the safety limits. If the respirations be over this limit, there should be suspicion of pleuritic effusion or pulmonary oedema. Dysptuva may be marked in some cases, especial]}- in upper-lobe pneumonias. It is not usually noticed in old people, in whom the respiration may not even be in- creased. Fain in the chest, usually referred to the nipple, occurs in 85 per cent, of all cases. It is a true pleuritic pain, and it does not occur unless the pleura is inflamed. It is a fairly constant symptom in old people. Congit usually comes early in the disease, but it may be deferred until after defervescence, or it may be absent alto- gether, especially in old people. The spnUmi is scanty, gelatinous, and rusty in color, the little pellets sticking to the side of the cup ; it is usually mixed with the ordinary sputum of bronchitis. This " rusty sputum " is very characteristic. At the onset there may be expectorated a little pure blood. In bad cases there may be the "prune-juice" expectoration of an abundant dark- brown fluid. This sign is a serious one. In some cases the patient will raise casts of the small bronchi that unroll in water. In children the sputum is usually swallowed instead of being expectorated. Cerebral Symptoms. — Headache, restlessness, and sleep- lessness are frequent ; they appear to be due to the pyrexia. Delirium belongs to the severe forms of the disease ; it is said to be more common in apex pneumonia. In some cases it depends upon the pyrexia and is marked by mental wander- ing, especially at night. In debilitated subjects and in very severe cases the symptoms of the " typhoid state " appear — rapid feeble pulse, great prostration, brown dry tongue, and a muttering delirium. The last-named symptom is com- monly seen in alcoholic subjects, who are, moreover, liable LOBAR J'NEUMON/A. 3OI to develop the typical symptoms of acute delirium tremens. Old people arc apt to wander in the mind and to evince a constant desire to leave their bed and walk about; as a rule, however, they are readily controlled. In some non-alcoholic adults there maybe acute mania. In children cerebral symp- toms are more constant, often presenting the clinical picture of acute meningitis. Convulsions at the onset may be fol- lowed by headache, photophobia, boring of the head into the pillow, convulsive movements, and coma. Digestive symptoms are usually not marked. There may be nausea and vomiting, especially in alcoholic subjects, and in some cases a catarrhal jaundice appears. The bowels are usually constipated ; the tongue is coated. A brown dry tongue belongs to the most severe cases. The tirinc is that of fever, concentrated and depositing urates. There is usually a diminished amount of sodium chloride, but this sign is not diagnostic. In about one-third of the cases albumin and casts are present from a complicat- ing parenchymatous nephritis, which, however, gives no symptoms. It is important to examine the urine in every case, to determine the presence of chronic Bright's disease, which adds so grave an element. The appearance of the patient is often characteristic. The decubitus is usually on the affected side. The expression is both apathetic and anxious. There is frequently a well- defined mahogany-colored flush on one or on both cheeks — not always limited, as was once supposed, to the affected side. Herpes labialis occurs in a certain number of cases : this sign is to be regarded as a favorable one. The herpetic vesicles frequently contain the pneumococci. The physical signs may be described as those occurring (i) in the stage of congestion, (2) in the stage of consolida- tion, and (3) in the stage of resolution. I. Stage of Congestio)i. — The normal ph\-sical signs are the crepitant rale, the subcrepitant rale, a slight dulness, and a localized deficienc\- in chest-expansion. The crepi- tant rale consists of a shower of fine dry crackles, heard directly under the ear at the end of inspiration only. This rale was formerly considered pathognomonic of pneumonia, and to be due to the inspiratory stretching of the alveolar walls stiffened by inllamniatory infiltration. It is now con- sidered to be a pure and simple pleural rale, and is con- sequently present only when the pleura is inllanied. The subcrepitant rale may arise either from the rubbing together of the inflamed pleurze or from exudate in the small bronchi. Slight dulness is apparent by a percussion-note of shorter duration, higher pitch, and less resonance than normal. Deficiency in chest-expansion is best appreciated by pal- pation. Fig. 31. — Physical signs of lobar pneu- monia during the stage of congestion : slight dulness or dull tympany; breath- ing feeble or harsh; crepitant and sub- crepitant pleuritic rales. Fig. 32. — Physical signs of lobar pneu- monia during the stage of complete con- solidation : dulness ; bronchial voice and breathing; increased vocal fremitus; crep- itant and subcrepitant pleuritic rales. Exceptional Signs. — There may be a general bronchitis with bronchial rales obscuring the physical signs. In these cases the disease may be mistaken for bronchitis or for tubercular disease. There may be only an area of feeble or harsh breathing, with an occasional subcrepitant rale. In- stead of slight dulness there may be a tympanitic note due to relaxation of the congested alveolar walls, or a note of mixed tympany and dulness. Should the lesion begin in the deeper parts of the lung, physical signs may be absent entirely. If the pleura be not involved, the crepitant rale is not present. 2. Stage of Co7isolidation. — The normal signs are dul- ness, increased vocal fremitus, bronchial voice and breath- ing, crepitant and subcrepitant rales, and diminished chest- expansion, Dulness is shown by a short, high-pitched LOBAR PNFJJMONfA. 3O3 note of feeble resonant quality, with an appreciable lack of resiliency to the percussing finger. Bronchial breath- ing consists of a harsh, loud, and high-pitched respira- tory murmur, in which the sound produced by expiration is higher pitched and more prolonged than that of in- spiration. Bronchial voice is high-pitched, loud, and nasal in quality. Exceptional Signs. — The dulness may have a decided tympanitic quality, resembling in some cases even the " cracked-pot " or the amphoric note. These modifications are more commonly observed in pneumonia of the apex ; they are especially marked in children. In some cases the note may be flat, especially if the bronchi be filled with exudate, but the flatness is never so complete as in pleural effusion. Should the pneumonic area be small, dulness may be obscured by the tympanitic note pro- duced in the surrounding lung-tissue by its congestion and relaxation. Bronchial voice and breathing may be absent They depend upon the flow of air in the bronchi, and they are absent if the bronchi are occluded or if the lung does not expand with respiration ; hence they may be brought out by coughing or by deep breathing. The crepitant rale may be absent, either because the pleura is not involved or because of the poor expansion of the lung. Vocal fremitus rarely is diminished or absent If the consolidation begin in the deeper parts of the lung— the so-called " central pneumonia " — the physical signs may be delayed for several days, making the diagnosis often extremely difficult In old people, in whom respiration is feeble, the only physical signs may be the subcrepitant rale and the feeble breathing. Dulness is frequently absent in the aged, in Avhom senile changes in the ribs allow of increased res- onance on percussion. 3. Stage of Resolution. — The dulness becomes less and less marked, bronchial voice and breathing become broncho- vesicular and finally normal, vocal fremitus diminishes to the normal limit, and moist bronchial rales appear. 304 .)/.l.\(.ll Vl- Till-: PKACI'JCl: OF MEDICJXK. Fig. 33. — Physical signs of lobar pneumonia during the stage of resolution : dull tym- pany or tympany ; broncho- vesicular voice and breathing, becoming harsh, feeble, or normal ; vocal fremitus, be- coming normal; crepitant and subcrepitant pleuritic rales; moist bronchial rales. lixct'piioual Signs. — The dulness may change to tympany, which is often the earhest sign of resolution. Crepitant and subcrepitant rales, if formerly absent, may be heard, from increased lung-ex- pansion. In some cases the moist bron- chial rales are not present. Should thickening t)f the [jjeura persist, slight ilulness, feeble breathing, and the crepi- tant rale may be present for a consider- able time. Complications. — Pleurisy with effu- sion is to be suspected should there be disproportional rapidity of breathing, and a continuance of fever beyond the natural duration of pneumonia. Empy- ema is marked by the occurrence of septic symptoms, erratic chills, irregular temperature curve, and sweating. The ph)'sical signs are those of fluid in the pleural cavity, but bronchial voice and breathing may be heard below the level of the fluid. In doubt- ful cases an exploratory aspiration should be resorted to. Abscess of the lung occurs in about i per cent, of cases, from added infection by suppurative microbes. It is usually seen in debilitated subjects. Septic symptoms are present. There is an expectoration of pus, often fetid, containing shreds of lung-tissue, and prostration is extreme. In old people there may be no marked symptoms. The physical signs are those of pulmonary cavities — tympanitic or " cracked-pot " note, cavernous voice and breathing, with moist and guigling rales. These signs are often present over a consolidated lung-area containing a large bronchus with adherent pleural surfaces, so that a diagnosis by physical signs alone is often impossible. Many so-called cases of " abscess of the lung " compli- cating pneumonia are really acute phthisis with the rapid formation of cavities. In doubtful cases a bacterial exam- ination of the sputum for the tubercle bacillus should be made. f.OBAR PNEUMONIA. 305 Gangrene of the lung is somewhat less common than abscess. The expectoration is a <^reenish or brownish fluid, of fetid ijangrenous odor, contain ini:^ shreds of decomposed lung-tissue and crystals of fatty acids. Constitutional symp- toms are usually pronounced. Pericarditis in some cases adds typical sjmiptoms — dysp- noea, rapid and feeble pulse, venous congestions, and char- acteristic physical signs. In other cases the diagnosis is less evident. Pericardial rales may be simulated by the rubbing together of overlying inflamed pleural surfaces at each systole of the heart, and signs of fluid maybe obscured should the pneumonia involve the overlying portion of the lung. Endocarditis may be either simple or malignant. The latter is to be suspected should septic and embolic symp- toms be present. Pneumonia occurring in a patient the victim of chronic endocarditis may upset compensation and lead to heart failure. During the pneumonia pre-existing, murmurs of valvular disease may be absent entirely. Meningitis may complicate pneumonia with especial frequency at different times and in different places. It may run its course with or without typical symptoms. This complication may be mistaken for epidemic cerebro-spinal meningitis with complicating pneumonia, for tubercular meningitis with lesions in the lungs, and for uncomplicated pneumonia in children with marked cerebral symptoms. Puhnonary o;devia usually ushers in the fatal issue. The heart failing, the right ventricle becomes more and more distended, with consequent congestion and oedema of the lungs. The pulse becomes rapid and feeble ; respirations are shallow, rapid, and attended by noisy bubbling sounds. The expectoration becomes profuse and frothy, and it may be blood-stained. Signs of deficient aeration of blood appear, and consciousness is lost some few hours before death. Sudden lie art faUure ma}- occur at any time, even after defervescence. The most usual time is about the time of crisis. In some cases thrombosis of the coronary or of the 20 306 A/.iXLAL (.>/■• riJE PKACriCE OF MEDICfXE. pulmonary artery may be found ; in other cases there seems to be no assignable cause. C/iivjiic interstitial pneumonia, or fibroid induration, may in rare cases result from the organization of the inflamma- tory exudate into connective tissue, rendering the affected area of lung permanently consolidated. Prog-nosis. — The average mortality in hospital cases ranges about 25 per cent. ; it is somewhat less in private practice. Pneumonia of the apex, an extensive lesion, and old age render the outlook serious, and the complications increase the mortality to a considerable degree. Alcoholism must be considered in making the prognosis. According to the New York Hospital records, the mortalit)' in non-alco- holic cases was 25 per cent. ; in slightly alcoholic subjects, 33 per cent. ; in those with a marked alcoholic history, 72 per cent. Patients subject to chronic Bright's disease are apt to die, especially if they be addicted to alcohol. At .the New York Hospital 4 such patients recovered and 36 died. The earlier the patient is put to bed, the better is the prognosis. Treatment. — Pneumonia is a self-limited disease and has no specific medication. In many cases no medicines at all are required. The patient should be kept in bed until at least five days after the temperature has become normal, and on a liquid or light diet. Restlessness and sleepless- ness may^ be controlled by phenacetine, sulphonal, chloral- amide, or by a Dover's powder given at night. Pain in the side may be relieved by hot poultices or by a hypodermic injection of morphine. Poultices need not be applied, how- ever, as a routine measure; in fact, many patients are more relieved by cold applications to the chest by ice-bag.s — a treatment which appears to exert a beneficial effect upon the disease itself All attempts to abort the disease have proved futile. Large doses of calomel — from 25 to 40 grains placed dry on the tongue — seem to exert a beneficial effect upon the course of the disease in some cases, producing a sedative effect, but there is always the risk of producing salivation. Venesection at the outset in robust subjects with pro- LOBAR PNEUMONIA. ^OJ nounced inflammatory symptoms is often of the greatest service, relieving the dyspncEa and the cerebral symptoms and reducing the fever. In the later stages, when the heart is beginning to fail, and cyanosis and symptoms of dilata- tion of the right ventricle appear, venesection may be em- ployed as a last resort. As an arterial sedative tincture of aconite or tincture of veratrum viride has seemed to be of service if given at the outset, but in robust patients venesection is preferable. The temperature, being of relatively short duration, rarely requires much treatment. The use of internal antipyretics as a routine is to be deplored, on account of their depressant effect. High and prolonged temperature should, however, be controlled. For this purpose hydrotherapy is the best treatment to be employed — either cold sponging, the cold pack, cold applications to the chest, or even the bath at 70° F. By the use of the bath the temperature is reduced, the pulse becomes stronger, and cerebral symptoms are markedly relieved. By far the most important treatment is that to sustain the action of the heart. Should the pulse become rapid and feeble and the second pulmonary sound weak, alcohol should be given freely, in doses sufficient to accomplish the end desired. In the aged and in alcoholic subjects it should be given from the start. The use of digitalis is frequently disappointing from its contractile power over the small arteries, unless it be combined with an arterial relaxant, such as nitroglycerin or iodide of potassium. A good combination is — I^. Potassii iodidi, gr. v; Ext. digitalis fluid., TTLj ; Ext. convallariae fluid., TTlxx. — M. Sig. Such a dose every three hours. As a cardiac tonic strychnine is rapidly gaining in favor. It may be combined with digitalis and aconitine with advan- tage, as in the following prescription : 308 M.LVC.iL OF TJ/J-: PRACTICE OF MFD/CIXE. R. Strychnine sulphate. Sjr. ^v'^^ ; Digitahne, g'- t^ ; Aconitine. t;r. y-^. Such a combination in pill form ma\- be t^iven ever}' two or three hours until the pulse is reduced to about lOO, but with such a form of treatment the patient should be watched carefully. Ammonia or camphor may also be employed. Should heart failure with increasing difficulty of breathing occur, free stimulation, cupping of the chest, and the admin- istration of pure oxygen gas should be employed ; in .some cases free venesection proves satisfactory. Complicating delirium tremens calls for free stimulation, for sedatives such as bromide, chloral, or hypodermic injec- tions of morphine, and frequently for plu'sical restraint. The sedative and tonic effect of the cold bath is often sur- prising in these cases. Expectorants serve only to upset the stomach, although in some cases of tardy resolution pilocarpine may be em- ployed, its depressant effect being carefully guarded by stimulants. Experiments recently made by Drs. G. and F. Klemperer upon the toxines of pneumonia are of wonderful and vital interest. These observers found that rabbits could be rendered immune by hypodermic injections of heated pneu- mococcus cultures, and that the blood-serum from these rabbits, injected into patients suffering from pneumonia, produced an immediate curative effect upon the disease. More recently the blood-serum of patients who had just passed the time of crisis has been used for the injections, with equally brilliant results, the theory being that the serum from immune animals or from convalescent patients contains an antitoxine capable of neutralizing the toxine caused by the growth of the pneumococcus in the bod}'. The latter, known as " pneumotoxine," has already been isolated, but the supposed antidotal toxine, the " antipneumotoxine," has not as yet been obtained in a chemically pure state. BN ONCIJO- PNE UMONfA . 309 BRONCHO-PNEUMONIA. Bitology and Synonyms. — Hroncho-pncunionia is the regular pneumonia of young children, but it may be .seen in adults, and it is not uncommon in old people. Primary cases follow exposure to wet and cold or the inhalation of irritating chemical vapors ; they are more common in the winter and spring months and among the debilitated tene- ment-house and asylum children. Secondary cases accom- pany many of the infectious diseases, especially measles, scarlet fever, whooping-cough, and diphtheria. Broncho- pneumonia may occur in any disease which keeps the patient in bed, the dorsal decubitus preventing free expec- toration, and the foul mouth of fevers allowing the growth of bacteria in the mouth. The bacteria enter the lung with the inspired air and infect it. Careful cleansing of the mouth in prolonged fevers will often prevent the occurrence of this so-called " aspiration- " or " inhalation-pneumonia." " Deglutition-pneumonia " is that form of pneumonia pro- duced by the passage of food or drink into the bronchi from choking at table, in deep coma, or from tracheotomy, intubation, or cancer of the larynx or the oesophagus. Suppuration or even gangrene may result in such cases. Patients with advanced emphysema are liable to subacute attacks of broncho-pneumonia. Tubercular broncho-pneu- monia will be considered under a separate heading. Bron- cho-pneumonia may be produced either by the ordinary pneumococcus or by the streptococcus of suppuration. Synonyms: Lobular pneumonia; Catarrhal pneumonia; Capillary bronchitis. Pathology. — The lesion consists of a bronchitis and a pneumonia. The broncldtis is general, involving the bronchi of both lungs. The large, the medium, and the smallest bronchi are all involved, although not always to the same extent. The mucous membrane of the bronchi show ordi- nary catarrhal inflammation ; the walls of the smallest bronchi are thickened by an infiltration of new cells, and may be dilated ; the smaller bronchi may contain pus. The pneumonia differs from lobar pneumonia in the location 3IO .U.LVC.IL OF THE PRACTICE OF MEDICLXE. of the affected areas and in the regular involvement of the connective-tissue walls of the air-cells. Around the bronchi are zones of consolidated lung-tissue, varying in size from a pin's head to that of a pea. These areas of peri-bron- chitic hepatization may be so slight as almost to escape notice, so that the lesion appears to be bronchitis alone. These cases were formerly described as " capillary bron- chitis." In other cases the areas are larger, so that the lungs are filled by these isolated nodular bodies ; while in yet other cases, the " pseudo-lobar form," the areas are large and confluent, so that the greater part of the lobe is rendered solid. The cut surface of a broncho-pneumonic patch is smooth, lacking the granular appearance of the hepatization of lobar pneumonia. Gray hepatization is but rarely seen. Microscopic examination shows the air-spaces filled with fibrin, pus, epithelial cells, and red blood-cells. In children there is a relatively greater proportion of epithelial cells in the exudate than in adults. The walls of the air-spaces are thickened and are infiltrated by small round cells or by fibrin, pus, and epithelium. The lung-tissue between the nodules may be either nor- mal or congested and cedematous, or it may be the seat of a diffuse pneumonia in which the air-spaces are partially filled with fibrin, pus, epithelial cells, and red blood-cells, or the air-spaces may be collapsed. These areas of collapse or atelectasis are depressed below the surrounding tissues and are of a bluish or blue-brown color. These areas may be small and may only surround the peribronchitic nodules, or the greater part of a lobe may be involved. In recent cases the air-spaces may be inflated by a blow-pipe inserted into the bronchus leading to them. The pleura covering the peripheral pneumonic patches is covered with fibrin. The bronchial glands are almost always swollen and inflamed. This condition may persist, rendering the glands susceptible to an added tubercular infection, from which systemic infection may result. Many cases of tuberculosis in asylums follow epidemics of measles, the sequence being measles, broncho-pneumonia, BR O NCI/0- PNE UAIONIA. 3 1 I inflammation, tubercular infection of the inflamed bronchial glands, general miliary tuberculosis. There is a common misapprehension that the inflamma- tion extends from the bronchi into the air-spaces which open into them. In point of fact, it is the air-spaces sur- rounding the axis of the bronchi that are involved. If hot knitting-needles be run into a loaf of bread, the path of each needle will represent a bronchus, while the charred bread surrounding its track will represent the position of the peribronchitic pneumonia. The interstitial inflammation of the walls of the bronchi and the air-spaces is a special feature of broncho-pneumonia. It is of especial importance from its tendency to become chronic, by the changing of the infiltrating cells into devel- oped connective tissue. Symptoms. — In young babies fever, prostration, and rapid breathing are the only constant symptoms. There may be no cough, and physical signs are not present. The disease runs almost regularly a fatal course within a few days. Mild cases in children may resemble severe ordinary bronchitis. In broncho-pneumonia the general symptoms, however, are more severe, and the physical signs point to an involvement of smaller bronchi than in bronchitis alone. A temperature of 102.5° oi" 103° F. persisting for three days gives evidence of more than a simple bron- chitis. Severer forms in cliildren may begin gradually or abruptly — gradually by the extension of a simple bronchitis, or abruptly by convulsions or vomiting. Should the pneu- monia be secondary to some well-marked infectious disease, the onset is somewhat obscured. When the disease is established there is a fever which is usually remittent in character, often markedly so. There is no typical curve, as in lobar pneumonia, and there is no day of crisis. The height of the fever is often proportional to the severity of the attack, but some patients do badly whose temperature ranges between 99° and 100° F. The circum- stances under which these low temperatures are met with are early infancy, low vitality, and great prostration with little 12 .U.LVr.lL OF Till: PRACTICE OJ- MED/C/iVE. reactionary power. The pulse becomes rapid, freiiiieiitly ranging from 140 to 180 in man)' children. Respirations may be as high as 50 to 80 to the minute, and they are marked b}' inspirator}- dilatation of the al.'e nasi. There i.s often an expiratory moan or grunt. There may be audible bronchial rales. The dyspnoea may make it difficult for the child to nur^e. There is frequently cough, which may be painful. The sputum is that of bronchitis ; it is usually swallowed, but it max- be vomited up. Rusty sputum is not present. In older children the sputa max- be blood- streaked. The face is flushed, the skin is dry, the tongue is coated ; vomiting is frequent, and it may interfere with the proper feeding of the child.. There may be restlessness, sleeplessness, or mild delirium, depending on the fever and the disposition of the child. The urine may contain small amounts of albumin and casts. In cases developing during J05° 1 2 3 4 r, 6 ; 8 9 10 n 12 13 14 15 16 108" 102' lOl" 100° < K A / 1 / -»^ l\ ^ s / V A V / \ \ ^ \ \ \J y V V "^ \ \ \ L / L: Fig. 34 — 'rypi';al broncho-pneumonia of the milder form (Holti. some severe disease, constitutional symptoms inay be ob- scured, the rapid breathing alone attracting attention to the lung. Cei'ebral Cases. — There are cases in which the cerebral symptoms may be so pronounced as to obscure those of pulmonary origin. There may be headache, repeated con- vulsions, delirium, photophobia, retraction of the head, and muscular twitchings. Pulmonary symptoms appear later in the disease in the majority of cases, with a subsidence of the cerebral symptoms. The diagnosis from meningitis in many cases is difficult. The points in favor of pneumonia are absence of tuberculosis or of suppurative ear disease, a higher respiration-rate, absence of paralysis, a more rapid pulse, and the presence of physical signs. The cerebral symptoms, moreover, are neither so severe nor so con- u TEMPERATURE wo OOOOTJOOOOO OOOO b> - w - • ::^ n w •=^~. =- *** ^ ""^ - — ■ =, O' ''^ — r> » m ^■ H -> ^ ..,-- -^ •< ^-- 3» W CC """■ — - :=. . H tc , . =- g ts o ^ :>■ ^ ^= — 5»» g d - — ==* 2 13 w _^ ^ g 13 E •■■=— - — ■ ^ . K Ol < B 5^ r ■^ ^J *- — "^^9 S 'Ji n: 1 B 3 L — -^ 2 ':^ ^ , *->. » Pi L: i: g E5 '" ■ '^ f^ g S 1 •^ — =~ to 1 "^^ ■ — r- — - L S m M r "^ ^ ^ I — ■ — — , « g K tc ' INTERLOBULAR AND VESICULAR EMPHYSEMA. 32 1 develop acute inflammation of the remaining portions of the lung. Treatment. — The only thing that can be done is to send the patient to a mild climate where the bronchitis will not be aggravated by exposure to cold and dampness. If this cannot be done, the general nutrition of the patient should be improved in every way, and the chronic bronchitis treated. INTERLOBULAR EMPHYSEMA. Etiology. — Interlobular emphysema usually follows severe expiratory efforts, as in whooping-cough, and is most fre- quently seen in the broncho-pneumonia of young children. The disease has also occurred as the result of straining efforts with closure of the glottis in parturition, excessive muscular exertions, and convulsions. Patholog-y. — By rupture of the air-spaces air escapes into the interlobular septa, rupturing into the pleural cavity to cause pneumothorax, or extensively infiltrating the con- nective-tissue septa and compressing the parenchyma of the lung. In rarer cases it may make its way into the medias- tinum and extend up the course of the trachea to the sub- cutaneous tissues of the neck. The symptoms are not distinctive. Pneumothorax may result, and severe cases may be followed by sudden death. VESICULAR EMPHYSEMA. -There are three distinct forms of vesicular emphysema — compensatory, substantive, and senile. Compensatory Emphysema. — When part of the lung is so disabled that it cannot expand fully, the remaining por- tions have to expand or the chest-wall will fall in. Com- pensatory emphysema consists, then, simply in an over- stretched condition of the lung, with distended air-vesicles whose walls are thinned. It occurs as a temporary con- dition in pneumonia, broncho-pneumonia, and with pleuritic effusions. When the cause is more permanent, as with phthisis, pleural adhesions, and interstitial pneumonia, groups of air-vesicles may remain permanently distended. 21 This form is a normal compensatory process, gives no symptoms, subsides with the subsidence of the original disease, and is of no })ractical detriment to the patient. Substantive Emphysema. — Etiology. — Much uncertainty exists as to the true nature of substantive emphysema. Formerly it was regarded as a mechanical over-inflation of the lung from forced inspiratory or expiratory efforts. This condition argued some weakness of the lung-tissue, so that it was supposed that, to account for the over-inflation, there must be a congenitally weak lung-tissue ; this theory ap- peared to be borne out by the markedly hereditary char- acter of the disease. It was found, however, that there were cases of emphysema without any dilatation of the air-spaces, so that this could not be regarded as an essential feature. Delafield describes the disease as a chronic interstitial in- flammation of the lung, with which condition more or less dilatation of the air-spaces is usually, but not invariably, associated. His studies have been so extensive and thor- ough that his descriptions of the disease process will be followed to the exclusion of other theories. Pathology. — The lungs are large, downy or feathery to the feel, and do not collapse when the chest is opened. Enlarged air-vesicles are usually visible, especialh' along the anterior margins, and on the inner surface of the lobe near the root of the lung. In some cases, however, there is no dilatation of the air-spaces, and these cases may even be attended by most marked symptoms of emphysema dur- ing life. The walls of the air-spaces are thickened in sonie parts of the lungs, thinned in others, and the epithelial cells lining them are often increased in size and number. Atrophic changes in the walls of the vesicles allow of per- foration, so that a number of vesicles may merge into a com- mon air-chamber. With the atrophy of areas of the vesic- ular wall there is a disappearance of the capillaries coursing over it, so that the number of channels between the right and the left heart becomes materially reduced. In many cases there exists a contraction of the smaller arteries, which still further increases the pulmonary obstruction. The septa between the lobules, the connective tissue around VESICULAR EMPHYSEMA. 323 the bronchi and the blood-vessels, and the pulmonary pleura are often considerably thickened, and frequently there arc adhesions between the pleural surfaces. There is regularly a chronic catarrhal bronchitis, but bronchiectasis is not common. There may be endarteritis of the branches of the pulmonary or bronchial arteries, and it is supposed that in many cases spasmodic contraction of these arteries occurs during the life of the patient. Secondary lesions result from the mechanical obstruction to the pulmonary circulation, both from the disappearance of some of the capillaries, and also from the contraction of the small arteries ; these lesions consist in the hypertrophy and dilatation of the right side of the heart. If dilatation and heart failure occur, there will be venous congestions of the skin, the serous membranes, and the viscera. The con- dition of the right heart — whether compensatory hypertro- phy occurs and remains established — is of the greatest im- portance to the patient. Associated lesions are usually found. They consist of chronic endocarditis, chronic endarteritis, and chronic diffuse nephritis. These lesions depend, as does emphy- sema, upon the slow production of connective tissue replacing pre-existing tissues, and they are therefore apt to be associated in the same patient. Symptoms. — Of the regular symptoms, dyspnoea is the most prominent. At first the dyspnoea is induced only by exertion, by indigestion, or by attacks of bronchitis ; later it becomes more steady and troublesome. Many of the attacks of dyspncea appear to be due to contraction of the small arteries of the lung. Symptoms of bronchitis are present, especially in the winter months. The patient has a paroxysmal, ineffectual cough, with muco-purulent expectoration. Exacerbations of the bronchitis are accompanied by an increase of the cough and the expectoration, and possibly by slight fever, night-sweats, and rarely by small hsemoptyses. Should bronchiectatic cavities form, they are marked by a charac- teristically profuse expectoration after change of position and by physical signs. 324 M.LVL'AL OF THE PRACTICE OF MEDICINE. Symptoms of asthma are commonly present ; they are usually most severe during the exacerbations of the bron- chitis. The respirations are labored and wheezy ; expiration is unduly prolonged. The obstruction in the pulmonary sys- tem allows of cyanosis, often of an extreme grade, but it is not incompatible with comparative comfort. When compensation fails and the right heart dilates, general venous congestions are gradualh' developed — con- gestion and oedema of the skin, congestion of the stomach, the liver, and the kidne}'s, and general dropsy. The s)-mptoms of chronic endarteritis, of chronic endo- carditis, or of chronic diffuse nephritis ma\- complicate the course of the disease and ma\' even obscure the diagnosis. Variations in the Course of the Disease. — The follow- ing clinical types of the disease are described by Delafield : " I. Some patients for years have a winter cough, with ex- pectoration of mucus and sometimes of a little blood. They are always a little short of breath when they exert them- selves. After a time they have attacks of spasmodic asthma. Then the dyspncea on exertion becomes more constant and more decided ; the patients lose flesh and strength ; venous congestion is established, drop.sy, and death. " 2. Other patients are fairly well except when they have attacks of acute bronchitis. Such attacks may be mild, lasting a few days or a few weeks, with cough, mucous ex- pectoration, sometimes hasmoptyses, asthmatic breathing, and a febrile movement ; or the attacks may be severe, and last two or three months, and, in addition to the symptoms ju.st mentioned, they develop venous congestion, albumi- nuria, and dropsy. "3. In some patients there is a history of attacks of spasmodic asthma for a number of years before the symp- toms of emphysema make their appearance. " 4. In some patients the evidences of emphysema are very slight for a long time. Then rather suddenly constant dyspnoea and venous congestion are developed, and the patients die in a {&\\ months." Physical Sig-ns. — Inspection may reveal nothing abnor- VESICULAR F.MPnYSF.MA. 325 mal. In advanced cases there is an increase in the antero- posterior dimensions of the thorax, approaching the " barrel- shaped chest " in some cases. The chest rises and falls en masse ■ixwdi with evident muscular action, dyspnoea being evident. Lateral expansion is not well marked. The head inclines forward, the shoulders are rounded, the sterno- cleido-mastoid muscles are prominent, and the respiratory- action of the diaphragm is increased. The thorax in em- physema has aptly been described as one of " permanent inspiration." Pulmonary resonance may be unchanged or vesiculo- tympanitic, or there may exist an exaggerated resonance of a tympanitic quality, or the resonance may be of a variety of tympany of a dull quality. This latter note, often called " wooden," is highly characteristic. The percussion bound- aries of the lung are increased in all dimensions, and, owing to the increased thickness of the covering lung, the borders of the heart are determined with great difficulty. The characteristic breathing is feeble compared with the evident expansion of the chest; the expiration is much longer than inspiration, and is of a lower pitch. More rarely both inspiration and expiration may be harsh, loud, and high-pitched. Sibilant and sonorous rales are usually present, and the bronchitis adds coarse mucous rales. Prognosis. — Substantive emphysema is essentially ch ronic, its course extending over years. Moderate degrees of em- physema are not incompatible with prolonged and active life, but in each case the questions must be, How much extra work is thrown upon the right heart ? and, How long can compensation be maintained? Due regard should also be had for the presence of associated diseases — diseased arteries, heart, and kidneys. Treatment. — Much can be done to check the course of the disease by sending the patient to some warm inland place for the winter months at least, where he can lead a life out of doors and not contract recurring attacks of bron- chitis. The general health should be built up in every 26 M.-lXi'AL OF THE PKACriCE OF MEDICINE. way ; over-use of tobacco and of stimulants is to be inter- dicted ; starches and sugars should be avoided. Attacks of dyspnoea are best controlled by drugs that dilate the small arteries — chloral hydrate, iodide of potas- sium, and nitroglycerin. A good combination is as follows : R. Liq. morph. sulph. (Magendie), TTlj ; Tinct. belladonnse, TTliijr Potassii iodidi. gr. vij ; Spiritus iutheris comp., TTLxv; Aqua;, 3SS. — M. Sig. Such a dose every three or four hours. Bronchitis is to be treated on general principles. Should the cough be harassing, the fluid extract of chekan, in dram doses every three hours, is often of the greatest ser- vice. The fluid extract, desiccated and given in capsule, is a conv^enient and pleasant form of administration. Ter- pin and the turpentine derivatives are of service should the expectoration be profuse. When the right heart begins to fail and venous conges- tions appear, cardiac stimulants are indicated. Of these strychnine is especially useful. The bowels should be kept freely open, and all tendency to flatulent dyspepsia is to be combated by diet and drugs. Should the venous conges- tions be urgent and the patient be fairly robust, free bleed- ing is often followed by marked improvement. GANGRENE OF THE LUNG. Etiology. — Gangrene of the lung is caused by infection by means of the putrefactive bacteria. As these germs are so common in inspired air, a condition of impaired lung- vitality must be presupposed. The disease is most com- monly caused by the entrance of organic foreign bodies into the bronchi, from food or other bodies being inhaled into the trachea, from " aspiration- " or " deglutition-pneu- monia," or from the perforation of the lung by cancer of the oesophagus or of the stomach. It may follow cavities, bronchiectasis, or fetid bronchitis. It occasionally follows GANGRENE OF THE LUNG. 327 embolism or pressure of the branches of the pulmonary or the bronchial arteries, and it is one of the rare sequehu of lobar pneumonia. Exceptionally it occurs in debilitated subjects, especially those with diabetes, without antecedent pulmonary disease. Pathology. — A circumscribed and a diffuse form are recognized. The circuviscribcd {oxvi\ occurs in single or multiple foci, usually in the lower lobe near the periphery. The gan- grenous area is converted to a greenish-brown offensive mass surrounded by congested or consolidated lung- tissue. The neighboring veins are frequently filled with infective thrombi that may become detached, causing sec- ondary foci in other parts of the body. In this way abscess of the brain may be developed. If the pleura be involved, pleurisy with a sanious or purulent effusion will result, or perforation of the pleura will lead to pyo-pneumothorax. Severe and even fatal hemorrhage will result from erosion of a large arterial branch. An intense general bronchitis always complicates the disease. Liquefaction of the gan- grenous area rapidly occurs, and, the softened portions being coughed up, a cavity with ragged necrotic walls is left. Should the patient recover, a connective-tissue cap- sule forms, enclosing the cavity, which may subsequently contract. The diffuse form may be so from the start or may follow the circumscribed form. A lobe or the greater part of a lobe, or even the entire lung, may thus become gangrenous. The diffuse form rarely follows lobar pneumonia. Symptoms. — Pidinonary. — There is a cough with an ex- pectoration which is fetid and usually abundant. On stand- ing, the expectoration separates into three layers — an upper layer, frothy and opaque ; a middle layer, clear and watery, and usually of a greenish or brownish tinge ; and a lower layer, of a greenish sediment which consists of mucus, pus, shreds of elastic lung-tissue, granular matter, crystals of fatty acids, and bacteria. Blood is often present in the sputa, and large hemorrhages 328 MAXi'AL OF THE PA'ACT/CE OF MEDICLXE. may occur. Marked and characteristic fetor of the breath is rarely absent. Pain occurs if there be pleurisy. Septic. — There is developed an irregular fever with pros- tration. The patient loses flesh and strength and passes into a typhoid condition. In cases in which the gangrenous area is encapsulated the septic symptoms are not so severe as one would expect. The physical signs are those of consolidation over a cer- tain area, followed b\- the signs of a pulnionar}' cavit)'. There are abundant moist bronchial rales. Physical signs of pleurisy with effusion or of p)'o-pncumothorax may be present. The diagnosis from fetid bronchitis is made by finding shreds of pulmonary tissue and elastic fibres in the sputum. The prognosis is bad, but not hopeless. The course may be acute, or the di.sease may last for months. Treatment consists in supporting the strength of the patient and in disinfecting the lung as thoroughly as our limited means will permit. The patient should wear con- tinuously a Robinson inhaler saturated with equal parts of alcohol, creosote, and chloroform. Terpin and the deriva- tives of turpentine are often of great service, while nn-rtol, (gr. iiss in capsule every two hours) is warmh- advocated. If the gangrenous area be localized near the surface of the lung, injections of antiseptics may be made directly into it, and if the patient be in fair condition, the cavity may be opened through the chest-wall and drained. ABSCESS OF THE LUNG. Etiology. — Aside from the cases of purulent infiltration complicating lobar pneumonia or broncho-pneumonia, ab- scess of the lung may occur from the following causes: 1. From the introduction of foreign septic substances into the bronchi, as in aspiration- or deglutition-pneumonia, from septic diseases of the throat or the neck, from perforation into the lung of cancer of the oesophagus or the stomach or ab- scess of the liver, or from penetrating wounds of the thorax. 2. It may complicate lobar pneumonia or phthisis, or it may be due to the suppuration of an echinococcus cyst. SYPIf/L/S OF 77 IF. LUXG. 329 3. More commonly abscess of the lung results from infec- tive emboli, the so-called "embolic" or " metastatic abscess." Multiple abscesses frequently occur with pyaemia or with malignant endocarditis involving the right heart. At first the lesion resembles an ordinary hemorrhagic infarction, but the embolic area rapidly becomes purulent and softens to form a cavity, while the pleura over it becomes infected, resulting usually in empyema or pyo-pneumothorax- The symptoms are frequently masked by those of the original disease. Respirations, however, are quickened, the temperature becomes higher, and the patient is evidently much worse. Pain, if present, is due to the pleurisy. Em- pyema or pyo-pneumothorax may add its symptoms. The sputum is abundant, purulent, and contains shreds of lung- tissue. The odor is offensive, but not so markedly so as in fetid bronchitis or in gangrene of the lung. The constitu- tional symptoms are those of sepsis. The physical signs at first are those of consolidation, be- coming changed later to those of a cavity. Complicating pleurisy with effusion or pyo-pneumothorax adds its charac- teristic physical signs. The prognosis is almost always fatal in embolic cases, but recovery occasionally occurs after pneumonia. Prompt and efficient treatment, however, may moderate the mortal- ity rate. The treatment should be entirely surgical, consisting in the opening and draining of the abscess-cavity. Recovery or improvement results in about one-half the cases so treated. SYPHILIS OP THE LUNG. Syphilis of the lung is a rare disease, but its actual occurrence is undoubted. Pathology. — Three distinct forms of lung-syphilis are recognized : I. White Hepatization, or White Pneumonia. — This form is seen in stillborn children with other evidences of heredi- tary syphilis. The lesion consists in the infiltration and thickening of the walls of the alveoli, the blood-vessels, 330 M.lXi\4L OF THE PRACTICE OF MEDICINE. and the bronchi with small cells. Some of the air-spaces are filled with epithelial cells. These cases are of patho- logical rather than of clinical interest. 2. Gu)}unata may occur m the lung as a late tertiary manifestation. The gummata are distributed through the lungs and are especially numerous at the bases ; they vary from a microscopical size to that of a lemon. Each gumma is usually surrounded by a zone of consolidation. There are usually a general bronchitis, thickened pleura, and some interstitial pneumonia as complicating lesions. Destructive syphilitic processes in the lung have not as yet been proved. Cases of gummatous pneumonia re- semble, clinically, tubercular broncho-pneumonia or new growths of the lung. 3. Sypliilitic Fibroid Pncunwfiia. — In this form the pleura is thickened, and bands of connective tissue extend from it into the lung. The bronchi are surrounded by a growth of connective tissue, which may either so compress them as to . cause urgent dyspnoea or may weaken them and allow of their dilatation. Patches of indurated connective tissue may re- place the lung-parench)'ma, rendering certain portions of the lung completely solid. All these lesions are found especially well marked at the base of the lung. The physical signs are those of bronchitis, bronchiectatic cavities, thickened pleura, and areas of consolidation. The treatment is that of tertiary syphilis, but it is usually ineffective. The course of the disease is slow, and the termination is usually fatal. NETAT GROWTHS OP THE LUNG. The most common forms of neoplasms of the lung are carcinoma, especially of the epithelial variety, and sarcoma; more rarely are found enchrondroma and osteoma. Primary growths are exceedingly rare. Primary carcinoma is usually found as a single growth at one apex ; it may involve other organs by metastasis through the medium of the bronchial glands, or it may involve the pleura and the chest-wall by direct extension. Secondary carcinoma occurs as scattered nodules NEW GROWTHS OF THE LUNG. 33 1 through out both lungs, each nodule being surrounded by a zone of congested and consolidated lung-tissue. Either a simple or a malignant pleurisy usually compli- cates the lesion. Sarcoma is usually secondary, and both lungs are involved by scattered nodules. The sarcoma is usually of the small- celled variety. Symptoms. — i. Symptoms due to involvement of the lungs depend on the size, number, and position of the malignant growths. If the nodules be small and scattered, the patient will complain of dyspnoea and of pain in the chest from the complicating pleurisy, and will develop a cough. The expectoration is either muco-purulent or bloody, or per- haps dark and mucoid, the so-called "prune-juice" expec- toration, which is highly suggestive. In other cases the expectoration resembles currant-jelly, and this appearance is almost pathognomonic. In the expectoration cancer- cells may be found. 2. Large single growths may cause pressure-symptoms. Pressure on the bronchi will cause cough, expectoration, haemoptysis, and dyspnoea. Pressure on the vena cava will cause congestion and oedema of the arm, the neck, and the upper portion of the thorax. Pressure on the oesophagus will cause dysphagia. Pressure on nerves will cause intercostal neuralgia. If the recurrent larj'ngeal nerve be involved, the patient will develop a brassy cough, laryngeal voice, and steady or paroxysmal dyspnoea. 3. Cancerous cachexia will be shown by a waxy pallor, loss of strength, slight afternoon fever, and oedema of the ankles. 4. There may be added the symptoms of primary or sec- ondary growths. Physical Signs. — Inspection may reveal distended veins of the upper thorax and the neck or bulging of the chest- wall, which may be mistaken for aneurysm, especially as the bulging part may yield a slight expansile pulsation or an appreciable transmitted expansion. There may be infil- trated cervical or axillary glands, and the seat of the primary growth may be detected. ^}2 .U.IXC'.I/. OF THE PRACTICE OE MEDICLXE. Physical signs depend upon the size and position of the tumors. 1. There ma)- be only the ph)-sical signs of a bronchitis with those of a dry pleurisy or of an effusion which in some cases is hemorrhagic. 2. Larger nodules give rise to the signs of scattered areas of consolidation. 3. A single large growth will give rise to an area of flat- ness, with absence of voice and breathing, surrounded by an area of dulness, with bronchial voice and breathing. The central flat area is usual!}- exquisite!}' tender on percussion. The prognosis is fata! in from six months to two years. Treatment is merely palliative, to relieve suffering. In- jections of the toxic products of the er}'sipelas coccus may be made in sarcomatous cases. ECHINOCOCCUS CYSTS OF THE LUNG. Small cysts may exist for a considerable time without causing symptoms. Large cysts tend to compress the lung and lead to secondar}- inflammator}- changes. Rupture into a bronchus will allow of the expectoration of fragments of the cvst-wall and of the hooklets, estab- lishing the diagnosis without doubt. Rupture into the pleura is not uncommon. Suppuration of the cyst may occur, and gangrene of the lung is not uncommon. ip) Tubercular Diseases of the Lung. TUBERCULAR INFLAMMATIONS IN GENERAL. Definition. — Tubercular inflammation, caused by infec- tion by the tubercle bacillus, is characterized by the pro- duction of new tissue of low vitality. Etiology. — The bacillus tuberculosis, first described in 1 88 1 by Koch, is now definitely proved to be the actual cause of tubercular disease. The bacillus is a short fine rod having a length equal to one-half the diameter of a red blood-cell. TUBERCULAR INFLAMMATIONS IN GENERAL. 333 When stained it presents a beady appearance, probably due to spore-growth within it. For the methods of staining the germ the reader is referred to works on bacteriology. The bacilli are found in all tubercular lesions, but they are more numerous in the acute forms of disease. They may gain access to the blood-vessels or the lymph-vessels, and become generally distributed throughout the body. They are thrown off in the expectoration of patients suffering from pulmo- nary tuberculosis in enormous numbers, and this infected sputum, when allowed to dry, enters the air as a fine dust, which spreads the disease in every direction and infects rooms, carpets, and clothing. Modes of Infection. — i. Hereditary or congenital tubercu- losis is very rare, although undoubted cases have occurred. 2. Acquired T?iberculosis. — (a) By Inhalation. — Inhalation is the most common method of infection, as is proved by the fact that 50 per cent, of all autopsies show some degree of tubercular disease of the lungs. Cloisters, prisons, asy- lums, and infected houses show a marked increase of tuber- cular inhabitants. The expired air, however, of tubercular patients is not infective. {b) By Inoculation. — Local tubercular lesions may result from inoculation incurred by handling tuberculous patholog- ical specimens, infected meat and skins, and by wounds being inoculated by impure instruments or by tubercular dust. Many cases of tuberculosis in children have followed the rite of circumcision, during which the wound has been sucked by a tuberculous operator. There is no evidence that tuberculosis can be conveyed by vaccination with humanized virus. (c) By the Ingestion of Tubercidous Meat or Milk. — Strik- ing examples of the infectious properties of the milk of tuberculous cows are, unfortunately, only too common, many cases of intestinal and mesenteric tuberculosis being directly traceable to this cause. Meat of tuberculous ani- mals is not always infective, and the process of cooking in all probability affords an efficient safeguard against this method of transmission. Conditions Favorable to Infection. — i. Constitutional 334 .^/.-t.yC-lL OF THE PKACriCE OF MEDICIXE. Conditions. — [li) A family history of tuberculosis is present in from lO to 50 per cent, of cases, according to various authors. . It is hard to say, however, in an\- given case, whether the child was born with some inherent tissue-weak- ness predisposing toward tubercular infection — a naturally good soil for the growth and development of the bacilli — or whether greater risk for accidental infection was run from the child living with, kissing, and sleeping with tuberculous parents. In either case, however, transmission of the disease is more common when the mother is tuberculous. (/;) Tubercular infection is more common among weakly, sickly subjects with deficient chest-expansion. Any depre- ciation of the general health diminishes the resistance of the tissues and favors infection. It is found that rabbits, by being allowed to run freely in the woods, may be kept in such perfect condition that they cease to be good subjects for the experimental inoculation of the bacilli. ic) No age is exempt, but in children tuberculosis of the bones, the lymphatics, the meninges, and the intestinal tract is much more frequent than in adults. id') The negro affords a fertile soil for the growth of the bacilli, and tuberculosis among the American Indians is especially frequent. 2. Local Conditions. — Any local weakness or inflammation renders the part of the body affected more susceptible to tubercular infection. Bronchitis, enlarged bronchial glands, and interstitial pneumonia are frequently found as predis- posing causes of pulmonary tuberculosis, while intestinal catarrh produces conditions favorable for the growth of the bacilli in the alimentary tract. Local injuries or operations may so weaken the tissues as to allow of infection. Thus a simple synovitis from injury may become tubercular, or pulmonary tuberculosis may fallow severe contusions of the chest. Structure of Tubercle. — The local action of the tubercle bacillus upon the tissues results in the proliferation of pre- existing cells and in the aggregation of leucocytes. To this collection of cells the name of " tubercle " is given. The first step in the formation of tubercle consists in the rUBERCULAR INFLAMMATIONS IN GENERAL. 335 increase in number of the fixed normal cells, especially those of the connective tissue and the endothelium of the capillaries. These proliferated cells are known as " epithelioid cells." Giant-cells are formed by the increase in protoplasm and in the nuclei of a single cell or by the fusion of several cells. Giant-cells are found, however, only in cases in which the bacilli have a low degree of vitality. The next step consists in the emigration from the neigh- boring blood-vessels of leucocytes which mix with or sur- round the above-mentioned epithelioid cells. A network or reticulum of fibres is found between the cells, probably representing the original interstitial tissue stretched apart by the increased cellular elements. The reticulum is most marked at the margin of the tubercle. No new blood-vessels are formed in the tubercular growth, and pre-existing blood- vessels are apt to show lesions of an obliterating endarteritis, so that the newly-formed tissue has but feeble vitality. When these changes have become sufficiently extensive the tubercle appears as a grayish point or nodule, to which the name " miliary tubercle " is given. By the growth and approximation of these miliary tubercles large areas may be involved, forming the so-called " diffuse tubercle." Histologically, tubercle cannot always be differentiated from other infectious tumors, such as those of syphilis or leprosy, or from ordinary granulation-tissue. Tubercle- tissue, however, is characterized by its natural tendency toward cheesy degeneration. Cheesy degeneration, or " coagulation-necrosis," is due partly to the local action of the bacilli upon the newly- formed cells, and partly to the scanty blood-supply of the tubercular nodule. At the centre of the nodule the cells die, lose their nuclei and their staining properties, and become translucent and structureless. This area of degen- eration presents an opaque, yellowish-white appearance, and by the extension and coalescence of these areas the degen- eration may become exceedingly extensive. Subsequently the degenerated area may undergo (i) softening, so as to form a cavity or an ulcer, (2) encapsulation, or (3) in it may be deposited the salts of lime. 336 MA.VLAL OF THE PRACTICE OE MEDICIXE. SpofittDicoiis hca/i)ig- of tiilnrcular fiodulcs may occur in two waws : 1. Tlvc nodule may be surrounded b\- a fibrous capsule; its cheesy centre may be converted to a putty-like mass which may be infiltrated with the salts of lime ; or it may liquefy and be absorbed, leaving only a puckered cicatrix. 2. There may be a great increase in the fibroid elements of the nodules, so that the tubercle becomes firm, hard, and does not increase in size. This fibroid or sclerotic change is more frequently seen in tubercles of the peritoneum. Secondary Inflammatory Processes. — Tubercle seldom occurs alone in the tissues, but the irritation caused by its growth produces secondary inflammatory changes, so that the tubercle may become a very composite structure. Symptoms of Tubercular Disease. — The action of tubercle bacilli is at first entireh* local. The affected area may be small, and the resulting symptoms consequently slight and locahzed. In other cases the local lesion may spread by continuity, so that large portions of important organs may be rendered unfit to fulfil their functions, with resulting symptoms that are not only local but general. In still other cases the lesion is at first localized, but from softening and breaking down of a tubercular deposit the bacilli may enter a blood-vessel or a lymphatic, enter the general circulation, and set up miliary tubercles wherever they happen to lodge. The symptoms resulting from such a scattering of the lesion are those of an acute infectious disease combined with the local symptoms of tuberculosis in different parts of the bod}\ This form is spoken of as " acute miliary tuberculosis ; " it is considered under the heading Infectious Diseases. The danger of this general infection must always be borne in mind in every tubercular inflammation, no matter how localized it may beat the onset. TUBERCULAR DISEASES OF THE LUNG. Under this heading may be included — i. Acute pulmo- nary tuberculosis ; 2. Chronic pulmonary tuberculosis ; 3. Acute pulmonary phthisis ; 4. Chronic pulmonary phthisis. 'J'UBKRCULAK /J/S/wlS/CS OF 77//-: 7.UNG. 337 ACUTK PULMOXAKV TUHMKCULOSIS. Etiology. — In this form of disease the bacilli reach the lung either through the inspired air or by being transported by the blood. In the latter case tubercular involvement of the bronchial glands may precede the pulmonary tuber- culosis. In other cases some old tubercular process is found to be the source of infection. Pathology. — Disseminated tubercles are found in part of a lung or scattered throughout both lungs. Each miliary tubercle is surrounded by a slight zone of congested or consolidated air-vesicles, but the greater part of the inter- vening lung-tissue is comparatively normal, and this condi- tion sharply defines the disease from pulmonary phthisis, in which consolidation of the intervening lung-tissue is an early lesion. The tubercles usually are first found at the apex of one lung, from which point they may spread ; or tubercles may be formed at once throughout both lungs in great numbers. There is always a catarrhal inflammation of the finer bronchi of that portion of the lung occupied by the tubercles ; in rarer cases the bronchitis is general. Tubercles in or near the pulmonary pleura result in pleurisy either with fibrin or with serous effusion. As the tubercles grow and coalesce, portions of lung may be rendered solid, but this consolidation is always a late manifestation of the disease. From areas of softening breaking into one another small cavities may be formed, and these cavities may be still further increased in size by tubercular ulceration of the bronchi leading into them. Symptoms. — i. Cases in which tubercles are rapidly formed throughout both lungs and in other parts of the body are really examples of acute miliary tuberculosis ; they are considered in the discussion of that disease. 2. The term " pulmonar}^ tuberculosis " is applied more properly to those cases in which tubercles spread from the apex of one lung and are not found in other parts of the body — a purely localized process. In some cases the disease may develop as a primary infection, while in other cases it complicates some pre-exist- 22 JO 8 .V.I.VC.IL OF TJ/E PRACTICE OE MEDICI XE. ing tubercular lesion. When the disease is established the symptoms depend upon the extent of lung involved, the bronchitis, and the pleurisy. The patient has a fever, higher in the afternoon, followed by sweating at night. The heart's action is rapid. Breath- ing is rapid and often insufficient, and is made more rapid by extension of the tuberculosis or by increase of the bron- chitis or of the pleurisy. However rapid the breathing, there is not apt to be much subjective dyspnoea, even though there be marked cyanosis. Cough is a fiiirly con- stant symptom, and may be most distressing. The expec- toration is muco-purulent and may contain blood. In the sputa the bacilli arc usually, but not invariably, present. Loss of flesh and of strength is noted from the first, but it seems to bear no direct relation to the extent of lung involved. There is often developed a peculiar pallor of the skin, resembling that of pernicious anaemia. In other cases the skin is cyanotic. In some patients the symptoms progress steadily, emaciation becomes extreme, and death results from ex- haustion or from secondary involve- ment of other organs, or the patient „ „,^ . , . . , mav pass into a typhoid state. In tiG. 38. — Physical Signs in the ■• >■ •' '■ earliest stage of pulmonary tu- OtllCr CaSCS tllC prOCCSS Will appar- barculosis : diminished e.xpan- ^y , c j_- vi 1 , entlv^ stop for a time, with a fjeneral sion ; percussion normal or j i ' o tympanitic : breathing weak or im[)rovement of all tlic symptoms. harsh : pleuritic or bronchial ^-^ . 1 i 1 • rales. Unce quicsccnt, the tuberculosis may never again extend, and a permanent cure may thus be affected. In other cases, after an interval the process will again start up and involve fresh areas of the lung, with a return of the old symptoms. In still other cases intercurrent attacks of bronchitis, pleurisy, or pneu- monia occur to modify the course of the disease. The physical signs may be described as appearing in three stages : I. The tubercles are scattered at one apex; there is a TUBERCULAR DISEASES OF THE LUNG. 339 localized terminal bronchitis and a dry pleurisy. There is diminished expansion at the apex. The percussion-note may be normal, tympanitic, or slightly dull. Vocal fremitus is usually unchanged. Breathing sounds may be feeble or harsh and puerile, but at this stage no tendency toward bronchial breathing is observed. On auscultation crepitant and subcrepitant pleuritic rales and fine bronchial rales are heard, affording strong presumptive proof of pulmonary tuberculosis when localized at one apex (Fig. 38). Fig. 40. — Physical signs of pulmonary tuberculosis in the final stages : a, signs of consolidation, gurgles, and pleuritic rales ; b, signs of consolidation and rales; c, dull tympany, prolonged, high-pitched expirations, rales; d, tympany, feeble breathing, rales. Fig. 39- — Physical signs of pulmonary tuberculosis in the advanced stage : a, di- minished expansion, dulness, bronchial voice and breathing, increased vocal fremi- tus; pleuritic and bronchial rales; b, dull tympanitic note, prolonged and high- pitched respiration, bronchial and pleuritic rales; c, tympanitic or normal note, feeble or harsh breathing, pleuritic and bronchial rales. 2. As the tubercles grow and coalesce, portions of lung — usually one or both apices — are rendered solid. Over these portions the note becomes dull, the expiratory sound becomes prolonged and high-pitched, and ultimately bron- chial breathing and bronchophony are developed. The physical signs noted in the preceding paragraph spread at the periphery of the lesion (Fig. 39). 3 When small cavities begin to be formed, gurgles make their appearance. The cavities are rarely large enough to yield other and more distinctive signs, although a number of small cavities may merge into one large antrum over which 340 M.IXL'AL OF /•///•; rK.ICf/CE OF MEDICIXE. can be obtained a tympanitic or a " cracked-pot " note with broncho-cavernous or cavernous breathing (Fig. 40). The diagnosis of puhnonar\' tuberculosis should be sus- pected in every case of dry pleurisy at the apex or of bronchitis at the apex. The disease should be suspected in every case of severe recurrent bronchitis or dry pleu- risy, if the constitutional symptoms be out of proportion to the apparent lesion. It should be suspected in the case of an)' patient with fever and rapid pulse without apparent cause, even in the absence of definite ]:)ulmonary s\,'mptoms. The positive diagnosis, however, can only be made by the finding of tubercle bacilli in the sputa. The prognosis of rapidly-spreading tuberculosis is bad. Under proper environment the disease may become chronic or may even become quiescent. Treatment of all tubercular diseases of the lung will be considered later (see p. 356). Chronic Pulmonakv Tuberculosis. Chronic pulmonary tuberculosis differs from the acute form in the chronicity of its course and the slow reactive nature of the secondary inflammatory processes. Three distinct clinical groups may be described : I. Miliary tubercles are formed at one apex and slowly spread downward. The opposite apex is next involved in like manner. When the disease is fully developed the tubercles are found scattered throughout both lungs. The miliary tubercles run a very inactive course, some becoming cheesy, while others undergo fibroid change or are encapsu- lated. There is a chronic bronchitis, at first limited to the apex, later becoming general. Bronchiectatic cavities may form, but they are of rare occurrence. Dry pleurisy, resulting in pleural adhesions and thickening, is due to the irritation of tubercles near or in the pulmonary pleura, and it is usually best marked at the apex. In the later stages of the disease the tubercles may become so closely aggre- gated as to cause partial or complete consolidation of por- tions of the lung, especially at the apices; while the forma- tion of small cavities occurs in the most advanced cases. TUBERCULAR DISEASES OF RlfR /.UNi;. 34 r Symptoms begin insidiously. The first complaint may be of a hacking cough with scanty expectoration, due, as proved by physical examination, to a localized bronchitis at one apex. In other cases a dry pleurisy at one apex will cause pain to be the initial symptom. Other patients suffer from haemoptysis while in apparently robust health. In other patients, the lesions give no subjective symptoms, and the presence of the disease is only discovered by a routine examination of the chest. When the disease has once developed there is a cough, usually troublesome and persistent. It may be dry and hacking or loose in character. Expectoration is scanty at first, but later becomes profuse, muco-purulent, contains bacilli, and frequently is tinged with blood. Haemopt}'ses may occur from time to time, but they are rarely profuse during the early stages of the disease. Dyspnoea is present according to the extent of lung in- volved, the bronchitis, and the pleurisy. At first noticed only on exertion, it may subsequently become steady and distressing. Extension of the pleurisy is marked by fever and pain. Rapid pulse is almost constant throughout the disease, so that pulmonary tuberculosis should be suspected in all patients whose pulse is continually rapid without apparent cause. Increased rapidity of the pulse and some afternoon rise in fever are caused by fresh accessions of tubercles or by exacerbations of the pleurisy or the bron- chitis. The patient loses flesh and strength, becomes anaemic, and is converted to a semi-invalid. Later in the disease, when small cavities form, " hectic " develops — the afternoon fever, bright eyes, flushed cheeks, night-sweats, and more rapid emaciation. The physical signs of chronic pulmonary tuberculosis resemble those of the acute form. There may at first be no physical signs, or there may be diminished expansion, tym- pany or tympanitic dulness, with feeble or harsh breathing at an apex. Auscultation reveals pleuritic and bronchial moist rales. In other cases thickened pleura at an apex yields dulness and diminished voice and breathing. Later 342 .V.LVC.IL OJ' THE rRACTICK OF MEDIC I. \E. appear the si^rns of partial or complete consolidation — dulness, bronchial voice and breathing, and increased vocal fremitus with a persistence of the bronchial and pleuritic rales. The final stage of small cavities is accompanied by gurgles, more rarely b}'- tympanitic or " cracked-pot " per- cussion-note and by broncho-cavernous or cavernous voice and breathing. Course of the Disease. — {(i) In some patients the lesion begins at one apex, but after a certain time does not pro- gress, and the patient lives for years without further trouble. The tubercles still remain in the apex of the lung, but they become encapsulated, fibroid, or calcareous. Many of these patients suffer so little from their disease that no suspicion of tuberculosis is entertained. There is always danger that at any time the process will start anew or be the cause of an acute general miliary tuberculosis. {b) In other patients the lesion is progressive only at long intervals. Exacerbations of the lesion are most apt to occur during the winter months, during any intercurrent pulmonary disease, or whenever the general health is allowed to deteriorate. Many old cases of tuberculosis are thus stirred into renewed activity by epidemics of the " grippc-" So a great many patients go on for years, each succeeding exacerbation becoming more and more .severe, until finally the extension-process becomes continuous. Under proper environment, however, the course even of these patients may be prolonged and the progress of the disease may ultimately be checked. ( Tubercle bacilli in the sputvim, first colored with anilin-fuchsin and then with methylene- blue ; X about 1000 (Vierordt). TUBERCULAR DISEASES OE THE LUNG. 349 penetrate the lung, extending inward from a thickened and adherent pleura. 4. The bro)icJu undergo the same inflammatory changes as in acute phthisis : {a) They are the seat of a chronic catarrhal inflammation, [b) Their walls may be infiltrated by the products of a tubercular or a non-tubercular in- flammation, and, being thus weakened, sacculated bron- chial dilatation will result, {c) If the infiltration be tuber- cular, ulceration of the bronchial wall will further increase the size of the bronchiectatic cavity. 5. Cavities are formed — {a) By the softening and break- ing down of areas of coagulation-necrosis ; {b) by bronchi- ectasis ; and (r) by tubercular ulceration of the walls of the bronchi. Cavities, when once formed, tend to enlarge, and as they increase in size they touch and open into one an- other. In this way the greater part of a lobe may be con- verted to a single large cavity. A blood-vessel is the last structure to be ulcerated in the formation of a cavity. An obliterating endarteritis usually occurs, converting the ves- sel to a fibrous cord, thus preventing hemorrhage at the time of its erosion. Should this conservative process not be completed, partial erosion of the arterial wall will allow of the formation of a little aneurysm, which may finally rup- ture, causing profuse hemorrhage. Conservative and heal- ing processes may occur even after a cavity has once formed. The wall of the cavity becomes thick and fibrous, and the lining may be smooth, resembling mucous membrane. Healing processes, however, do not occur in cavities of any size. 6. The pleiij'a over the involved area of lung is regularly the seat of a chronic inflammation, resulting in thickening and adhesions. This form of chronic inflammation is really conservative, as, by the strengthening of the pleura by con- nective tissue the risk of perforation of cavities or of bacte- rial infection of the pleura is minimized. The lesions of chronic phthisis usually begin at the apex of one lung and extend downward to involve the upper lobe and the apex of the lower lobe. The opposite apex is then regularly affected. 350 M.IXr.lL OF TJIE rKAC7ICE OF MFJUC/XE. Complicating and secondary lesions will be considered under the heading " Complications." Symptoms. — The mode of onset is varied and insidious. 1. The disease may begin with dyspeptic and anaemic symptoms not readily alleviated by treatment. Amenor- rhoea is an early symptom of these anaemic patients. 2. There may be a gradual loss of flesh and of strength, with a slight afternoon rise in temperature. 3. The symptoms of a " neglected cold " may precede other symptoms. Cases of recurring or of persistent bron- chitis, especially in a young person, should always be re- garded with suspicion. 4. Chills and fever due to tubercular infection may be mistaken for those of malarial origin. 5. The disease may begin with a laryngeal cough and huskiness of the voice, and on examination either a ca- tarrhal or a tubercular laryngitis may be found, or the larynx may appear simply anemic. 6. Haemoptysis may be the initial symptom, preceding other manifestations of the disease by months or even by years. 7. There may be dry pleurisy, especially at an apex or in the scapular region, or a pleurisy with effusion running an acute or an insidious course. According to Bowditch, phthisis ultimately develops in one-third of the cases of pleurisy with effusion. A double pleurisy with effusion is much more suggestive of tubercular origin. Symptoms of the Developed Disease. — i. Piduionary Symp- toms. — (rt) Cough is an early and almost a constant symp- tom. Dry and hacking at first, it later becomes looser and more frequent. It may be so distressing as to prevent sleep, and sufficiently severe and paroxysmal to provoke vomiting and thus to interfere with the patient's nutrition. (/>) The sputum varies in amount and character in the different stages of the disease. At first the expectoration is mucous and of a glairy consistency, presenting nothing suggestive of tubercular trouble. Later in the disease the sputum becomes muco-purulcnt and contains little grayish or grayish-green lumps. When cavities form the expectoration is more pro- TUBERCULAR DISEASES OF TJ/E LUNG. 35 I fuse, especially in the morning or after sleep, is more puru- lent, and finally the sputa assume the nummular form of separate solid purulent masses which sink in water. The expectoration of phthisical patients has usually a heavy sweetish odor, although it may be fetid. In cases of con- solidation without much bronchitis the sputum may not be abundant at any time. Generally the quantity of the spu- tum gives a fair test of the activity of the disease. Exam- ination of the sputum for tubercle bacilli should always be made in doubtful cases. The bacilli are usually present early in the disease ; they are abundant in proportion to the intensity of the tubercular process. A diminished number of bacilli affords grounds for a more favorable prognosis. The presence of bacilli in the sputum is an infallible proof of the existence of tuberculosis, but their absence does not necessarily exclude the disease. Tuberculosis can be ex- cluded only after repeated examinations of the sputa show absence of the bacilli. The demonstration of elastic fibres in the expectoration only proves the existence of some destructive pulmonary lesion, the fibres being found in tuberculosis, gangrene, and abscess of the lung. If the sputum be pressed between two thin cover-glasses and held against a black ground, the elastic fibres can usually be recognized with the naked eye. From the appearance of the elastic fibres it can be told whether they are derived from the bronchi, the alveoli, or the blood-vessels. Hemorrhage occurs in 60 per cent, of all cases of chronic pulmonary phthisis ; it may appear early or late in the dis- ease. Large early hemorrhages never lead to phthisis, as is erroneously supposed, but arise from a small undiscovered lesion. The small early hemorrhages usually arise from the congested or ulcerated walls of the bronchi, and the blood is admixed with sputum. Large late hemorrhages arise from the erosion of an artery or from a ruptured aneurysm of an artery within a cavity ; in these cases the blood is pro- fuse and is unmixed with sputum. For the differential diag- nosis of haemoptysis from haematemesis see Pulmonary Hemorrhage. 35- .u.ixr.iL or the PRAcriCE of medicine. Small hemorrhages from congested bronchi may reHeve congestion and may be followed b\' a feeling of general im- provement. Large hemorrhages are often fatal, either from the exhaustion ami anaemia induced by them, or by reason of the hemorrhage itself, or because blood is aspirated into the bronchi of the other lung, causing aspln-xia or septic pneumonia. Pai)i may be a distressing symptom or it may be absent entirely. When present it is due either to the pleurisy, to the muscular strain of coughing, or to intercurrent intercostal neuralgia. Tenderness is often elicited by percussing over the locality of a dry pleuris)'. Dyspncca on exertion increases with the extension of the disease and with the exacerbations of the bronchitis. Con- stant dyspnoea usually indicates excessive involvement of both lungs or points to some pleural complication, h^xtreme dyspncea with cyanosis is practically unknown in uncom- plicated cases. Pain and sudden urgent dyspnoea suggest pneumothorax. Constitntional Symptoms. — P'ever usually is marked in proportion with the advance of the lesion, and a persistently normal temperature usually means that the disease is not progressing. It is possible, however, for consolidation alone to cause no fever, the febrile condition in general being due to the bronchitis and to the suppuration -in the cavities. The fever is usually remittent or even intermittent, the minimum temperature occurring between 2 and 6 o'clock A. M., the maximum being noted between 2 and 6 o'clock p. M. The afternoon rise of temperature is usually accom- panied with flushed face, brilliant eyes, and a " hectic flush." The early morning remission is marked by profuse cold night-sweats, especially about the head and the neck. The sweating in advanced cases also recurs during the day, after sleeping. When extensive suppurating cavities exist the morning temperature may be subnormal. A continuous high temperature suggests an intercurrent pneumonia. The temperature is often influenced by rest and by good nurs- ing, and usually declines with hospital care. The tempera- TUBERCULAR DISEASES OE TJ/E LUNG. 353 ture becomes also less marked under favorable changes of climate. The pulse is rapid, full, and compressible, and there may be capillary pulsation visible under the finger-nails. The patient loses flesh and strength and becomes anaemic. These changes depend upon the fever, the progress of the disease, and the proper feeding and treatment of the patient. The weight, which gives a good index of the progress of the disease, should always be considered in the prognosis. It is possible, however, for the patient to retain flesh, strength, and color even with a well-advanced lesion. The mental state is peculiarly cheerful, and even mori- bund patients are firmly confident of a speedy recovery. Menstruation in women becomes irregular or ceases altogether. Digestive Symptoms. — Anorexia may be a well-marked symptom, so that there is actual loathing for all food. Nausea and vomiting may appear in the later stages, being due to paroxysms of coughing or to dilatation or a chronic catarrhal inflammation of the stomach. As a rule, how- ever, phthisical patients digest well, although the stomach lacks its normal peristaltic power and the gastric juice is deficient in HCl. DiarrJicea often appears in the later stages of the disease ; it may be due to waxy or fatty degeneration of the liver, to catarrhal enteritis, to amyloid degeneration, or to tubercular ulcerations of the intestine, especially of the large bowel. Tubercular ulceration of the ileum may cause no diarrhoea, but it induces an" emaciation that cannot otherwise be accounted for. In some cases no lesion is found post- mortem to account for the diarrhoea. Physical Signs. — i. Signs of Early Cases. — There is usually appreciated by palpation a diminished respiratory expansion at one apex ; this sign, which often precedes all other physical signs, is of great diagnostic importance. The percussion-note over and under the clavicle may be normal or slightly dull. Breathing (i) may be simply feeble, or (2) the inspiration may be inaudible, while the expiration is unduly prolonged, or (3) the respiratory 23 354 M.l.yr.-IL OF THE PRACTICE OF MEDICLXE. niuriiiur may be harsh and rude and of the peculiar wavy, jerky character s[)oken of as " cog-wheel " breathinij. Fine moist, bronchial rales and subcrepitant pleuritic rales are fre- quently heard even in early cases. 2. Signs of Evident Consolidation. — The deficienc}' of local chest-expansion becomes more marked, and inspection may show some sinking of the infraclavicular spaces. The percussion-note is slightly dull ; the breathing and the voice approach the broncho-vesicular (louder and higher piched than normal, with an expiration longer and higher in pitch than inspiration). Vocal fremitus is usually increa.sed unless there be thickened pleura. These physical signs are distinctive when obtained at the left apex, but are nearly the signs normally obtained at the right apex ; the pres- ence of bronchial and pleuritic rales, however, not being normal to either apex, may make the diagnosis evident. Later, when consolidation becomes more marked, the dul- ness becomes more pronounced, the breathing and the voice become bronchial, vocal fremitus is increased, and the bronchial rales become coarser and more numerous. 3. Signs of Cavities. — Numerous scattered cavities with- out much surrounding consolidation and without pleuritic thickening may yield a nearly normal percussion-note. On auscultation, however, bronchial breathing and gurgles are heard. Small cavities filled with secretion may give rise to marked dulness or even flatness. Tympany is excited over cavities of about the size of an English walnut. The tympan- itic quality is best marked when the patient's mouth is open, constituting " Wintrich's sign:" A " cracked-pot " note is obtained by firm, sharp percussion over superficial cavities having yielding walls, with open communication with a bronchus. This note often comes and goes, is reproduced by coughing, and is best heard when the percussor's ear is placed directly in front of the open mouth of the patient. It must be remembered that a " cracked-pot" note may be normally heard at the right apex in some children. An amphoric note is heard by percussing large cavities with smooth rigid walls. The breathing over cavities may be bronchial, broncho- TUBERCULAR DISEASES OE I'lfE LUNG. 355 cavernous, or cavernous. The breathing signs, however, change their character according to whether the cavity is empty or is filled by secretion. A distinctive form of breath- ing heard over cavities consists of a respiratory murmur, beginning as vesicular and suddenly breaking into bron- chial. Gurgles and churning sounds are heard over most cavities, but there are exceptions in which the cavities are dry. It should never be forgotten that the signs of a cavity may be simulated exactly by a patch of consolidation over a large bronchus, so that the diagnosis of a cavity should always be made with extreme caution. Complications. — There may be pleurisy with effusion or empyema. Perforation of the pleura over a softening tuber- cular nodule results in pneumothorax or of pyo-pneumo- thorax. There may be tubercular inflammation of other organs, especially meningitis, tubercular laryngitis, and ulcerations of the intestine. The kidneys may be tuber- cular or may be the seat of amyloid change. Chronic diffuse nephritis may develop. The liver may be waxy, fatty, or the seat of tubercular deposits. Tubercular peri- tonitis may be present, or septic peritonitis may result from the rupture of tubercular intestinal ulcerations. Phthisis at any time may be complicated by pulmonary tuberculosis or by acute general miliary tuberculosis. Lobar pneumonia is not uncommon as a terminal event. There may be developed in phthisical patients a form of insanity resembling that occurring during the convalescence from acute diseases. Peripheral neuritis is occasionally observed. The prognosis is grave, but not hopeless. Favorable results are common in early cases properly treated by change of climate, while spontaneous cures are not infrequent, even under unfavorable hygienic surroundings. The prognosis is dependent upon the constitutional vigor and the finan- cial condition of the patient, and the rapidity of growth and the extent of the lesions. Repeated haemoptyses are unfavorable. 356 MA.VUAL OF THE PRACTICE OF MEDICINE. Treatment of Tubercvilosis in General. TheVe arc three indications for treatment: (i) To prevent tlie spread of the disease ; (2) to arrest the disease ; and (3) to reheve symptoms. 1. PropJiylactic Treat incut. — {a) For the Goural Public. — The sputa of all tubercular cases should be collected and destroyed. The patient should be warned not to spit about the house or in the street. Portable spit-cups are invented for the collection of the sputa ; or handkerchiefs may be used for the purpose if they are thoroughly boiled, after use, in a receptacle separate from that for the other clothes. A phthisical patient should sleep alone, and separate state- rooms on steamships should be provided for tubercular cases. Rooms infected by tubercular sputa should be disinfected thoroughly before they are again occupied. There should be governmental inspection of dairies and slaughter-houses, and tuberculosis in animals should be stamped out by killing the infected animals. Patients with tuberculosis should not marry. In women with a suspected tubercular tendency the risk of develop- ing the disease is largely increased b\' childbearing. [b) For the Individual. — A child born of tuberculous parents should receive careful prophylactic treatment. The mother of a tuberculous child should not nurse it nor sleep in the same room with it. The child should enjoy the recreations of an outdoor life, and studious habits, especially in crowded schools, should be sacrificed for athletic pur- suits. Sedentary occupations are undesirable. Nasal ob- struction, enlarged tonsils, and adenoid disease, if present, should receive prompt attention, so as to allow of the fullest extent of breathing. All intercurrent diseases are to receive more than usual attention, and the general health is to be kept at the highest pitch by fresh air, sufficient sleep, proper food, and tonics whenever they may be required. 2. To arrest the disease two things are necessar}- — to keep the general health good, and to prevent complicating inflam- mations. These conditions are complied with by {a) climate, {b) hygiene, {c) diet, and {d) drugs. TUBERCULAR DISEASES OE THE LUNG. 357 {a) Suitable change of climate affords the best chance for permanent recovery. Usually, however, the change is in- sisted on too late, and hopeless, even dying, patients are sent on long journeys away from friends and home com- forts. There is no one climate suitable for all tuberculous patients, and in the selection of a climate good judgment and common sense must be employed. Generally speak- ing, the requirements are a pure atmosphere, an equable temperature, and a maximum of temperature. As to the exact choice, much depends upon the patient. Young and robust patients with early lesions do best usually in a cold, bracing climate, where they can lead an active outdoor life and become strong and muscular. Such cases do well in the Adirondacks or in Colorado. Those who are unable to take physical exercise by reason of age, sex, or advanced pulmonary lesions do best in a warm, dry, equable climate, where they can sit outdoors and keep from catching cold without being obliged to exercise. Such a climate is to be found in Southern California, North and South Carolina, Georgia, Florida, Mexico, Egypt, and Algeria. The more unable such patients are to exercise, the warmer the climate they seem to need. Some patients are rendered worse in the cool climates and are debilitated by warm air. Such patients should travel from place to place until they find a climate in which they improve in one or two weeks. Other patients seem to do best by a variety of climates, and they improve by continually travelling. {J}) Hygiene. — Tubercular cases require a maximum of fresh air and sunshine. The sleeping-room should be airy and sunny. Exercise in the open air should be graded to the strength of each patient, much harm being done by con- scientious exercise past the point of moderate fatigue. The skin should be kept open by skin-frictions and daily baths. The patient should avoid exposure to inclement weather, but over-coddling weakens him and increases his liability to catch cold. The patient should wear flannels through- out the year, but should not be over-clothed, as the danger of catching cold is thereby increased. {c) The diet should be simple, wholesome, and abundant. 35^ J/.7.\r.//. OF THE PKACTICE OF MEDICIXE. The rule is that tubcrcuhii' cases should be over-fed. In addition to the ordinary diet, as much milk and cream as possible should be taken, and all dyspeptic s)-mptoms should receive proper attention. If milk and cream are not well borne, cod-liver oil should be given in as large doses as the patient will tolerate. Superalimentation by the stomach-tube is often of great benefit. Alcohol with meals may be allowed if it agrees. {d) Drugs. — A large number of specifics are lauded every year, but each one fails in fulfilling expectations. There is no specific treatment. A glycerin extract of the culture of the tubercle bacilli was first used by Koch, and it was found to exert a specific effect on tubercular inflammations. Injec- tions of one milligram were followed by intense constitu- tional and local reaction, and cures of external tuberculosis, such as lupus, were recorded. In internal tuberculosis, however, old quiescent lesions were stirred into activity, and acute miliary tuberculosis often developed from a local lesion. Various modifications of Koch's lymph have been used, but they should be used with extreme caution. At present the feeling among the profession is strongly against the use of the lymph, but modifications and improvements may in the future place it among the standard list of specific drugs. Creosote, which has been gaining steadily in favor, is one of the best remedies in use. It may be given in 4-minim doses at first, gradually increased to 10 or 15 minims three times a day. It may be given with compound tincture of gentian or with glycerin and whiskey, and it should be diluted largely with water at the time of its administration, or it may be given in capsules. Only the pure beechwood creosote should be prescribed. The " enteric pill " of Parke, Davis & Co. contains creosote ; it is not dissolved until it reaches the small intestine. The patient may wear continuously a perforated zinc inhaler (Robinson's) kept moistened with equal parts of alcohol, chloroform, and creosote. Creosote may also be given by the rectum, from 5 to 20 drops being mixed with the white of one o.^^ and water and given every day. Guaiacol or the carbonate of TUBERCULAR DISEASES OF 'J'JIE JJJNG. 359 creosote may be used in substitution. Iron, strychnine, and arsenic are useful tonics in combination, to combat the anaemia and to build up the general strength. The hypo- phosphites are useful tonics, but they have no specific action. Injections of antiseptics into the diseased pulmonary tissues have been advocated warmly ; they are not com- monly employed, however, as bad results have occasionally followed their use. In some cases the inhalation of compressed air has been of great service. 3. To Relieve Symptoms. — Fever, as a rule, is best treated by change of climate and by fresh air. When the tempera- ture is high, however, patients should not atteTnpt much exercise, and frequently they do better when put to bed for a few days. Sponging with cool water relieves the fever- ishness and makes the patient comfortable, but other more radical measures are to be used with extreme caution. For the sweating, aromatic sulphuric acid is the best and the simplest remedy. Sponging the body with vinegar and water upon retiring is frequently effective. Zinc oxide, gr. ij, with ext. hyoscyami, gr. iij, in pill is a favorite combina- tion, while atropine in doses of gr. -^^ at night is fairly steady in its effects. Picrotoxin (gr. -g^) may be used, but with extreme caution. Strychnine is often of use. Cough, if not too troublesome, is best left alone. If it be dry or harassing, opium or codeine may be given at night to secure sleep. Hydrocyanic acid, belladonna, and the expectorants, in combination with codeine, often relieve this troublesome symptom, but care should be taken that the stomach be not disturbed by nauseant remedies. If the cough be accom- panied with profuse expectoration, the expectorants are not indicated, but reliance should be placed upon creosote, tur- pentine and its derivatives, and the mineral acids. Pain in the chest is to be treated by counter-irritation. For the treatment of haemoptysis see Pulmonary Hem- orrhage. Diarrhoea should be treated on general principles, but opium in some form has almost always to be used. 3C0 M.LVr.lL OF THE PRACTICE OF MEDICEXE. 4. DISEASES OF THE PLEURA. FIBRINOUS OR DRY PLEURISY; PLASTIC PLEURISY. Etiology. — Tliis form of pleurisy may be primary or sec- ondar}^ The primary form ma\- appear to be due to expos- ure to wet and cold, but modern theories regard cold merely as a predisposing factor to bacterial infection. The second- ary form complicates any acute or chronic pulmonary disease involving the periphery of the lung. Thus, pleurisy occurs in conjunction with pneumonia with abscess, gangrene, or cancer of the lung, and with hemorrhagic infarctions. Occurring with pulmonary tuberculosis and phthisis, it ma}' be the earliest indication of tubercular disease, and many cases of so-called "primary pleurisy" owe their origin to a small undisco\"ered tubercular lesion in the lung that may finally develop and give rise to symptoms. Pleurisy may be secondary to inflammation of organs other than the lungs. Thus, pleurisy may arise from caries of the ribs or of the vertebrae, from perforation of an oeso- phageal cancer, from tubercular disease of the bronchial glands, from pericarditis, or from peritonitis. Cases follow- ing erysipelas of the chest-wall are not infrequent. Patients with gout and with Bright's disease are more subject to pleurisy than are others. A pleurisy develops during the course of acute rheumatism, the pleura being involved, as are other fibro-serous membranes, as one of the regular manifestations of the disease. The belief is gaining ground that pleurisy, after all, results from the action of various micro-organisms, the most common of which are the streptococcus pyogenes, the pneumococcus, and the bacillus tuberculosis. Probably there are man)' other micro- organisms capable of causing the disease, and further bac- terial examinations are desirable to enable cases of pleurisy to be grouped according to their microbic cause. Pathology. — The pleura becomes congested, dr\', and loses its normal lustre. P'ibrin and serum infiltrate the thickness FUiR/NOUS OK DRV I'LEUKISY. 361 of the pleura and make their way to the free surface, so that the pleura is coated with a layer of lymph of variable thick- ness. The exudate may be shaggy in appearance or may be thick and stratified. Microscopicall}^, the fibrinous exu- date consists of fibrin, leucocytes, red blood-cells, and serum. The serum, however, is but slight in amount and undergoes rapid absorption. Subsequently the exudate becomes absorbed or becomes organized into connective tissue, so that the pleura is thickened and adherent to the opposing pleural surface. Dry pleurisy usually begins in the pulmonary pleura and is limited to a small area. The opposing pleural surface usually is involved secondarily. Symptoms, — The symptoms of secondary pleurisy are often masked by those of the primary disease. Pain in the side and the friction rale are the only characteristic symptoms. In primary cases the attack may begin with a chill and with fever rarely over 102*^ F. The pain, which is sticking or stabbing in character, is referred to the site of the pleu- risy. The pain is rendered worse by deep breathing or by coughing. There may be tenderness in the intercostal spaces over the lesion. The breathing is rapid and shallow, and there may be a dry, painful cough which is of reflex origin. In mild cases a stitch in the side on deep breathing may be the only symptom. Physical Signs. — The characteristic physical sign of dry pleurisy is the pleural friction sound, which may be crepi- tant or subcrepitant or which may resemble a moist mucous rale. The crepitant rale is a fine dry crackle or shower of crackles heard at the end of inspiration only ; it arises only in the pleura. A subcrepitant rale is a fine, moist, sticky sound, heard with inspiration, with expiration, or with both. Mucoid rales may arise from the rubbing together of surfaces covered with very moist lymph ; they may ex- actly simulate the bronchial rales. The differential diagnosis between pleural and bronchial rales is as follows : ?62 j/.i.vr.iL OF THE pkact/ce of medicine. Pleuritic Rahs. I. May be of the crepitant variety. ?. Sound superficial, tiirectly umler the ear. 3. Fairly constant. 4. Not influenced by coughing. 5. Over local area, which does not alter its position. 6. AH of one variety. Bronchial RRles. 1. Never the crepitant variety. 2. Sound " deep in." 3. Very inconstant. 4. Influenced by coughing. 5. May be over large areas or in shifting areas. 6. Usually assorted rales of all kinds. The occurrence and diagnosis of the pleuro-pericardial friction sound has been described under Pericarditis (p. 173). The absence of pleuritic rales does not necessarily ex- clude pleurisy, as the rales may come and go, may only appear on deep breathing, and may, moreover, arise at areas which are deeply seated, as in diaphragmatic or mediastinal pleurisy. The duration of the disease is from three to ten days. The prognosis of the attack itself is good, but a broader view must be taken than that of mere temporary recovery. The cause and the significance of the pleurisy and the sequelje that may result from a thickened and adherent pleura must be considered. Treatment. — During the attack the patient should be kept quiet, but need not necessarily be confined to the bed, or even to the house, unless the symptoms be severe. Counter-irritation by cupping, by iodine, or by blisters often diminishes the pain and checks the spread of the inflamma- tion. Hot poultices are not so efficient as ice-bags applied locally. In all cases a brisk purgative should be given at the start, preferably calomel or magnesium sulphate. For the pain morphine may be given, and the chest may be strapped with adhesive plaster as for fractured rib, to dimin- ish the friction between the inflamed pleural surfaces. In rheumatic cases salicylic acid or its derivatives should be given in full doses, as for acute articular rheumatism. PLEURISY ^WITH EFFUSION. Etiology and Synonym. — The etiology of sero-fibrinous pleurisy is the same as that of the plastic form. The former seems, however, to be due to a severer form of bacterial infec- PLEURISY IVI'J'II EFFUSION. 363 tion. Pulmonary tubercular disease follows, in time, one- third of the so-called " primary " cases. Synonym : Sero- fibrinous pleurisy. The pathology of the sero-fibrinous is the same as that of the plastic form, except that there is added an excessive exudation of serum; moreover, the inflammation involves a larger area than in dry pleurisy. The exuded fluid is of a composition resembling that of blood-serum ; its color is citron-yellow, and it may be clear, or somewhat turbid from flocculi of fibrin or from leucocytes and desquamated cells from the pleural surface. Blood may be present from rup- ture of fine blood-vessels or in the case of cachectic and debilitated subjects. The amount of the exudation varies greatly. An amount under 300 cubic centimeters does not give rise to physical signs in an adult. From one to two pints is the usual quantity, but eight to ten pints may be exuded. The exudation sinks to the dependent portions of the pleural sac unless encapsulated by previously existing adhesions — a somewhat rare occurrence in sero-fibrinous pleurisy. The fluid in the pleural sac rarely changes its level with any change in the position of the patient, being practically encapsulated by fibrinous adhesions between the lung above and the costal pleura. The upper level does not follow the ordinary laws of water-level, but follows a curve to which the name of " Garland's S-curve " is given. Mechanical EflFects of the EflEusion. — The lung floats upward, its base resting on the fluid. As the fluid takes the place of the lung in the pleural vacuum, the lung is free to shrink, from its own elastic retraction, until the pleural sac is two-thirds full of fluid ; when this point is reached the lung is in a condition of elastic equilibrium. Any excess of fluid over this amount exerts a direct pressure on the lung, so that in extensive effusions the lung is compressed, form- ing a dense, airless, carnified mass at the dome of the pleu- ral cavity. The heart is bodily displaced to the opposite side, but it undergoes no twisting upon its axis, so that kinks in the great vessels do not occur. The diaphragm is sagged downward, and in right-sided pleurisy the liver is depressed. The intercostal spaces bulge, especially in 364 M.-LVCAL OF TIJK PRACTICE OF MKDICI.XF. children, and the affected side measures from one-half to one inch more than the other side. The symptoms are iiijfaniiiiatory and viccliaiiical. 1. InJJaiiiDiatory syviptoDis may occur acuteh- or sub- acutely. If the onset be sudden, there may be a chill, which, however, is never so severe as in pneumonia. The temperature rises to from 101° to 103° F., attains its maxi- mum on about the third day, and slowly subsides, reaching the normal in from seven to ten days. The temperature is fairly continuous, not remittent as in empyema, and there is no definite crisis. Persistence of the fever after two weeks, or a temperature higher than 104° F. at any time, suggests Qmpyema or tuberculosis. Prostration is in proportion to the severity of the inflammation and the fever. The pulse is rapid and compressible. Pain is marked at the onset, but it becomes less marked as the effusion is poured out, sep- arating the opposing inflamed pleural surfaces. There may be a reflex cough with a scanty mucous expectoration. If the onset be insidious, the inflammatory symptoms are less marked. The chill is absent, the fever is rarely over ioi° or 102° Y., and prostration is so slight that the patient is up and frequently is able to work. 2. Mechanical symptoms depend upon the amount of the effusion and upon the rapidity with which it is poured out. Dyspnoea results from the pleuritic pain and from the diminished expansion of the lung. It may be present only on exertion, or it may be so extreme as to be most distress- ing. The more rapidly the effusion is poured out, the more marked is the dyspnoea. The position of the patient in bed is often suggestive. Before the effusion is poured out he lies upon the sound side, so as not to press the inflamed pleural surfaces together by his weight. After the effusion occurs he lies upon the affected side, so that the weight of the fluid will not embar- rass the action of the heart or of the sound lung. Cyanosis is likel)' to occur in cases with large effusions, and the heart's action may be weak and irregular. The physical signs may be described as occurring before PLEURISY WITH EFFUSION. 365 effusion, during the effusion, and after absorption of the effusion. Before the effusion the friction rales of dry pleurisy are present, expansion is limited, and the percussion-note may be slightly dull. During the Effusion. — There is an important distinction to be made between the physical signs of moderate and those of excessive exudation. I. The signs of moderate effusion begin to appear when the exudation reaches ten or twelve ounces in adults or three or* four ounces in children. {a) Beloiv the level of the fluid there should be diminished expansion, slight bulging of the intercostal spaces, espe- cially in children, and an in- creased girth of the affected side. The percussion-note is flat, the upper limit of flat- ness describing " Garland's S-curve." This curve begins low in the back, rises to its highest point in the axilla, and then sinks with a slight descent to the sternum. The upper line of flatness is rarely influenced by a changed position of the patient. In left- sided pleurisy flatness replaces the normal tympany of Traube's semilunar space. Below the line of the fluid the voice and the breathing are muffied and even lost, and vocal fremitus should be absent. It is claimed that the whispered voice may be transmitted through serous, but not through purulent, effusions (Baccelli's sign). Exceptionally, below the level, voice and breathing may persist, though distant and indistinct ; pleuritic rales may be heard through adhesions persisting below the level. In children soft bronchial voice and breathing may be heard, even if there be no compression of the lung. In some cases, especially in aged subjects, the percussion- note may be dull or dull-tympanitic below the fluid. Vocal fremitus may persist below the level, from adhesions extend- FiG. 41. — Garland's S-curve. 366 MAXLAL OF THE PRACTICE OF MEDICIXE. ing downward through the cfTusion, or the fremitus may be transmitted alont; the cliest-wall from tlie lung above or from the opposite side. (/;) At the level of the flind there should be dulness and pleuritic rales. Exceptionally, a bleating of the voice (cegophony) is heard, being elicited by having the patient pronounce the words " want " or " plant." CEgophony, however, is a sign of rare occurrence. Pleural rales may be absent at the line of fluid. {c) Above the level of the fluid, in moderate effusions, the physical signs maj^ be normal, or there may be a tympanitic percussion-note WMth feeble breathing. Tympany in these cases is due to relaxation of the lung-tissue ; it is most marked under the clavicle, constituting " Skoda's sign." In some cases in children the note under the clavicle may even be of the " cracked-pot " order, and may lead to the erro- neous diagnosis of a cavity, especially as cavernous breathing may be heard, by reason of a large bronchus approaching the chest-wall owing to the retraction of the lung. Both bronchial and pleural rales are often heard over the retracted lung. (- the trans- udation, and no relief follows medicinal measures, repeated aspirations are to be resorted to. HEMOTHORAX. Etiology. — Hemorrhage into the pleural cavity may occur from rupture of an aneurysm, from erosion of an intrathoracic vessel, or from injuries resulting in fractures of the rib or in laceration of the lung. L YMPIIADENITIS. 383 Patholog-y. — The blood may coagulate and be absorbed if not too excessive in amount. If infection occurs, there may be pleurisy with effusion or empyema. The symptoms are those of hemorrhage — pallor, dysp- noea, thready pulse, sighing respirations, and restlessness, associated with pleuritic pain and dyspnoea. Symptoms of pleurisy with effusion or of empyema may develop in in- fected cases. The physical signs are those of pleural effusion. The friction rale is, however, absent. Prognosis. — A large haemothorax, such as arises from rupture of an aneurysm, is rapidly fatal. Small hemorrhages, especially those due to injury, may terminate in absorption and recovery. The treatment is that of acute anaemia — by transfusion, warmth to the extremities, and small doses of opium. A small haemothorax is best left alone. If the clot be infected or be large enough to interfere with respiration, it may be evacuated by incision. 5. DISEASES OF THE MEDIASTINUM. LYMPHADENITIS. Simple lymphadenitis follows inflammations of the lungs or the bronchi, especially in children. More rarely the con- dition arises in the course of some infectious diseases, espe- cially typhoid fever and diphtheria. The lesion consists of swelling and congestion of the gland, resulting either in resolution or in enlargement. Suppuration rarely occurs. Not infrequently the glands become secondarily infected by the tubercle bacilli. The adhesion of an enlarged gland to the oesophagus may result in a traction-diverticulum. The symptoms are rarely ob.served. In some cases bron- chitis with paroxysmal cough results from congestion and irritation of the neighboring structures. Suppurative lymphadenitis may follow simple or tuber- 384 MAXLAL OJ-' rilE PRACTICE OF MEDJCJXE. cular inflaniniation of tlic glands. The pus may finally be inspissated, infiltrated with lime -salts, and encapsulated, or it may rupture into- the bronchi or the oesophagus. Tubercular lymphadenitis regularl)^ accompanies tuber- cular lesions in the lung. In other cases the glands filter- ing out the impurities gaining entrance to the lungs may primarily be infected. The tubercular glands may attain a large size and may cause the pressure-symptoms of a medi- astinal tumor. The caseous masses may become inspis- sated and encapsulated, or the\- ma}- rupture into neighbor- ing organs. The lungs, the pleura, or the pericardium may be involved secondarily by extension. General tuberculous infection so commonly results, especially in children, that search should be made for tubercular glands of the medias- tinum in every case of acute miliary tuberculosis of obscure origin. MEDIASTINAL TUMORS. Of 520 cases of mediastinal tumor reported by Hare, cancer occurred in 134, sarcoma in 98, and lymphoma in 21. Less frequently are found dermoid and hydatid cysts, fibroma, lipoma, gumma, and enchondroma. Growths formed by the aggregation of tubercular glands and aneur- ysms have previously been described. Cancer may be primary or secondary. Sarcoma is more apt than cancer to be primary, men are more frequently affected than women, and the majority of cases occur between the twenty-fifth and fortieth years. The symptoms are due to increasing intrathoracic pres- sure. Dyspnoea is the most marked symptom ; it is due to pressure on the trachea, the recurrent laryngeal nerve, the lungs, or the bronchi. In the latter stages of the disease orthopncea is usually developed. Cough may be parox- ysmal, resembling that of whooping-cough, or there may be a brassy cough as with aneurysm. Pressure on the thoracic duct occasions rapid emaciation. Dysphagia occurs if the oesophagus be compressed. Compression of the thoracic veins results in cyanosis of the chest, the arms, the head, and the neck, and in extraordinary attempts to establish Qidema of the head and the upper extremities with sarcoma of the mediastinum. MEDIASTINAL TUMORS. 385 collateral circulation. Congestion and oedema of the lung may be occasioned by pressure on the pulmonary vein. Pleural effusion is apt to appear either by an involvement of the pleura by the new growth or from pressure of the tumor on the vena azygos or on one of the intercostal veins. Pain is not as common with tumor as with aneurysm. Physical Signs. — There is evident dyspnoea. Some valuable aid in localizing mediastinal new growths is afforded by noticing what position of the patient best re- lieves the pressure-symptoms and modifies the dyspnoea. There may be blueness of the upper part of the body and arms, while the enlarged thoracic and anastomosing abdom- inal veins stand forth prominent and distended. According to Osier, the distention and enlargement of the thoracic veins are more marked with lymphadenoma than with cancer or with sarcoma. The sternum or the intercostal spaces on either side may be bulged forward or may be involved by the growth. A transmitted expansion frequently suggests aneurysm, but it is not so marked, there is no lateral expan- sion, and there is no diastolic shock. The tracheal tug is seldom if ever obtained, and over the tumor no murmur is detected, as in the latter disease. Dulness is elicited by percussion over the growth, either over the upper sternum or between the spinal column and the scapula in case of involvement of the posterior mediastinum. The breathing on either side may be feeble from bronchial compression or may assume a tubular character. The physical signs are modified by the signs of pleural effusion or of cancer of the lung or the pericardium. Diagnosis. — Many points of differential diagnosis from aneurysm of the aorta have already been alluded to. In many cases a positive diagnosis cannot be given, although, should the patient live over eighteen months, a malignant mediastinal growth may probably be excluded. The prognosis depends upon the nature of the growth. Treatment. — In cases of lymphoma the administration of arsenic is often followed by a diminution of the growth. For radical cure surgical treatment alone can avail, but as this is rarely possible, the medicinal treatment is merely 25 86 .V.l.VC.I/. OF rilE rRACTICE OF MEDICIXE. palliatix'c. to quiet the pain and to relieve the dj'spnoia. Opium may be given without conscientious dread of form- ing a habit. ABSCESS OF THE MEDIASTINUM. This affection is usually of traumatic origin ; it may, how- ever, be secondar\- to infectious fevers, to pytemia, to ery- sipelas, or to suppurative disease of the adjacent viscera. Chronic abscesses are usual!}' of tubercular origin. The abscess, which is usually situated in the anterior medias- tinum, is more common in males than in females. The pus may finally become inspissated and encapsulated, or it may rupture through the sternum, through an intercostal space, or into the oesophagus or the trachea, or it may burrow into the abdominal cavity. The symptoms are those of abscess and pressure. Pain is marked from the start, is of a throbbing character, and is associated with exquisite tenderness. Irregular fever, chills, and sweating mark the presence of pus. Cough, dysphagia, and dyspnoea occur as pressure-symptoms. The prognosis must be guarded, owing to the possible complications. Treatment. — In the earlier stages the ice-bag or the cold Leiter coil should be employed continuously. When pus has formed it may be evacuated by trephining the sternum. EMPHYSEMA OF THE MEDIASTINUM. This condition is met with in trauma, follows the oper- ation of tracheotomy, and may result from rupture of the peripheral air-vesicles of the lung during violent cough- ing or straining. Air may enter the cellular tissue of the mediastinum by perforation of ulcers of the trachea, the bronchi, or the oesophagus. The emphysema may be limited to the mediastinum, may rupture into the pleura, causing pneumothorax, or may spread to the neck and even to the entire body. The treatment is entirely symptomatic. DISEASES OE 7V/E I'/fYMUS GLAND. 387 MEDIASTINAL HEMATOMA. Hemorrhage into the mediastinal tissues occurs in hemor- rhagic conditions, from erosion or rupture of blood-vessels or from rupture of an aneurysm. The symptoms are those of hemorrhage and mediastinal pressure, while ecchymoses may appear after a few days in the lumbar region, DISEASES OF THE THYMUS GLAND. Hypertrophy is occasionally met with in children ; it may cause spasm of the glottis (thymic asthma) or sudden death. Abscess may develop in syphilitic children. Sarcoma and carcinoma may originate in the thymus gland and may give the regular symptoms of tumor in the mediastinum. The gland may be enlarged during the course of leukaemia or of Hodgkin's disease. Hemorrhages in the gland-tissue are not uncommon dur- ing scurvy and purpura haemorrhagica. IV. DISEASES OF THE DIGESTIVE SYSTEM. i, DISEASES OF THE OESOPHAGUS. ACUTE CESOPHAGITIS. Etiology. — The oesophagus may be inflamed — (i) by the spread of inflammation from the phar\-nx or the stomach ; (2) by mechanical or chemical irritants or corro- sives ; (3) by pseudo-membranous inflammation secondary to diphtheria or to some acute infections ; (4) by the pus- tules of variola; (5) in rare cases oesophagitis may develop in sucklings without known cause. Lesions. — The inflammation may be diffuse or localized, and either catarrhal, pseudo-membranous, or phlegmonous. The pustules of variola result in ulcerations. There may be a mycotic inflammation secondary to thrush and resem- bling it in its pathological features. The swallowing of cor- rosives is followed by sloughing and ulceration. Symptoms. — Pain on swallowing is a nearly constant symptom, and a continuous substernal ache is frequently observed. Food may be regurgitated ; if coated with blood or with pus, ulceration is indicated. In cases of caustic poisoning the lips, the mouth, and the pharynx exhibit evidences of corrosion, and the symptoms of toxic ga.stritis are present, usually with some associated shock. Rupture of the oesophagus may occur. Patients recovering from the acute symptoms ultimately develop oesophageal stenosis. Some cases of acute oesophagitis, even if severe, occa- sion but a trifling amount of discomfort. The treatment of acute oesophagitis consists in the administration of the proper antidote in case of corrosive mineral poisons. Demulcent drinks and cracked ice are of service in diminishing the pain and the inflammation. 388 STENOSIS OF rilE (T^SOP/MGUS. 389 The nourishment should be bland and unirritating. Fluids alone should be given during the acute stages, while in severe cases rectal alimentation should be insisted upon. CHRONIC CESOPHAGITIS. A chronic catarrhal inflammation of the mucous mem- brane lining the oesophagus is produced by improper and irritating food and by the presence of tumors or stricture of the oesophagus itself; or the chronic form may result from an acute attack. The symptoms consist chiefly in the raising of mucus- coated regurgitated or vomited food. The treatment is that of the underlying cause. STENOSIS OP THE CESOPHAGUS. Synonym. — Stricture of the oesophagus. Stenosis may result — (i) From compression from without by tumor of the neck or the mediastinum, by aneurysm, by re- tropharyngeal abscess, or by a large pressure-diverticulum. (2) From obstruction of the lumen by foreign bodies, and rarely by tumors and polypi. (3) From contraction of the ivall. {a) There may be cicatricial contraction following the healing of ulcers due either to corrosive poisons or to diphtheria, small-pox, or, more rarely, to syphilis or to tubercular dis- ease. A rare form of ulceration, the " round ulcer," is seen at the lower end of the oesophagus. This ulcer is produced by self-digestion by regurgitated gastric juice, after the man- ner in which ulcer of the stomach is caused, (f) There may be malignant groiuth of the wall, usually epithelioma. (c) There may be spasmodic contraction or {d) congenital narrowing at some part. Symptoms. — In all cases of stenosis of the oesophagus these cardinal symptoms are present — difficulty in swallow- ing, pain, and the regurgitation of food. The cases may, however, conveniently be described in three groups. Cicatricial Stenosis. The stricture may occur at any part of the oesophagus, but it is most frequent in the lower third. The whole 390 M.tXr.lL OF THE PKACTICE OF MEDICLXF. length may be involved. The stenosis may reach such a degree that liquids can barely trickle through. The CESophagus above the stricture is usual!)' much dilated, and its walls are thickened. After the histor\' of antecedent ulceration the patient complains of increasing difficult)- in swallowing, the food being cut finer and finer and washed down with water. In severe cases liquids alone are taken. The food seems to stick, and after a time it is regurgitated. The lower down the stricture is, and the more dilated the oesophagus above it, the longer the time after eating before regurgitation occurs. The ejected food may be macerated and mixed with mucus, but that it has not reached the stomach is proved by the absence of gastric odor and by the alkaline reaction of the food. The latter test, however, is not infal- lible if the food be retained some hours before being regur- gitated, because of the formation of fatty acids in it. Pain is not a marked feature except at the time of swallowing the first bolus. ■ • The diagnosis is made by the passage of the oesophageal bougie. A conical bougie on an elastic whalebone stem should be employed, but the soft-rubber stomach-tube may be used. It is of the utmost importance, before passing the bougie, to exclude aortic aneurysm producing stenosis by compression, because of the danger of causing rupture of the aneurysmal sac. The tube should never be passed when ulceration of the cesophagus from any cause is sus- pected. Auscultation is frequently serviceable in cases where the bougie cannot be employed. The auscultator, listening to the left of the dorsal spine while the patient swallows a mouthful of water, hears a loud splashing, gurg- ling sound at the site of the stricture, below which the sound is absent or only slightly audible after a pause. The prognosis depends upon the degree of stenosis and upon its dilatabilit)'. In advanced grades death may ensue from inanition or from rupture of the dilated oesophagus above the stricture ; or, should the regurgitated food enter the larynx, suffocation or aspiration-pneumonia may result. Treatment. — Gradual dilatation by the persistent use of STENOSIS OP' THE (ESOTI/AGUS. 39 1 the oesophageal bougie should be employed, and in many- cases the results are remarkably good. The diet should be compact and nourishing, and rectal alimentation may be resorted to. In advanced cases the stricture may be cut, or an opening may be made into the oesophagus below the stricture (cesophagostomy), or into the stomach (gastrostomy). Cancerous Stricture. This form of oesophageal stricture is usually primary. Epithelioma is most common; scirrhus and encephaloid are rare. The growth usually occurs in the lower third, next in frequency in the upper third, of the oesophagus. Be- ginning in the mucous membrane, it extends to form an annular constriction, usually involving one or two inches of the tube. Ulceration of the growth may occur, so that the stenosis becomes less marked, but the ulceration may extend and perforate the lung, the trachea, a bronchus, the mediastinum, the aorta, or the pericardium. Erosion of the vertebrae may occur. Secondary growths in adjacent lymphatic glands are common. The oesophagus above the cancer is usually dilated, and its walls are thickened. ♦Epithelioma is seen in patients over forty years of age; it is more common in men than in women. The symptoms resemble those of the cicatricial group in their essential features. Dysphagia is progressive, and it becomes so extreme that emaciation and inanition rapidly result. The regurgitated food frequently contains blood and pus in small quantities, and it may contain cancer-cells and fragments. Pain is a marked feature, being aggravated by attempts at swallowing. The cervical lymph-glands are enlarged, and symptoms of cancerous cachexia are present. The oesophageal bougie must be used with extreme caution to avoid penetrating the ulcerated wall, as such an accident has not infrequently occurred. The soft-rubber tube is generally preferable in these cases. The diag-nosis is made positive by the finding of cancer- fragments in the eye of the tube. In cases of ulceration of the epithelioma in which no real degree of stenosis longer 39- MAXi'AL OF THE PKACTJCE OF MFDKFXE. persists, the tube may pass witliout difficulty. In these cases, however, d)-sphay,"ia and regurgitation of food may be nearly as marked as if there were an actual narrowing of the lumen ; these symptoms are to be explained on the theory that downward peristalsis is checked at the site of the growth, and that a reversed peristalsis results in regur- gitation. The prognosis is hopeless. Patients usually die, from inanition, perforation, or aspiration-pneumonia, about one }'ear after the s}-mptoms begin to be noticed. The treatment consists in the proper feeding of the patient b\- nourishing liquid and concentrated food, by feed- ing through a stomach-tube or by the rectum. Gastrotomy or oesophagotomy offers but little chance even of prolong- ing life. Spasmodic Stenosis (CEsophagismus). This form of oesophageal stenosis occurs chiefl)' in \'oung hysterical women or in those with marked neurotic tenden- cies. It may occur after an attack of choking, or as a nervous affection in those bitten by dogs and in dread of hydrophobia. It may occur from reflex causes, such as pregnancy, and it often complicates organic lesions of the oesophagus itself The lesion consists of spasm of the oesophageal wall, usually at either the pharyngeal or the cardiac extremit)-. In the former case it is often associated with spasm of the pharyngeal muscles. The symptoms consist of inability to swallow, regurgi- tation of food, and a sense of substernal pain or constriction. The dysphagia comes on abruptly and is not progressive — two characteristics which distinguish the spasmodic from the other forms of stenosis. There are, moreover, periods of marked improvement; or the dysphagia may be only for certain articles of food, varying in individual cases. The inability to swallow is never so extreme as to endanger the life of the patient by inanition, although the disease may last for days, weeks, or even for months. Intermissions, however, usually mark the protracted cases. Associated DILATATIONS AND DIVEA'IICULA. 393 hysterical or hypochondriacal symptoms are usually pres- ent, rendering the diagnosis the more evident. The prog-nosis is perfectly good. The treatment consists in passing the oesophageal bougie. Difficulty may be encountered by reason of the spasm, but patience and gentleness will usually succeed in accomplish- ing its passage. Often a brilliant cure follows the first treat- ment, but in obstinate cases a daily passage of the bougie may be needed, usually before the principal meal, to restore the confidence of the patient. Sedatives, such as valerian, the bromides, and phenacetine, may be given, and tonic treatment is indicated in nearly every case. DILATATIONS AND DIVERTICULA. Dilatation may be primary or secondary. Primary dilatation, which is rare, is due to a congenital defect in the muscular tissue of the oesophageal wall or to its paralysis. The oesophagus is enormously dilated and is usually longer than normal. The principal symptom is dysphagia from lack of sufficient peristalsis. Secondary dilatation occurs with stenosis above the point of constriction. The condition is to be suspected if a patient with organic stricture of the oesophagus regurgitate large quantities of macerated food. The retention of such quan- tities of food may cause pressure-symptoms. Diverticula are of two forms : Pressure-divertiadinn. — This form is most common at the posterior wall of the oesophagus, at its junction with the pharynx. From weakness of the muscle at this point a bulging of the mucous and submucous coats takes place, forming a hernial sac, into which food passes. Owing to lack of expulsive power, food collects and becomes macerated, the sac growing larger and larger. The sac may be emptied from time to time by contraction of the muscles of the neck or by external manipulation. It may be large enough, when full, to press forward and occlude the oesophagus. The diagnosis is made by the presence in the neck of a tumor which can be emptied by manipulation, and by alter- 394 M.l.yC'.lL OF TIIK PRACTICE OF MEDICIXE. nately passing;- the bouf^ie dcnvn the tesopliai^us and into the sac. Tra(tion-divcrliculuin. — This form is situated on the ante- rior wall of the cesophai;us, opposite the bifurcation of the trachea. Should the mediastinal glands normally present at this point become inflamed, they will enlarge and may become adherent to the wall of the oesophagus ; b\' the subsequent contraction of the glands the wall is drawn out into a funnel shape, never more than a quarter of an inch in depth. This form gives no symptoms, although in rare cases perforation has been known to occur. PARALYSIS OF THE CESOPHAGUS. This rare condition develops from diseases of the brain and the cord, from hysteria, and occasionally as a post- diphtheritic paralysis. The symptoms consist of difficulty in swallowing. The passage of the bougie reveals, however, no stricture. Paralytic dilatation may subsequently be developed. The treatment consists in nourishing the patient by the stomach-tube, in treating the original cause, and in faradi- zation of the oesophagus. RUPTURE OP THE CESOPHAGUS. This accident may occur during violent and sudden at- tempts at vomiting in healthy people, but it is exceedingly rare, rupture usually being due to the perforation of an oesophageal ulcer or of a foreign body. The condition is fatal within a few days, and treatment is merely symptomatic. VARIX OF THE CESOPHAGUS. Varicose veins may develop in the lower portion of the oesophagus, as an evidence of congestion, of heart disease, or of cirrhosis of the liver. Chronic oesophagitis with vomit- ing of mucus usually results, and rupture of the varicose veins may lead to fatal hemorrhage. ACUTE CATARRIlAf. CAS7A'/'/VS. 395 2. DISEASES OF THE STOMACH, ACUTE CATARRHAL GASTRITIS. Etiology and Synonyms. — Among the causes predis- posing to acute catarrhal gastritis may be enumerated lesions of the heart or of the liver causing chronic conges- tion of the stomach, and any condition of depreciated health or of fever that renders it difficult for the stomach to digest the food properly. Gouty individuals are apt to suffer from gastritis, and personal idiosyncrasy often plays an important role. The exciting cause is usually a dietetic error — over- feeding; eating when too tired to digest properly; food unsuitable for digestion, as hot bread, unripe fruit, or food improperly cooked. Over-indulgence in alcohol is a frequent cause. Severe attacks follow the taking of irritants or of tainted meat or fish, poisoned ice-cream, poor milk, or unripe fruit. Certain articles of diet, varying with each individual, may precipitate an attack. Gastritis is frequently symp- tomatic of an infectious disease or fever. Synonyms: Acute gastric catarrh ; Acute indigestion. Pathology. — The mucous membrane of the stomach is swollen, congested, and covered with tenacious mucus. There may be small submucous hemorrhages or small superficial erosions. The cells of the gastric tubules are swollen and cloudy, and the interglandular tissue may be infiltrated with leucocytes. Hydrochloric acid is usually temporarily absent from the gastric secretion, being replaced by lactic acid and the fatty acids. The most frequent seat of inflammation is near the pylorus, and the inflammation may extend to the duodenum or, especially in children, may involve the entire small intestine. The symptoms are divided clinically into two sets of cases : I. Simple Gastritis {Acute Indigestion^. — The appetite is lost or is diminished except for highly-seasoned food. There are uncomfortable feelings referred to the stomach, in some cases amounting to severe colicky pain. Nausea is frequently complained of, and vomiting usually affords 396 M.lXrAL OF THE PK.tC77CE OF MEDICINE. relief. The vomited matters, which consist of undigested food mixed with mucus and bile, are of an acid reaction from the presence of lactic and fatty acids. The patient complains of headache, depression, and prostration. The tongue is coated and the breath is offensive. The bowels are usually constipated, although diarrluLa ma\- follow the attack. Fever usually is slight, although in some cases the temperature may reach 102° or 104° F. The abdomen is usually somewhat distended and tender in the epigastric region. Herpes, urticaria, or erythema may appear, espe- ciall}' in cases caused by eating shell-fish. In young infants vomiting, fever, and prostration are the principal symptoms. In the symptomatic gastritis of infec- tious disease, vomiting and increased prostration are the prominent symptoms. The vomiting may be so excessive as to interfere with the nourishment of the patient. 2. Gastritis from Ptovidiiic-poisoni)ig. — This form of gas- tritis follows the eating of tainted meat or fish or of ice- cream containing the alkaloidal poison tyrotoxicon. Cases frequently occur in small epidemics among those who have eaten of some particular article of food. The symptoms are those of a severe gastritis, with marked prostration and in- cessant vomiting. In severe cases constitutional symptoms of an alarming nature appear; the pulse becomes rapid, the heart's action feeble, the skin becomes cold and clammy, and the patient is apt to die. Treatment of Gastritis. — The first indication is to rid the stomach of whatever is irritating it. Nature often does this by the vomiting, otherwise a simple emetic is usually indi- cated. The bowels should be opened, castor oil or saline laxatives usually being employed for this purpose, although blue mass or calomel is often beneficial. A natural diarrhoea should not be checked. Should it be excessive and exhaust- ing, a dose of castor oil (.5ss) and tincture of opium (TTL xv) in combination should be given. Tlie diet should be light and easily digestible. These rules suffice for the majority of mild cases. In more severe cases the stomach should have a rest and food should be interdicted for a day, although cracked ice and carbonated waters may be given TOXIC GAS'J-h'/'JfS. 397 freely. When the vomiting is constant, rectal alimentation may be resorted to. Distressing symptoms should be con- trolled by appropriate medication. The vomiting should not be checked until the stomach is empty ; after that bismuth in full doses, bicarbonate of soda, oxalate of cerium, or even small doses of codeia or of morphine, may be given. Pain is best relieved by emesis, by counter-irritation over the stomach, by poultices or mustard pastes, and by the ad- ministration of large doses of bismuth. Codeia or hypo- dermic injections of morphine are to be given only in severe cases. Stimulants may be indicated in the gastritis of ptomaine-poisoning. TOXIC GASTRITIS. This form of gastritis follows the swallowing of concen- trated acids, alkalies, or irritants, frequently taken with suicidal intent, or of certain non-corrosive poisons like phos- phorus, arsenic, and antimony. In the former case the mucous membrane of the mouth, the oesophagus, and the stomach is marked with areas of necrosis surrounded by zones of intense inflammation, while the submucosa is hemorrhagic and infiltrated with serum. In severe cases perforation of the stomach may occur. In the non-corrosive poisons the process consists in fatty degeneration of the glandular elements, small-celled infiltration of the entire glandular connective tissue, and hemorrhage. The symptoms are intense burning pain in the mouth, throat, and stomach, difficulty in swallowing, and constant vomiting, the vomited matters usually containing blood, and frequently containing portions of necrosed mucous mem- brane. The abdomen is distended and exquisitely tender. In very severe cases symptoms of collapse appear ; the pulse is rapid and feeble, the skin is cold and clammy, and there is great prostration, frequently interrupted by restlessness or by convulsive movements. Albumin is usually present in the urine, and there may be hematuria. Perforation of the stomach is followed by death in collapse within a few hours. If the patient recovers there may result stricture 398 m,l\l:il of the rRAcrict of mfdicixe. of the CEsophagus or extensive cicatrices in the stomach, lead- ing to chronic atroph)' and inanition. The. treatment is that of severe gastritis. Emetics should, however, not be given, on account of the danger of causing perforation. Siphonage of the stomach is preferable, a soft- rubber stomach-tube being passed with caution, and the stomach being washed with solutions of the appropriate chemical antidote. Hypodermic injections of morphine are needed to allay the pain and distress. Rectal alimen- tation is usually necessary; it should be resorted to in the severer cases. ACUTE CROUPOUS GASTRITIS. Synonyms. — Diphtheritic gastritis ; Membranous gastritis. Croupous gastritis may occur as a secondary infection with diphtheria, but is more common as a secondar}- pro- cess in pneumonia, t}'phus and t\-phoid fever, pyaemia, puer- peral fever, and Asiatic cholera. The symptoms are those of an intense gastritis together with those of the primary disease. The diagnosis cannot be made during life. The treatment is that of the severer forms of gastritis. ACUTE SUPPURATIVE GASTRITIS. Etiolog-y and Synonyms. — This uncommon disease oc- curs more often in men than in women. It is rare as a primary disease, usually occurring after pyaemia, puerperal fever, or other septic diseases. It may also complicate the course of carcinoma of the stomach. Syno)iy»is : Phlegmonous gas- tritis ; Purulent gastritis. Pathology. — The lesion, which consists in a suppurative process in the submucosa, presents itself in two forms — a diffused purulent infiltration, and a localized abscess ; in the latter case rupture may occur into the stomach or into the peritoneal cavity. The symptoms are those of gastritis and of a severe in- fection. There is severe pain in the stomach, usually with exquisite tenderness in the epigastrium. If the abscess be large, it may be felt externally. Vomiting is persistent and CHRONIC CATARRHAL GASTRITIS. 399 agonizing, and the vomited matters may, in rare instances, contain pus. Jaundice has occurred in a few instances. Peritonitis may occur as a terminal event. The symptoms of general infection are an irregular fever ranging between 102° and 105° F., rapid and feeble pulse, prostration, delirium, and finally coma. The disease may in rare instances run a subacute course, with pain, vomiting, irregular fever, and erratic chills. The diagnosis is made with the utmost difficulty, espe- cially in primary cases. Aid may be afforded if the abscess be large enough to be appreciated by the touch and if vom- iting of a large amount of pus occur. Prognosis is fatal, except in rare cases in which a localized abscess ruptures into the cavity of the stomach or into the colon. The treatment is simply palliative. MYCOTIC AND PARASITIC GASTRITIS. The invasion of the stomach by the bacillus of diphtheria and the pus organisms of phlegmonous gastritis has already been described. A fatal case of the growth of favus has been reported. The tubercle bacillus may involve the gas- tric mucous membrane, while sarcinae and the yeast fungus are frequently found in cases of fermentation and in dilated stomachs, and serve to increase the inflammation. Ascarides, taeniae, earth-worms, maggots, and the larvae of certain dipterae have been found to be the cause of acute gastritis. CHRONIC CATARRHAL GASTRITIS. Synonyms. — Chronic dyspepsia; Chronic gastric catarrh ; Atrophy of the stomach. Etiology. — The causes of chronic gastritis are various and may be classified as follows : Dietetic Causes. — Among these may be enumerated over- eating, over-indulgence in ice-water during meals, rapid eating, irregular meals, improperly cooked and unsuitable food, such as rich fried food, pastries, or hot bread, and the abuse of alcohol, tea, or tobacco. 400 MAXi'AL OF THE PRACTICE OF MEDICINE. Constitittioiiol Oriiscs. — Chronic gastritis may be produced by any debilitating disease which reduces nervous force or deteriorates the blood. The food, not being digested prop- erly, is retained in the stomach, ferments, and sets up a chronic inflammation. In this way the gastritis is often associated with auitmia, chlorosis, tuberculosis, Bright's disease, diabetes, gout, and uterine disease. Local Causes. — The disease may be secondary to lesions of the stomach, such as cancer, ulcer, or dilatation, or it may follow passive congestion of the mucous membrane as in cirrhosis, or in any obstruction to the portal circulation, chronic heart disease, and certain diseases of the lung pro- ducing general venous congestions. Pathology. — Three forms of chronic gastritis are de- scribed — a simple, a sclerosing, and an atrophic. 1. Si III pi i Chronic Gastritis. — The mucous membrane is thickened, grayish, or congested in appearance, and is covered with thick tenacious mucus. The veins are usually congested, and patches of pigmentation from small sub- mucous hemorrhages are common, especially near the pylorus. The membrane frequently has a granular or reticular appearance from irregular growth of connective tissue. The connectix'e tissue and the muscular coats are usually also thickened, especially around the pylorus. The gastric tubules are atrophied, cystic, or deformed, the cells are the seat of a mucoid degeneration, and between the tubules there is an abundant small celled infiltration. In very mild cases the mucous degeneration of the cells of the tubules may constitute the only lesion. In uncomplicated cases there is no increase in the actual size of the stomach. 2. Sclerosing Gastritis (or Sclerotic Gastritis). — In this form the hypertrophic changes of the connective tissue and muscular coats are exceedingly marked, and especially about the pylorus. There maybe a resulting pyloric stenosis with a secondary dilatation of the stomach. There is a rare form in which the walls of the stomach become converted to cirrhotic connective tissue, and is attended by a diminution in the size of the stomach. To this form the term " cirrho- sis ventriculi " or cirrhotic atrophy has been applied. CHRONIC CATARRJIAI. GAS7'A'/77S. 4OI 3. Atrophic Gastritis. — This form may occur as a terminal process of the first variety or may be atrophic from the start. The wall of the stomach is thinned, the mucous membrane is thin, smooth, and hght grayish in color ; its glandular elements undergo fatty degeneration and atrophy. In advanced cases nothing remains of the mucous membrane but a layer of round cells, a few cysts, and fibrous tissue. To this condition the term " achylia gastrica " has been given. Symptoms. — Three clinical forms may be recognized : I. Simple gastritis. 2. Sclerosing gastritis. 3. Atrophic gastritis. I. Simple Gastritis. — Distress or oppression in the stom- ach is a fairly constant symptom. It usually is slight, but in rare cases it amounts to actual pain, never severe enough, however, to cause the patient to vomit, as in gastric ulcer. It usually occurs after eating, but it may be more or less constant, and in some cases is aggravated when the stomach is empty. In other cases the pain consists of a burning feeling under the sternum due to hyperacidity, and may be associated with eructations of a sour acid fluid. There may be tenderness over the stomach, more commonly diffused and rarely severe. The appetite is usually impaired, although some patients complain of unnatural hunger. There maybe appetite only for highly seasoned or peculiar articles of food. Flatulence is not a marked symptom unless gastric atony is present as a complication. Nausea and vomiting are com- monly observed, and are, in large measure, dependent upon the quality and quantity of food. The vomited matters are not abundant, and consist of food in various stages of di- gestion mixed with mucus. Small quantities of blood, either bright red, or darker, from alteration of the blood- pigment, may be vomited from time to time. A special form of vomiting is commonly seen in alcoholic cases, occur- ring in the morning, and consisting of mucus, bile, and saliva that has been swallowed during the night. " Dry retching" in the morning is also common in the alcoholic cases. The tongue is usually heavily coated, and is indented by the teeth. The edges and tip may be red, and in some 402 MAXr.lL OF THE PRACTICE OF MEDICIXE. cases the whole tongue has a " red-beef" appearance. The breath is usuall}- offensive, and a bad taste in the mouth is complained of, especiall)' in the morning. Saliva and the phar\-ngeal secretions are usualh' increased, and the patient may comj^lain of a cough, the " stomach-cough," usual!}' of pharyngeal irritation. Tiic urine may be dimin- ished in quantity, of high specific gravit)', and may deposit uric acid, urates, phosphates, or calcium oxalate. The patient loses flesh and strength in accordance with the gravity of the case ; this symptom is the most reliable means of estimating the true extent of the inflammation. From the passage of undigested food into the intestine an enteritis may result, or a functional disturbance of the liver may be induced, adding its symptoms. Among these symptoms may be cited hot and cold flashes, marked enough to suggest malaria to the patient, headache, dizzi- ness, and an inaptitude for mental and physical work. Marked dizziness, however, does not occur unless there is a complicating atony. The motor power of the stomach is good, fermentation does not ordinarily occur, and vomiting of food eaten some time previously is not a symptom. In many cases classical symptoms are entirely wanting, and the occurrence of a gastric disorder may be known only by gastric analysis. In other cases the symptoms are those of a nervous indigestion. In some cases anaemia and constipation are the only symptoms noted. In other cases the patients complain of intestinal flatulence, constipation, or a tendency to diarrhoea, pressure and pain in the abdomen, and by the test-breakfast a gastritis is found, giving rise to the enteritis from which the symptoms arise. 2. Sclerosing Gastritis. — In this form the symptoms of gastritis are obscured by those of gastric dilatation. The clinical picture is one of pyloric stenosis, and a diag- nosis from carcinoma may be made with difficulty, espe- cially when the thickening about the pylorus is felt as a tumor through the abdominal wall. If lactic acid is present with absence of HCl, a differential diagnosis may be im- possible. Hemorrhage does not, however, occur. In cases of " cirrhotic atrophy " there may be inability of CHRONIC CATARRHAL GASTRIRIS. 4O3 the stomach to hold more than a small amount of nourish- ment at any one time. 3. Atropine Gastritis. — There is entire absence of any digestive power whatever in the stomach. The symptoms are those of severe dyspepsia with failing nutrition. Vomit- ing is a prominent feature, and there may be lancinating pains, not always dependent on food, the clinical picture resembling that of cancer. In other cases a progressive anaemia is developed, resembling pernicious anaemia, and occurs whenever the intestinal mucous membrane becomes atrophied in like manner to that of the stomach. Gastric Analysis. — Although the diagnosis may be sus- pected by the clinical symptoms, a gastric analysis should in every case be made, not only to establish the diagnosis, but to afford the only positive indications for treatment. The results of gastric, analysis are very different in the three clinical types. Simple Gastritis. — In the fasting condition mucus is found, usually bile-stained and alkaline, although in some cases there may be reactions for free HCl. There are no food- remains, showing that the motor power of the stomach is good. The gastric contents one hour after the Boas test- breakfast show presence of mucus, and the food more or less imperfectly digested. In the majority of cases the total acidity is low ; free HCl is scanty or absent, the greater part of the total acidity being furnished by the combined acid. In moderate cases the total acidity falls to 20 or 30, in more marked cases, to 10 or 12. In these cases of low acidity the ferments are reduced or absent. The zymo- gens, however, are more constantly present, and in simple cases should be present in dilutions of yb-q. If rennet zymo- gen be active in j^ dilution, the prognosis is good ; when inactive in dilutions under -gY, the prognosis is uncertain ; when inactive in dilutions under -^, the prospect of recover}^ is slight. In other cases there is hyperacidit}-, the gastric inflammation acting as an irritative lesion upon the glandular cells. This form of hyperacid gastritis is especially seen when there is a complicating gastric atony, and is not at all 404 J/.I.VC.IL OF THE PKACriCl: OF MKD1CL\'E. uncommon. Starch digestion is good with subacidity, poor with high acidity. Lactic acid and fatty acids do not appear. Microscopically there are no striking abnormalities. Sclerosing Gastritis. — Tiie fasting stomach shows the presence of food-remains in various stages of digestion and fermentation. The test-breakfast usually shows marked reduction in free and combined HCl. Lactic acid may be present. Li rarer cases the gastric analysis resembles that of benign pyloric stenosis of cicatricial origin. Atropine Gastritis. — The fasting stomach is empty, both of food-remains and of mucus. The test-breakfast shows entire absence of digestion. Il^-drochloric acid, both free and combined, the ferments, organic acids, and mucus are ail absent ; the zymogens are absent or greatly reduced. Prognosis. — The course is essentially chronic, with periods of improvement from time to time. The symptoms often come and go, depending on the general health and upon the thoroughness and efficacy of the treatment. Although mild cases are recovered from, a guarded prog- nosis should be gi\-cn if tlie disease has lasted any length of time. Relapses ma}^ be induced by trifling indiscretions. A better prognosis can be gi\'en if no intestinal catarrh exists. The danger of atrophy must be considered in severe and long-continued cases, for this condition tends to shorten life by inanition and anaemia. Treatment. — Dietetic and Hygioiic. — Detailed attentior. should be paid to the correction of all dietetic errors that may seem causative of the disorder. The patient should not eat hurriedly, nor should he eat heartily when too tired to digest properly, nor indulge in severe exercise after a hearty meal. Due attention should be paid to the condi- tion of the mouth and teeth. Careful supervision should be made as to the maintenance of general health. The patient should have sufficient sleep, exercise, and fresh air. Ansemic and weakly conditions should be combated by appropriate medication. Change of air and travel will frequently do more than all other means combined. The surest indications for diet are found by gastric anal- ysis. In cases of normal or increased acidity, meats are CHRONIC CATARRHAL GASIRITIS. 405 allowed, while if the acidity be low, meats are to be given sparingly or replaced by fish or one of the concentrated nitrogenous foods, such as somatose, nutrose, or plasnion. In severe cases the food should be finely prepared, the meats scraped or hashed, the vegetables in the form of puree or thickly creamed. Cereals, as a rule, are well digested, especially in cases with subacidity. Milk is usually well borne, except in cases of high acidity. Stimulants, spices, highly seasoned food, and food well known to be difficult of digestion, such as pork, cabbage, and new veal, should be excluded, and, as a rule, tea or cocoa should be used instead of coffee. Too much iced water should not be taken during the meals. When con- stipation exists, honey, fruit compotes, and buttermilk should be added, with or without the help of enemata, so that cathartics by the mouth can be positively discontinued. The number of the meals depends upon the motor con- dition of the stomach-wall and upon the acidity. High acidity and atony if present are to be treated by frequent feedings ; otherwise, three meals a day are sufficient. Mechanical. — When mucus is present in the stomach, lavage is an almost indispensable mode of treatment; not only does it free the stomach from its mucus, but seems to exert a stimulating effect upon glandular activity. The stomach should, by preference, be washed in the morning before breakfast and the process continued until the wash water is entirely clear. If the mucus is tenacious, the addi- tion of lime-water to the water (sj-Oj) is to be advised. The addition of antiseptics is not necessary. The results of lavage are extremely good, and in the majority of cases, when combined wdth dietetic rules, con- stitute a sufficient treatment. If gastric atony coexists, so that it is impossible to get the lavage-water out of the stomach, the advisability of washing the stomach is ques- tionable. When over a pint of residual lavage-water remains, it is contraindicated. In these cases an intro- ductory treatment by intragastric faradism will strengthen the stomach to such a degree that lavage becomes possible without leavincr an excess of residual water. 406 MAXL'AL OF THE PRACTICE OF MEDICIXE. The use of mineral waters is of the greatest service, for by their administration glandular activity may be stimulated, and hydrochloric acidity be brought toward the normal. In catarrhal gastritis, when the hydrochloric acid is greatly reduced, Kissingen water (Racoczy) is to be used, but it is of no benefit if acidity be entirely absent. With moderately reduced acidity, Wiesbaden (Kochbrunncn) ; with normal or increased acidity and over-production of mucus, Carlsbad is to be employed. Small doses onl)- should be given (one- half glass of the natural water, or a similar quantity of the artificial, made by adding the artificial powder to water), and should be taken in the fasting condition. Medicinal. — With proper dietetic and mechanical treat- ment, there need be but little resort to drugs. Certain symptoms, howe\-er, may require special treatment. Loss ©f appetite is best combated by lavage and the ap- propriate mineral water. Among the best of the stomachic tonics are condurango, nux vomica, and small doses of creasote. Nausea and vomiting, if uncontrolled by diet and lavage, may be treated by rest, hot applications to the abdomen, and small doses of chloral (gr. ij) and chloro- form-water (.^j). The use of hydrochloric acid and pepsin is largely in vogue, but not much is to be expected from their employ- ment. The largest dose of hydrochloric acid that could be given by the mouth has very little effect in raising the acidity of an ordinarily small meal, certainly the ordinary doses of lo to 20 minims of the dilute acid arc without appreciable result. As the motor power of the stomach is good and as stagnation of food does not occur, there is no indication for the acid to be given in the fasting condition for its dis- infecting effect. Empirically, however, 20 to 30 minims of the dilute acid may be given after or during meals, and seems, in certain cases, to increase the appetite, acting as a stomachic tonic. Pepsin is entirely useless. If HCI is present in the stomach, an abundant supply of pepsin is also present, and in the absence of HCI, pepsin is inert. ATONY. 407 The treatment of sclerosing gastritis is that of benign pyloric stenosis, by lavage and by surgical operation. In atrophic gastritis, food suitable for intestinal digestion should be given. Frequent meals are to be given, and the food should be finely divided. In these cases pancreatin with sodium bicarbonate is of service. ATONY. Synonyms. — Muscular insufficiency ; Myasthenia gas- trica. A condition with dyspeptic symptoms, characterized by the complete but delayed passage of food from the stomach into the intestine. Etiology. — Primary cases follow irregular modes of life, and persistent overloading of the stomach with solids or liquids. It may be induced by any depreciation of physical or mental tone, and accompanies conditions of malnutrition. It is one of the local manifestations of a general neuras- thenia, and often occurs in a number of members of a family. It is frequently seen after diphtheria, typhoid fever, or in- fluenza, less frequently after other exhausting diseases. It occurs as a complication of a variety of gastric disorders. Atony especially complicates gastroptosis, and is one of the chief factors in inducing the symptoms of this condition. With nervous indigestion, carcinoma, and perigastric adhe- sions it occurs very commonly. To a less extent does it occur with ulcer and chronic gastritis. Pathology. — There is a simple muscle weakness of the gastric wall without any essential lesion. Symptoms. — There is distress after eating, described usually as a " load " or " weight." The distress is propor- tionate to the quantity, but not to the quality of food, liquids furnishing the same amount of discomfort as solids. The oppression appears usually one-quarter to one-half hour after meals, and gradually disappears, so that the patient is relieved when the stomach is empty. In severe cases the distress is more continuous. Sensations of hunger may be appreciated, but the appe- titite is too quickly appeased by a few mouthfuls of food. In other cases the appetite is totally lost. 40S J/.l.Vr.lL OF THE PKACriCE OF iVEDICIXE. Gas in the stomach is a prominent symptom, and occurs both after meals and in the fasting condition, so that it is ver)' co,mmon for the patient to awake early in the morning with flatulence. The gas is not easil)- raised, owing to the poor expulsive power of the stomach. There may be an odor to the eructated gas of food eaten some time previous ; this symptom is not only very suggestive of atony, but gives in addition a very good means of estimating its severity — the longer after eating the eructated gas retains the odor of ingested food, the longer the retention of food within the stomach. The eructated gas, however, is not offensive, as in dilatation. There is usually hyperacidity with any or all of its symp- toms, heart-burn at height of gastric digestion, and eructa- tions of sour fluid relieved by alkalies. The bowels are usually constipated. Gastric vertigo is more common with atony than with all the other gastric disorders combined. Physical Examination. — It is important to determine the size and position of the stomach, as an underlying gastroptosis predisposes regularly to atony, and its detec- tion affords strong presumptive evidence of an existing aton\-. If six ounces of water are given in the fasting condition, there should, normally, be no succussion sounds over the stomach by quick vertical tapotement. If, however, suc- cussion sounds are present, atony exists, and the lower limit of these sounds gives a fairly definite idea of the lower border of the stomach. Succussion sounds may also be elicited when fluid contents are present in the transverse colon, but as the bowels are almost regularly constipated in these cases, a mistake should hardly ever be made. Lavage in these cases usually results in a large quantity of residual water that cannot be syphoned or expressed, in most cases varying between 15 and 25 ounces. Gastric Analysis. — If the patient is given the Boas dinner of two meat sandwiches and ten ounces of water at nine o'clock at night, the stomach should be empty the following morning, showing the ability of the .stomach to empty itself if given sufficient time. In some cases the ATONY. 409 stomach may contain a liquid consistinc,^ of mucus, bile, and hydrochloric acid, but microscopically there are no food-remains. The test-breakfast shows usually a high degree of acidity, the prolonged stay of food within the stomach acting as an irritative lesion. In long-standing cases the secretory power of the stomach may be exhausted and subacidity may result. The gastric contents contain no previous food- remains as in dilatation, and offensive fermentation does not occur. Lactic acid is not present. The quantity of test- breakfast expressed is usually greater than normal. In many cases the test-breakfast is obtained by aspiration of gastric contents only. Prog-nosis.— The course of atony is slow, although sub- ject to great variations in the severity of symptoms. The prognosis largely depends upon the ability of the patient to carry out a sustained course of treatment, and upon the recuperative power of each individual patient. The prognosis is worse if atony be secondary to gastroptosis. The question whether atony ever passes into dilatation is at present unsettled, but the consensus of the best authorities is that while such an outcome is possible, it is extremely rare. Treatment. — Almost without exception the patients are poorly nourished and neurasthenic. The strictest attention should therefore be paid to the general health, and the diet should be carefully supervised. As gastric acidity is nor- mal or hyperacid in the great majority of instances, a general mixed diet is allowable, and superalimentation is to be advised, although care should be exercised that the stomach is not mechanically overloaded at any one time. For this purpose frequent small meals are indispensable, and the diet should be as dry as possible, about three pints of liquids only allowed in the twenty-four hours. Milk may be badly borne by these patients, so that its administra- tion is a matter of personal experiment. Exercise after meals should be prohibited. The constipation should be treated by laxative diet and by enemata. Cathartics are to be absolutely forbidden. Lavage, as a rule, does harm, 410 MAXr.lL OF THE PKACriCE OF MEDICINE. the stomach is nicchanicalK- tn-crdistcndcd by the wash- water, and as terincntation and retention of food in the fasting stomach do not occur as in dilatation, there is not the same necessity for washing the stomach. Lavage should, therefore, be only employed when demanded by other complicating lesions, such as marked mucous gas- tritis, etc. Faradism is a most important form of treatment, and is productix'e of great improx'cmcnt in s\-nipt(jnis and in tlie actual atonic condition. It ma\' be given externally or by the intragastric method, the latter being far preferable. In the external method, a large flat electrode is placed over the twelfth dorsal vertebra extending to the left of the spine, the other electrode is placed over the epigastrium. Fig. 43. — The author's intragastric electrode. Slowly interrupted currents should be passed as strong as comfort will allow for fifteen minutes. The intragastric method consists in the passage of one electrode into the stomach, the other electrode being placed o\-er the epigas- trium. The intragastric electrode, modified by the author from the instrument of Einhorn (see Fig. 43), is warmly recommended, and is easy of introduction even in the most sensitive patients. From fifteen to twenty seances, two or three times a week, are usually sufficient to obtain a marked improvement. If toward the conclusion of the seance the abdominal electrode be placed at various spots over the colon, much good is done to the accompanying constipa- tion. DILATATION OF THE- STOMACH ; GASTKECTASIS. 4II DILATATION OP THE STOMACH ; GASTRECTASIS. Etiology. — As in this condition the stomach is unable to empty itself of its contents, three causes are theoretically possible: (i) A mechanical obstruction at the outlet; (2) Muscular weakness of the organ ; (3) A paralytic condition of the gastric nerves. While there are cases in which rapidly induced muscular weakness and paralytic conditions are directly responsible for acute dilatation of the stomach, these cases are exceedingly rare. The occurrence of dilata- tion from atonic conditions, the so-called " primary " or "atonic dilatation," is the subject at present of great dis- cussion, but the consensus of opinion of the best authorities is that while atonic dilatation is possible, it is extremely rare, and that, practically, the causes for a dilated stomach are to be found in a mechanical narrowing of the pyloric outlet. Mechanical obstniction may be intrinsic or extrinsic. Intrinsic causes are cicatricial contraction following ulcer of the pylorus or duodenum, carcinoma, hypertrophic thickening, as in stenosing gastritis, and congenital narrow- ing of the pylorus. Temporary stenosis occurs with pyloric spasm. Extrinsic causes embrace kinking of the duodenum, as in gastroptosis, pressure of gall-stone or abdominal tumor, or the traction of peritoneal bands and adhesions. Patholog-y. — Whenever obstruction occurs at or near the pylorus it becomes difficult for the chyme to pass from the stomach. This difficulty may be compensated by hypertrophy of the muscular wall of the stomach, so that no actual retention of food occurs. In the majority of cases, however, there is no compensation and food is retained, stagnates, and ferments. The continual presence of residual food within the stomach and the pressure of gases gener- ated by the fermentation cause, in time, an actual increase in the size of the stomach. It is a misconception, however, that the actual size of the stomach is essential in any way. The main fact is that the fasting stomach cojitains residual food which it is unable to expel — the actual size of the stojn- 412 MAXCAL OF THE PRACTICE OF MEDICIXE. ach is tiitirilv a secondary and less iiii/^or/anf matter. There are cases of p\'loric obstruction in which the size of the stomach is not increased. The retention k.^{ fermenting food regularly gi\-es rise to a chronic gastritis. Symptoms. — The symptoms due to the primary cause precede or accompany those of dilatation, and the recogni- tion of these is of value in the diagnosis. Of the regular s)'mptoms of dilatation, vomiting is the most characteristic. It is diagnostic for the patient habitually to vomit food taken the da}' previous. According to the size of the stom- ach and the degree of pyloric stenosis the stomach will be more or less rapidly overfilled with food and drink, and the consequent disengorgement leads to a certain periodicity in the vomiting. For the characteristics of the vomited matters see heading of " Gastric Analysis." In \ery bad cases the stomach may, toward the close of the disease, lose its contractile power, so that vomiting ceases ; this sign is to be regarded as of serious import. Heart-burn and acid eruc- tations are frequent from the fermentation of retained un- digested food. There may be dragging feelings and a sense of weight from the mechanical effects of the dilatation. Pain and oppression are commonly observed. The bowels are usually constipated, although attacks of colicky pain and diarrhoea may occur, from the passage of the acid fer- menting food into the intestine. If stenosis of the pylorus is marked, little food or fluid may pass the obstruction. In consequence, loss of flesh and of strength become apparent, the patient is unnaturally hungry and thirsty, the urine becomes diminished in quan- tity and is concentrated, and painful cramps of the muscles may occur. Physical Signs. — Tnspcction. — The abdomen is large and bulging, and the position of the greater curvature may be seen. In cases with pyloric stenosis waves of peristalsis or of antiperistalsis may be seen, especially in cases of benign stenosis of considerable duration. Palpation often reveals the peristalsis. If there be ste- nosis of the p}'lorus from simple or cancerous thickening, the mass may be detected. In many cases the boundaries DILATATION OF THE STOMA C//; GASTRECTASIS. 413 of the stomach may be appreciated, the feeHng of resistance being compared to that of an air-cushion. Bimanual palpa- tion may elicit splashing sounds. These sounds, which are caused by the shaking together of air and water, may often be elicited in a healthy stomach after eating. To be of any diagnostic value, the splashing sounds should be produced when the normal stomach is empty — two hours after drinking, seven hours after a general meal. The most accu- rate means for determining the size of the stomach are fur- nished by inflation. This should always be done with caution, and never to an extreme degree, especially if cancer or ulcer be supposedly present. The patient may be given gr. xx-oj of bicarbonate of sodium, followed by an equal amount of tartaric acid in water, and the inflated stomach can then usually be felt and seen distinctly. A stomach- tube should be at hand for the withdrawal of the gas should unpleasant symptoms occur. Another method is by passing a stomach-tube and pumping air through it by a Davidson syringe. The introduction of a stiff tube, so that it may be felt along the greater curvature, is an accurate means of locating the lower curvature, but is not altogether devoid of risk. Electric illumination of the stomach, or gastrodiaphany, is entirely misleading. It is important to remember, first, that many cases of pyloric obstruction exist without any actual increase in the size of the stomach, and, second, that the determination of the lower border in an abnormally low position does not mean that the stomach is enlarged, for a normal sized stomach may be displaced downward (see Gastroptosis). To be sure then of actual dilatation the upper curvature must be made out by inflation and the vertical measure- ments must be greater than normal. Third, there are many stomachs larger than others. These so-called cases of " megalogastria " give no symptoms. TJie size of the stoju- ach is unimportant unless at the same time there be food re- te)ition in the fasting condition. Gastric Analysis. — If a patient be given the Boas supper at night, there should be no food-remains in the fasting stomach the followinsf morning. It is otherwise with dila- 414 M.tXrAI. OF THE PRACTICE OF MEDICINE. tation of the stomach. On passiiijj; the tube food-remains in a fermenting condition are removed, often in large quantities, and are often composed of food taken a long time previous, Tliis fi)iding of food-remains in the fasting stomach is the most positive proof of dilatation, and this procedure should never be dispensed with. The stomach contents differ in no wa)' from the vomited matters ah'eady alluded to. Upon standing three distinct layers are to be distinguished, an upper, of a brownish froth ; a middle, of a turbid fluid ; and an under layer of food and debris. The clinical analysis of benign stenosis (non-cancerous) differs from that of malignant stenosis (cancerous) in im- portant particulars, and is of the greatest service in diag- nosis. In benign stenosis the total acidity is high, hydrochloric acid in free and combined form is present in increased quantity, lactic acid is absent. Microscopically are to be found food-remains in a fairly digested condition without the presence of meat-fibres. There are many yeast-fungi and sarcinae ventriculi. A continual presence of bile bespeaks a stenosis of the de- scending portion of the duodenum below the papilla. In malignant stenosis the acidity is high from the presence of fatty acids and of lactic acid. Hydrochloric acid is not, as a rule, present in a free state, although small quantities of combined acid are usually detected. Microscopically food-remains are found, meat-fibres are present, yeast and a variety of bacteria are seen. Sarcinae are not present. An especial form of bacteria is the Oppler-Boas bacillus, a long non-motile bacillus, occurring singly or in long jointed chains. These are supposed to be a variety of lactic-acid bacilli, and are almost constantly found in malignant stenosis. When carcinoma develops on the site of an old ulcer, hydrochloric acid is usually present throughout its course in excessive amounts. The gastric analysis, resembling that of benign stenosis, together with the presence of a tumor and a cancerous cachexia, should enable a correct diagnosis to be made. Prognosis. — The prognosis of malignant stenosis is that DILATATION OF HIE STOMACH; GASIia-.CIASIS. 415 of cancer of the stomach. In many cases of benign stenosis the pyloric lesion remains stationary and compensatory hypertrophy of the stomach-wall develops, so that with care and treatment the patient goes along in comparative comfort. In other cases medical treatment is simply pal- liative, and resort must be had to surgical interference, the results of which are exceedingly satisfactory. Treatment. — Attention to the diet is of the first import- ance, and without it neither a cure nor an improvement can be expected. The food should be simple, concentrated, and easily digested, and in bad cases should be taken in small quantities at frequent intervals. Carbohydrates and fatty food should be permitted only in the smallest amount, and liquids are to be partaken of sparingly. In advanced cases a resort to predigested foods and peptones for short periods is often of service. A cup of hot water before meals will allay excessive thirst more effectively than a larger amount taken with or after the meals. To relieve the dilated stomach of its accumulated contents the stomach should be emptied and then be washed clean with warm water or with weak alkaline solutions. If fermentation be active, a i per cent, solution of salicylic acid or of resorcin may be used. Lavage should be practised the last thing at night or early in the morning, and it should be repeated every day or every second day, according to the require- ments of the case. By systematic lavage not only is the weight of the accumulated food removed, but the stomach is relieved of mucus and the irritating fatty acids of ferment- ing food. Strychnine is of great value, through its power to restore tone to debilitated muscular fibre ; it is of special service in dilatation not depending upon pyloric obstruc- tion^ Iron and tonics are indicated to restore general sys- temic tone. The empirical use of sweet almond oil before eating (one- half wineglassful) has apparently been of great service. In benign stenosis the added element of a possible pyloric spasm must be considered and treated by lavage, gastric sedatives, as chloral, bromide, and hyoscyamus, and by the reduction of the high acidity by nitrate of silver and alka- 410 .V.LVr.lL OF THE PRACTICE OF MEDICEXE. line powders (see Hyperacidity). The marked improvement of so many cases by lavage is to be explained by the lessen- ing by this means of an associated pyloric spasm. Intragastric faradization has been recommended. Massage from the fundus toward the pylorus is often beneficial. It should be cmplo\'ed daily, fi\'e hours after the principal meal. If there be bulging of the epigastrium, a cushion, a pad, or an elastic abdominal bandage should be worn. In cases of marked stenosis, where medical means fail, operative procedures are indicated. The pyloroplastic operation of Mikulicz has been fre- quently performed with benefit, but gastro-enterostomy, by reason of its greater simplicity and in perfection of stomach drainage, would seem to be the preferable operation. The results of operation in cases of pyloric stenosis are often brilliant. ULCER OF THE STOMACH. Etiology and Synonym.s. — Ulcer of the stomach is found at post-mortems more frequently than it is diagnosed during the life of the patient, evidences of present or past ulceration being found in 5 per cent, of persons dying from all causes, the scars being the more common. Females are more fre- quently affected than males, in the proportion of 3 to 2. The greatest liability is between the ages of twenty and forty years ; but the disease is not uncommon up to the age of sixty, especially in the case of chronic ulcers. It is more common in ansemic and chlorotic patients and those with menstrual disorders, and is not infrequently associated with tuberculosis. It occurs especially among servant girls and in shoemakers, in the latter case being consequent, possibly, upon pressure on the stomach while at work. It is not as common in America as in Europe. Synonyms : Peptic ulcer; Round ulcer. Pathology .^ — There is but one ulcer in 80 per cent, of all cases, but as many as thirty-four ulcers have been found. The usual situation (86 per cent.) is on the posterior wall near the pylorus, close to the lesser curvature. The ulcers vary in diameter from one-half to two inches, although they may be much larger. The usual shape is round or oval, ULCER OF rilE STOMACH. 417 although the large ulcers are apt to be irregular, and several ulcers may coalesce to form one of an irregular shape. The ulcer has an oblique funnel shape, becoming smaller as it extends deeper, the successive ulcerated coats being dis- tinctly terraced. The floor has a clean, " punched out" appearance, free from inflammatory changes, but in old cases the floor and walls of the ulcer may be indurated and thickened. The depth varies, the ulcer sometimes involving only the mucous coat, at other times extending to the deeper structures and even perforating the stomach-wall. The mucous membrane of the stomach shows almost regu- larly the lesions of a subacute or chronic catarrhal gastritis. Changes in the blood-vessels of the stomach have been found in a large proportion of cases. Among these changes may be mentioned thrombosis and diffuse endarteritis of the arteries supplying the ulcerated area. Small aneurysms have been found in the floor of the ulcer. Sequelae and Complications of Ulcer. — These complica- tions are of the utmost importance. 1. The ulcer may cicatrize. In some cases hardly any scar is left ; in other cases, especially if extensive ulceration of the muscular coat has occurred, considerable puckering or deformity may occur. Cicatricial stenosis of the pylorus with dilatation of the stomach is a not infrequent result. It often happens that large ulcers may remain open for years without showing signs of healing (13-18 per cent, of cases). These chronic ulcers are usually situated near the pylorus. 2. The ulcer may perforate the wall of the stomach. Gastric contents enter the peritoneum, and a rapidly fatal septicaemia follows. Perforation, which occurs in 6 per cent, of all cases, is more common with ulcers of the ante- rior than with those of the posterior walls (in the proportion of 9 to i). 3. Adhesions may form between the stomach and the surrounding viscera, especially the left lobe of the liver, the pancreas, and the omental tissues — Nature " putting a patch on " to reinforce the weakened spot and to prevent perfora- tion. These adhesions are far more frequent in the chronic than in the acute cases. Extension of the ulceration and 27 41^5 .U.t.VL.lL OF THE PKACJICK OF MEDICLXE. secondary infection by pus microbes may lead to fistulous tracts and suppurating; ca\ities in these adhering organs. Gastro-intestinal fistuhv are thus lormed, and perforation into the pleura, the pericardium, and the left \entricle of the heart has been known to occur. The suppurative process may extend along the \eins, causing a suppurative p}'le- phlebitis with multiple abscesses in the liver. The adhe- sions may not be extensive enough to prevent perforation, but may suffice to shut the site of rupture from the general peritoneal cavity, so that a localized peritoneal abscess results. Perforation of the posterior wall produces an air- containing abscess in the lesser peritoneal cavity, known as " subphrenic pyopneumothorax." 4. Erosion of a blood-vessel is of common occurrence. This accident may occur with recent acute ulcers, but it is more common in the chronic form with spreading ulcera- tion. Ulcers on the posterior wall of the stomach may erode the splenic artery or the artery of the lesser curve. 5. In 5 or 6 per cent, of cases carcinoma develops on the base of the ulcer, forming the so-called ulcus carcinoma- tosuni. Pathogenesis. — All authorities agree that gastric ulcer results from self-digestion of part of the stomach-wall by the gastric juice. Self-digestion is prevented in the normal stomach by the circulation of alkaline blood in the gastric mucous membrane. The generally accepted theory for ulcer is that whenever, for any reason, the circulation stag- nates in a certain area of the stomach-wall, and its nutrition fails, the part is acted on and destroyed by the gastric juice, especially if it possess hypcrpeptic powers. Hyperacidity is present in nearly all the cases, but is probabl\' of more importance in interfering with the healing of the ulcer than in causing it, for it has been proved that traumatic lesions of the stomach heal rapidly in the majority of instances, unless there be at the same time considerable hyperacidity, in which case healing is delayed. Interference with the circulation of a part of the stomach- wall may be caused in a variety of ways. Experimental embolism of the gastric arteries has been followed by ulcera- ULCER OF THE STOMACH. 4I9 tion, and this experimental evidence accords with the funnel shape of the ulcer and with the actual post-mortem demon- stration of an embolus or a thrombus plugginj^ the nutrient artery in some cases. This is also demonstrated by the occurrence of multiple acute ulcerations of the stomach in acute pyaemia. Aside from these cases, however, embolic ulceration of the stomach is extremely rare, and thrombosis of the gastric artery seldom occurs except with carcinoma. It is believed that the gradual obliteration of the artery by atheroma is one of the principal causes for chronic ulcera- tion in adult cases. The common occurrence of ulcer with anaemia and chlorosis is to be explained by the liability to submucous hemorrhages and the high gastric acidity so common to these cases. Local pressure or traumatism is supposed to act locally to produce changes in the circula- tion. Talma suggests that a cramp-like contraction of the stom- ach, or full contents, may cause such pressure on the arte- ries traversing obliquely the muscular coat as to interfere with the circulation and to allow of ulceration. By filling the stomach of an animal with gastric juice and ligating the orifices, he found that by causing firm contractions with faradism, ulcer resulted. Fenwick has lately drawn attention to the occurrence of solitary glands in the mucosa, inflammation of which may give rise to ulceration of the stomach, and which can assume the characteristic form of acute perforating ulcer. Symptoms. — There may be any or all of the symptoms of chronic gastritis. These dyspeptic symptoms may be trifling or of the most aggravated character, but to some extent they are almost invariably present. The distinctive symptoms are pain and tenderness, vomiting, and the vom- iting of blood. Pain is the most constant, symptom. The characteristic pain is sharply localized in the epigastrium, frequentl}^ run- ning through to the back. It is brought on by eating, usu- ally within a few minutes, and it is aggravated by irritating food or by an excessive quantity of food. It ceases when the stomach is relieved' of its contents either by the normal 420 M.IXL.IL OF THE PKACT/CI-: OF MFDICIXE. exit of food throu<^h the pylorus or b>- the act of vomiting. The pain is increased by exercise and is diminished by rest. There is usually a localized area of tenderness an inch or so below the ensiform cartilage. There may be, how- ever, rehef from pressure on the epigastrium. There is usually an area of cutaneous h)'i)era;sthesia in the epigas- trium or left h)'pochondrium, over which stroking of the skin is painful. Over the tenth to twelfth dorsal vertebrae, about one inch to the left of the median line, is elicited a tender spot in about one-third of the cases. When present this dorsal point is very characteristic. In many ca.ses this classical pain is not present, variations being common. {(I) In some cases there is the ordinar}^ pain of an asso- ciated gastritis. (/;) In other cases the pain does not occur until two or three hours after eating or until the stomach is empty ; the pain, being due to hyperacidity, is relieved by food. (c) In some cases the pain comes on in attacks at in- tervals for weeks or months, and then the patient goes for a long time without attack*; ; the pains, however, return after a variable length of time. {d) In other cases the pain is reflected to the nerves of the abdominal wall and has the characters of a neuralgia. Vomiting. — The characteristic of the vomiting rests not with the act itself, but in the relief it gives to the pain. A pain after eating, vomiting, and relief is the regular sequence. The vomited matters, which consist of undigested food, usually without evidences of fermentation, generally contain HCl in more than the normal quantity. The vomiting with ulcer is not constant, and when it does occur it varies greatly in severity, some patients vom- iting nearly everything they eat, others vomiting but sel- dom, if at all. In other cases the vomiting is due to the associated gastritis. Vomiting of blood occurs in about one-half the cases. The vomiting may be slight, but more commonly it is pro- fuse. If profuse and sudden, the blood raised is red, partly clotted, and unaltered. If less profuse, it may be retained in the stomach for a longer time, so that by alteration by ULCER O/' TJIF. S 70 A/AC//. 42 1 the gastric juice it becomes black or brown, resembling " coffee-grounds." Repeated hemorrhages lead to a high grade of ansemia ; sudden profuse hemorrhage may cause death. In most cases some blood, and in rare cases all the blood, passes the pylorus and is evacuated with the stools, giving them a black, tarry appearance. On adding water to these stools a more characteristic blood-color is developed. In old ulcers with a thickened base an indurated mass may be felt on examination in the neighborhood of the pylorus. In these cases the symptons of dilatation of the stomach may be present. Hysterical and anaemic symptoms are often present ; fre- quently they may so overshadow the symptoms of the ulcer that the latter condition is overlooked. Varieties in Clinical Course. — i. In some cases the dis- ease runs a latent course and is found after death from some other disease, without having given symptoms during life. 2. Some cases run a latent course until there occurs a profuse hemorrhage which may terminate fatally or which may be followed by the symptoms of chronic ulcer. 3. With or without a brief history of gastric disturbance, sudden perforation occurs, causing speedy death. 4. In some cases the characteristic symptoms are not marked, but resemble those of chronic gastritis, so that a diagnosis cannot with certainty be made. 5. In some patients the disease shows periods of appar- ent cure, after which there is a return of the symptoms. It is hard to say whether fresh ulcers form or whether the cicatrix of an old ulcer becomes ulcerated. 6. In some cases the anaemia and cachexia from malnu- trition become so marked as to suggest pernicious anaemia or cancer. 7. In other cases the symptoms of pyloric stenosis and secondary dilatation of the stomach are so marked that the symptoms of the primary ulcer are overlooked. The prognosis is uncertain, as a fatal hemorrhage or perforation may occur at any time. The possibility of fistulae and suppuration without the stomach, as noted under the heading of " Pathology," should be kept in 4::-: m.i.\l:il of tj/e practice of medicexe. mind. The duration of the disease varies tVoni a {cw months to a number o{ years, the average beiny; from three to five years. Relapses are frequent. Reeent ulcers are more amenable to treatment than old, indurated ulcers. The older statistics are : death from hemorrhage occurs in 4 per cent, of all cases; from perforation, in 6.5 per cent. About 15 per cent, of all cases of ulcer of the stomach are said to be fatal, but this seems altogether too high a per- centage. Under modern treatment the statistics are much better. Leube reports 556 cases, with a mortality of 2.4 per cent.; I per cent, died of hemorrhage ; I per cent, of perforation. Under treatment 79 per cent, were permanently cured in four or five weeks; 20 per cent, improved, but were not perma- nently cured; i^ per cent, only were unimproved. The general mortality from other sources has been reduced to about 4 per cent. It is often hard to tell when the s)-mptoms of ulcer end, as gastritis, neuralgia, or dilatation of the stomach due to the presence of the cicatrix may continue gastric symptoms. Treatment. — The secret of treatment is to reduce gastric acidity and to give the stomach as much of a rest as possi- ble. When the diagnosis is made, absolute rest in bed should be enforced until acute symptoms have subsided. The following modification of Lcube's treatment in these cases is advised : The patient should be kept absolutely at rest in bed, and for three days should be nourished entirely by rectum. Small quantities of aerated water ma)' be taken to assuage thirst. Hot poultices should be applied to the epigastrium. At the end of three days the poultices may be discontinued, and applications of w^et flannel covered by oiled silk and changed every six hours, may be substituted, and should be continued for four weeks. From the third to seventh day the diet should consist of 6 07.. of equal parts milk and lime-water every two hours, and rectal alimentation continued. During the second week, 7 oz. of milk and i oz. of lime-water are to be given every two hours, with custards and vegetable puree, rectal alimenta- tion discontinued. During the third week, farinaceous pud- ULCER OF THE STOMACH. 423 dings, crackers, toast, zwieback, sweetbreads, baked potatoes, and fish may be added. During the fourth week, birds and fowl may be taken, in addition to simple vegetables without much vegetable fibre. For some time the patient should avoid raw fruit, very hot and very cold drinks, and all stimu- lating and highly seasoned food. Nitrate of silver may be given after the third day. The patient receives |- gr. three times a day for three days, \ gr. t.i.d. for three days, and -f gr. t.i.d. for three days. The cycle is then recommended and continued throughout the four weeks. During this treatment of silver, diarrhoea may set in, necessitating the administration of bismuth or the discontinuance of the drug. If nitrate of silver is not well borne, a glass of hot Carlsbad water morning and night may be serviceable. Under this treatment pain, vomiting, and tenderness rapidly subside, and the results are permanent in 80 per cent, of cases. When patients cannot take the rest-treat- ment, the results are not as satisfactory. The diet should be on the lines indicated, and the medicinal treatment is the same. Large quantities of subcarbonate of bismuth may be given in the fasting condition once or twice a day (oiij in .Ivj of water). Lavage is contraindicated except in long-continued cases with pyloric obstruction. Hsematemesis is to be treated with absolute rest and quiet of body and mind and by the giving of cracked ice. The patient should be put as rapidly as possible under the influ- ence of opium, preferably by hypodermics. Drugs by the mouth, such as gallic acid, ergot, and acetate of lead, are of no service, and the efficacy of local applications of ice is doubtful. Stimulation should be moderate, as a depressed state of the circulation is nature's method of checking hem- orrhage by allowing the formation of a thrombus. After hemorrhage all food should be withheld from the stomach for several days. Anaemic and cachectic conditions should be treated steadily and persistently by iron, arsenic, good fresh air, and a change of climate or of occupation if necessar}\ 424 M.IXr.lI. OF THE PRACTICE OF MEDICIXE. S\.W'^\c\x\ interference is indicated in the following condi- tions : 1. In repeated uncontrollable hemorrhajj^e. 2. When severe pain and repeated vomiting persist after medical treatment and diet. 3. When the ulcer perforates. 4. When cicatricial p}'loric stenosis occurs. For ixirticulars the reader is referred to special works on Surgery. CANCER OF THE STOMACH. Etiology. — Next to the uterus, the stomach is the most frequent seat of primary cancer, the organ being involved in 21.4 per cen:. of a total of over 30,000 cases. According to Welch, cancer of the stomach is the cause of death in i per cent, of all persons d}'ing after the age of twenty years. It is almost always primary. The actual cause of cancer of the stomach is not understood. It occurs in men a little more fre- quently than in women, and it is more common in some races than in others, pure-blooded negroes being comparatively ex- empt. Three-fourths of all cases occur between the fortieth and seventieth years, but the occurrence of cancer between the ages of twenty-five and forty is not as exceptional as is often represented. The influence of heredity is seen in 14 percent, of all cases. Chronic gastritis has preceded cancer in a fair number of cases, and carcinomatous changes in the wall of an old gastric ulcer have been described. Pathology. — The varieties met with, in the order of fre- quency, are cylindrical-celled epithelioma, encephaloid, scir- rhous, and colloid cancer. According to Welch, the pyloric region is involved in 60.8 per cent., the lesser curvature in 1 1.4 per cent., the cardiac end in 8 per cent, the posterior wall in 5.2 per cent., the whole or the quarter part of the stomach in 4.7 per cent., multiple tumors 3.5 per cent., greater curvature in 2.6 per cent., anterior wall in 2.3 per cent., fundus in 1.5 per cent. Cancer begins in the mucous membrane of the stomach and grows in all directions. The portion of the growth projecting into the cavity of the stomach may be broad and CANCER OF THE STOMACH. 425 flat or cauliflower-like, or ulceration may occur, allowing of hemorrhage or of perforation. Perforation into the peri- toneum occurs in 4 per cent, of all cases, being usually pre- vented by the formation of adhesions between the stomach and adjacent structures. More rarely perforation occurs into the colon or through the abdominal wall, or fistulae may be formed into the lungs, the pleura, and the small intestine. Ulceration is most common with encephaloid and cylindrical-celled epithelioma, less frequently in scir- rhous and colloid cancer. Growths about the pylorus are apt to cause pyloric stenosis with secondary dilatation of the stomach. Growths in the cardia are apt to cause stenosis and secondary dilatation of the oesophagus. Chronic catar- rhal gastritis almost invariably occurs with the growth of cancer. Encephaloid cancer grows rapidly and forms cauliflower- like masses projecting into the cavity of the stomach, tend- ing to ulcerate easily. It is soft, of a grayish-white or reddish-white color, and contains much blood. Micro- scopically the growth consists of a scanty stroma enclosing alveoli filled with irregular polyhedral and cylindrical cells. Metastases are common. Cylindrical-celled epithelioma somewhat resembles the encephaloid, but is firmer, especially at the edges. It is prone to ulcerate and to form metastases. Cysts contain- ing mucus are often found. This form of tumor consists of elongated tubular spaces filled with columnar epithelium with an abundant stroma, and it resembles the structure of tubular glands. Scirrhous cancer may occur as a hard, circumscribed tumor or as a diffused thickening of the gastric wall. It is hard to the feel, and it is most often found at the pylorus, causing stenosis. Scirrhus has but little tendency to ulcer- ate. It consists of a hard fibrous stroma with relatively few and small alveoli. Colloid cancer shows itself as an extensive uniform infil- tration and thickening of all the layers of the wall of the stomach. It spreads with great frequency to involve adja- cent structures, although actual metastasis is comparatively 426 MA.VrAL OF THE PRACTICE OF MEDICINE. rare. It shows trabecuKx' of connective tissue enclosing large alveoli filled with translucent colloid niateri.il. To this variety the name of " alveolar cancer " has been ap- plied. These varieties are often mixed in the same specimen, so that it is hard to say in what class the growth is to be placed. Secondary cancerous growths occur by (i) direct exten- sion, involving the oesophagus or any structure to which the stomach may become adherent, or by (2) metastasis. This latter is most frequent in the lymphatic glands in the neighborhood of the stomach ; next in frequency in the liver, the peritoneum, the omentum, and the intestines; less frequently in the pleura and the lungs. The liver is involved in about one-third of all cases. The cervical and inguinal lymphatic glands are not infrequent]}^ involved, and occa- sionall}' growths occur subcutaneously near or at the navel. The symptoms of cancer of the stomach may be de- scribed as gastric, constitutional, and those due to the sec- ondary growths. Gastric Symptoms. — {a) As chronic gastritis almost inva- riably accompanies cancer of the stomach, it gives rise to any or all of its regular symptoms. The appetite is usually more completely lost than in uncomplicated gastritis. {b) Pain occurs in 92 per cent, of all cases, being rarely absent except in old people. The pain is severe, more or less continuous, and is described as burning, gnawing, or neuralgic. It may be referred to the epigastrium or be- tween the scapulae, but the locality of the pain is no indi- cation of the seat of the growth. Pain is usually increased by eating, although this may not be evident until some little time after taking food. The pain differs from the typical pain of ulcer (i) in be- ing more continuous, so that the patient is often awakened at night by it; (2) in being less dependent on food; (3) in the increased pain being delayed some little time after tak- ing food ; (4) in being less sharply localized ; and (5) in not usually being relieved by vomiting. There is generally ten- derness on pressure over the growth, but the tenderness is less marked and less sharply localized than in ulcer. CANCER OF rilF. STOMACIL 427 {c) Vomitini^ occurs in from 80 to 88 per cent, of all cases. As a rule, it does not appear until the latter part of the disease, when the cancer has attained a considerable size, whereas the vomiting of ulcer comes on early. Vom- iting is more frequent if either orifice be involved. If the pylorus be affected, vomiting occurs longer after eating than if the cardiac orifice be involved, the food often re- maining for some hours in the stomach without being digested. There are cases, however, in which vomiting is an early and a distressing symptom, severe enough to cause a fatal termination. If the stomach be dilated, the vomit- ing may be typical of that condition. The vomited matters consist of undigested food, often fermenting and mixed with mucus. Fragments of ulcerating growths may be found, establishing a diagnosis. These fragments, however, are more frequently found in the washing out of the stomach. {d) Hemorrhages. — It is important to distinguish between the slight and the copious hemorrhage of gastric cancer. An admixture of a small quantity of blood with the vomit is present in about half the cases. The blood is brown or black, resembling coffee-grounds, the normal pigment hav- ing been converted by the acids of the stomach into dark- brown haematin. Copious hemorrhages occur in about one-eighth of the cases. The blood may be bright red or more or less dark- ened, according to the length of time it has been retained in the stomach. Following profuse haematemesis some black tarry blood is usually passed with the stools. Hemorrhage in cancer differs from that in ulcer (i) in being more frequent ; (2) in being usually less copious ; (3) in being retained longer in the stomach, with the conse- quent "coffee-ground" appearance; and (4) in occurring in the later stages, when the cancer is ulcerating and the patient is emaciated and cachectic, whereas in ulcer the hemorrhage is an early symptom, occurring when the patient is apparently in good health. (t') If dilatation of the stomach or stenosis of the cardiac end of the oesophagus complicate, the symptoms of these conditions will be added. 428 .VAXr.lL OF THE PRACTICE OF MEDICIXE. Constitutional Symptoms. — The patient grows progres- sively anaemic, developing a waxy or "beeswax" pallor which is quite characteristic ; emaciation and prostration become more and more marked ; there may be a slight irregular rise in the afternoon temperature. Slight oedema of the ankles is common, and a general itching of the skin is complained of — a symptom which in old people should suggest cancer or diabetes. In rare cases chills with par- oxysmal elevations in temperature ha\e been recorded. Delirium or coma may occur as a terminal event. Symptouis of tJic sccondaiy grozi't/is vary according to their size and location. Metastases in the liver cause a general enlargement of that organ, with pain, tenderness, and jaundice. Ascites is not uncommon. Involvement of the peritoneum and the omentum gives rise to ascites and abdominal pain and tenderness, and on examination the thickened masses may be evident. The glands above the clavicle are often enlarged. The subcutaneous nodules near the umbilicus have been alluded to. Gastric Analysis. — Two distinct sets of cases are en- countered : one of the ordinary' cases, the other of ulcus carcinomatosum. I. In ordinary cases free HCl is usually absent (87 per cent.), although small quantities of the combined acid may be encountered. Lactic acid is usually present in sufficient quantities to give a decided reaction to Ufflemann's test. In doubtful cases the stomach should be washed the night before the test-breakfast, and no milk should be allowed for the twenty-four hours previous to the examination. In almost all cases there is a decided loss of the motor power of the stomach, as shown by the presence of food-remains in the fasting state. The loss of motility is not, as a rule, accompanied by any increase in the actual size of the stomach, unless the growth obstruct the pylorus, in which case dilatation may occur, although usually to a very mod- erate degree. Cancer of the stomach is almost certainly present when (i) HCl is absent. (2) lactic acid is present, and (3) stagnation of food in the stomach occurs. The CANCER 0/< TJIE STOAIACJf. 429 diagnosis is more uncertain if only two of the three condi- tions are present. Microscopically are usually found food-remains, the meat fibres showing deficient digestion, yeast fungi, and very rarely sarcinas. The Oppler-Boas bacilli are almost always found, and occur as long, non-motile rods joining each other at an acute angle. They occur in stagnating gastric contents with the presence of lactic and the absence of hydrochloric acid, and possess considerable diagnostic value, as these conditions are present almost exclusively in gastric cancer. 2. In ulcus carci)iomatosuni HCl is usually present in nor- mal or increased quantity, together with lactic acid and food stagnation. Such gastric analysis, with the clinical history of cancer and the presence of cancerous cachexia, should make the diagnosis positive. Physical Examination. — Owing to the position of the stomach, only tumors of the pylorus, of the anterior wall, and of a large part of the greater curvature are accessible to examination. Tumors of the fundus, of the posterior wall, and of the greater part of the lesser curvature cannot be detected unless of some considerable size or unless the stomach be displaced downward. Tumors of the cardiac end cannot be detected at all. As the growth is usually at or near the pylorus, the tumor is in most cases felt in the epigastric region as a firm, hard, nodular mass, tender on pressure. It is not in- fluenced by respiration unless adhesions with the liver are present. Owing to the weight of the growth dragging the pylorus downward, the tumor may be felt as low down as the iliac region. A definite tumor is felt in 80 per cent, of all cases. Examination may be made with the patient lying down, with the knees drawn up so as to relax the abdominal wall ; in doubtful cases examination in the knee-chest position may be more satisfactory. Inflation of the stom- ach with gas (see Dilatation of the Stomach) may be re- sorted to ; this procedure frequently brings the tumor into reach. In cases of colloid cancer no regular tumor- mass may be felt, but the stomach-wall feels abnormally 430 MAXrJI. OF THE PRACTICE OE MEDICIXE. thick and resistant. It is rare to feel a tumor before the third to the sixth month of the disease. Peculiarities in the Clinical Course. — i. Some cases run a latent course, death resulting from some intercurrent disease. This occurs especially in aged subjects. 2. In some cases gastric symptoms may be insignificant, while anaemic and cachectic symptoms are marked. These cases are often diagnosed as pernicious anaemia or Bright's disease. The blood count is rarely if ever below i,ooo,000, as in pernicious anaemia. 3. In other cases gastric symptoms are developed, but are not characteristic. These cases are often diagnosed as chronic gastritis or dilatation. 4. There are cases in which the symptoms of the primary gastric cancer are obscured by symptoms arising from the secondary growths. These cases are then diagnosed as primary cancer of the liver or of the peritoneum. The prog-nosis is practically hopeless. The duration of the disease is usually about two years. Cases live about one year after the diagnosis is made. Occasionally may be seen cases with a rapid course terminating in from three to six months. Treatment. — If the growth be localized and non-adhe- rent to other structures, and if no secondary deposits are present, surgical interference may be justifiable. Resection may be performed, although the results as yet are far from encouraging. W'hen stenosis of the pylorus exists, gastro-enterostom)' may be advised, to drain the stom- ach. An improvement usually occurs in the subjective symptoms, although there is no effect upon the actual progress of the lesion. Medicinal treatment, on the other hand, is merely palliative. Condurango at one time was lauded as a specific, but it is now recognized only as an excellent stomachic tonic, in some cases relieving the pain and the vomiting. It may be given as a decoction, a wine, or a fluid e.xtract. Hydrochloric acid is indicated as an aid to digestion, and it is usually of service. The pain and the vomiting are to be controlled on general principles of treatment. As the disease is certainly fatal, there can G/1S TR OP TOSIS. 43 I be no objection to giving opium, as it makes no difference whether or not the habit is formed. NON-CANCEROUS TUMORS OF THE STOMACH.^ These growths are rare and are not causative of destruc- tive symptoms. Polypi are the most common form. They are composed of hypertrophied mucous membrane, are rarely larger than a bean, and are usually multiple. Sarcomata are rare. Fibromata and lipomata are occa- sionally met with. Lymphoniata may be found in connec- tion with leukaemia or pseudo-leukaemia. Myoinata or Jib ro- viyomata may occur in the form of large polypi. Cases of foreign bodies have often been mistaken for tumors. The most remarkable instances are the hair balls in hysterical women who are in the habit of eating their own hair. GASTROPTOSIS. By this term is meant a sinking downward of the entire stomach, which assumes a vertical position without any change in the actual size of the organ. It is usually asso- ciated with a similar displacement of the small intestine {e7iteroptosis), of the large intestine {coloptosis), and of the right kidney {nephroptosis). To the downward displace- ment of all of the abdominal viscera, the term " splanch- noptosis " has been applied. Patholog-y. — There is a downward displacement of the stomach with laxity or lengthening of the supporting liga- ments. In some instances the stomach is retained in its faulty position by adhesion. Etiolog-y. — In some cases there is a congenital weakness of the gastro-hepatic omentum, to which there seems to be a family predisposition. Tight lacing and weakness of the abdominal wall, such as occurs after repeated pregnancies, are common causes. In rare cases the stomach is drawn down by contracting adhesions. Chlorosis seems to be an important predisposing cause. In some cases the condition develops after sudden loss of flesh. Gastroptosis is far more 43- .V.I.VC.I/- OF THE PRACTICE OF MEDICIXE. common in women than in^nicn, and the s}'mptoms usually appear during adult life. Symptoms. — There are no characteristic symptoms, and the condition may run a latent course, revealing itself only by a routine examination. In other cases symptoms are present and usually follow one of two clinical types. 1. The condition may remain latent for many years and then, usually after physical or mental strain, symptoms of a neurotic nature develop, such as hx'peraesthesia, hyperacidity, or p)'loric spasm (see Gastric Neuroses). With the local neuroses appear any of the symptoms of a general neu- rasthenia. In these cases the symptoms are usuall}^ inter- mittent, and depend largely upon the general condition of the patient. 2. In other cases gastric atony develops, gastroptosis being the most common cause for this condition. The symptoms of atony are well marked, gastric neuroses of any type are present, and, with rare exceptions, the patients are profoundl}' neurasthenic. Hyperacidit}', constipation, and flatulence are prominent s)-mptoms. In these cases the symptoms are more or less constant. In either type gastritis may occur as a complication, but very rarely is it sev^ere. Dilatation of the stomach may occur with gastroptosis in one of three ways : {ci) there may be kinking at the duodenal angle ; [b) there may be pyloric spasm, to which the gastric hyperaesthesia and hyperacidity, so common in gastroptosis, predispose ; (r) there may be downward traction of the mesentery from an associated enteroptosis, so that the superior mesenteric vessels and roots of the mesentery press like a cord upon the junction of the duodenum and jejunum. To this form of obstruc- tion the term " arterio-mesentcric constriction" lias been applied. Diag-nosis is made by finding the greater curvature below the umbilicus, if at the same time dilatation can be excluded. The fact that the stomach is free from food- remains in a fasting state is sufficient to exclude dilata- tion. The most accurate method is by inflating the IIEMORRI/AGE FROM THE S'JVMACIL 433 stomach and then by determining^ the upi;ei' and lower borders by inspection, palpation, and percussion. Gastro- diaphany, or the electric illumination of the stomach, is the least accurate of the methods at command. The diagnosis should n(jt be considered complete unless the presence and extent of an associated atony and the secre- tory functions of the stomach be investigated. If dilata- tion occur as a complication, it is of importance to differen- tiate between a pyloric spasm and the other causes of pyloric obstruction. Prog-nosis is unfavorable for permanent recovery, although much can be done by treatment. The prognosis is better in the cases without atony. Treatment. — The clothing should be loose and sus- pended from the shoulders, so that constriction about the waist does not occur. Anaemic conditions should receive appropriate medication and the general health should be improved in every possible way. Should the abdominal wall be weak, a tight, well-fitting abdominal belt is of ser- vice. It should be adjusted before rising and worn through- out the day. The diet should be general. When atony complicates, small, frequent meals are indicated and intra- gastric faradism should be employed. Gastric neuroses should receive appropriate treatment. The bowels should be controlled by diet and by ensemata, as cathartics are contraindicated. Lavage is not to be employed unless dilatation or gastritis affords positive indications for its use. Surgical treatment is not to be advised unless dilata- tion occur, in which case gastro-enterostomy may be in- dicated. Before advising such an operation, however, a functional pyloric spasm should be excluded as a cause, as these cases usually yield to internal medication w'ithout operation. HEMORRHAGE PROM THE STOMACH. Synonyins. — Haematemesis ; Gastrorrhagia. Etiology. — The causes of hemorrhage from the stomach are exceedingly various ; they may be grouped as follows : 28 434 MAXrAL OF THE PRACTICE OF MEDIC EVE. 1. Traiiinatisin. — (^ wounds or the rough introduction of a stiff stomach-tube. (/') Chemical injuries by strong acids or alkalies or by corrosives. 2. Local Disease of the Stomach. — {a) Ulceration from ulcer or cancer, [h) Disease of the blood-vessels, such as miliary aneurysm, atheromatous or fatt\^ degeneration, or varices of the veins. 3. Congestion of the Gastric Mucous Meinbrane. — (rilliant results often follow the use of small doses of bromide, chloral, and chlorform-water, as in the following prescrij)tion : I^ Sodii bromid., gr. vj ; Chloral hydrat., gr. iij ; Aq. chloroform., 3J ; Spiritus anis., gr. \. — M. Sig. — Such a dose four times a day. To prevent recurrences the underlying cause should be detected and removed. Neurasthenic conditions require appropriate treatment. Arsenic in free doses, but not to the point of tolerance, frequently acts as a specific. The com- bination of valerianate of zinc (gr. iij) with small doses (gr. ■|-) of nitrate of silver is often useful. Hyperacidity and hypersecretion, if present, require their special treatment. Secretory Neuroses. 1. Nervous subacidity occurs as a temporary condition in depressed mental conditions. It commonly occurs during the first few days of menstruation in healthy subjects. The subacidity of the chronic gastritis can be usually excluded (i) when ferments and zymogens are present in normal proportions and (2) when subacidity varies with normal or excessive secretion. 2. Hyperacidity exists where HCl is present in over ^-^ per cent, after a test-breakfast, and is one of the most com- mon forms of indigestion. Before, however, a diagnosis of neurotic hyperacidity is made, gastritis with over-production of HCl, ulcer, atony, and pyloric obstruction must be ex- cluded. There is pain of a gnawing, burning character, which is referred to the epigastrium or the heart, or it may be substernal. It is often spoken of as " heart-burn." There are eructations of acid fluid setting the teeth on edge. Digestion for starches is usually delayed. The symptoms usually occur one to two hours after eating or may be longer delayed. Instant relief is usually afforded by the administration of alkalies or the taking of food. There are 440 .u.ixr.i/. OF THE pkactick of medicixe. certain cases wliich |;i\c tlicsc symptoms in which L^astric analwsis shows a ni^)rmal iJcrccntai^e of IICI, ami arc to be cx[)hiinc(.l by there bein^ a pecuhar hxpcr.csthesia or sen- siti\encss of the stomach to acitl. 3. Periodic Hypersecretion. — Syiioitynts. — Gastrosuccor- rhcea or Rossbach's ^.istroxynsis. — There occur, from time to time, attacks of burning gastric pain, with vomiting of acid fluid containing IICI. The attack lasts from a few hours to several da}s. The condition may occur as a primary neurosis, occurring especially among the educated classes, or it ma)' be secondary to disease of the central nervous system, as locomotor ata.xia, m)'clitis, or progres- sive paresis. It is not uncommon as a complication of gastric ulcer. 4. Continual Hypersecretion {Rcichviaiuis 7)iscasi-). — This condition is characterized by the constant presence of gastric juice in the fasting stomach. To be of pathological significance, at least 75 c.c. should be obtained on a number of occasions, as smaller amounts maybe present in a variety of other conditions, or as large a quantity may appear as a temporary phenomenon in otherwise healthy stomachs. Excluding these minor or transitory cases, Reichmann's disease is a somewhat rare condition. It does not appear to be a primary neurosis. There is no distinct pathological cause. The majority of cases complicate gastric aton\', ulcer, or the milder degrees of p)'loric obstruction, whether of organic or spasmodic origin. It may also occur with the hyperacid form of chronic gastritis. The syinptoiiis are those of hyperacidity. Burning pain is often complained of in the fasting condition, so that the patient is obliged to take soda during the night or before breakfast. The great majority of cases present a variety of neurasthenic symptoms. Trcatuieiit is often very unsatisfactory. The fluid may be withdrawn every morning before breakfast, through a tube. Good results have been obtained by the systematic use of alkalies and by the emplo\nient of atropine. A tablespoon- ful of olive oil before meals has also been of service. Carls- GA:vrh-ic NEUROSES. 441 bad or Vichy waters may be used — Llie former before meals, the latter between meals. Atonic conditions of the stomach- wall should be controlled by frequent feedings and by intragastric faradism. Motor Neuroses. 1. Nervous Vomiting-. — Nervous vomiting does not arise from organic disease, but is a pure motor neurosis depending upon cerebral or reflex irritation. Etiology. — Nervous vomiting may accompany lesions of the brain, the cord, or the meninges, hysteria, neurasthenia, or migraine. It may be due to reflex irritation from lesions of the abdominal or pelvic organs, and it occurs with sea- sickness and pregnancy. In neurasthenic males nervous vomiting may be due to irritation of the genito-urinary organs. The gastric crises of locomotor ataxia are described elsewhere. The "periodical vomiting " of Leyden is asso- ciated with gastric pain ; it occurs in anaemic and nervous patients. The synipioins of nervous vomiting differ from those of ordinary vomiting in that nausea and retching are seldom observed. It is rather a regurgitation than a vomiting Food is usually ejected after meals, but the vomiting, which may occur at irregular intervals, is so little dependent upon dietetic errors that the name " causeless vomiting " is often applied to these cases. In hysterical cases, although all food may apparently be vomited, the general nutrition may remain good. Treatment is to be directed to the underlying cause. Change of climate is often of great service, especially in cases of the primary periodic vomiting of Leyden. 2. Peristaltic Unrest. — Peristalsis of the stomach is in- creased, with the production of loud splashing sounds often heard at a considerable distance. This condition is not un- common in neurasthenic subjects; it is usually increased by emotions. 3. Rumination ; Merycismus. — H}'sterical and feeble- minded patients ma}' regurgitate the food and chew the cud like ruminating animals. The habit is frequenth- difficult to 442 MJXL'AL OF THE PA'ACTICE OF MED/CLVE. cure, but it seems to exert no evil elTect upon the {general health. 4. Nervous eructation consists in the eructation of large quantities of gas, indcpentlent of food. The eructations are accompanied with spasmodic contraction of the participating muscles, arc explosive in character, and are not under mental control. The gas raised is atmospheric air that has been swallowed. 5. Pyloric spasm may occur with hyperaisthesia of the stomach, with hyperacidity, and with dilatation of the stomach with gases as a reflex neurosis. It commonly complicates ulcer of the pylorus. The attack gives rise to considerable cramp-like pain referred to the epigastrium, and there is stagnation of food. In ordinary cases the attack subsides. In other cases it continues, and may give rise to a considerable degree of dilatation. 3, DISEASES OF THE INTESTINES. MORNING DIARRHCEA. The etiology and pathology of morning diarrhoea are unknown. It is probable that the disease is functional and not mflammatory. Some cases seem due to a sagging of the transverse colon {coloptosis). The symptoms consist of diarrhoea, usually limited to the early morning hours. There may be but one passage, or the diarrhoea may continue throughout the forenoon. The passages are usually painless and are accompanied by the passage of flatus. The diarrhoea may be varied by periods during which the bowels are normal or consti- pated. Mental worry is usually associated with the dis- ease, and exhaustion may occur should the diarrhoea be excessive. In protracted cases the diarrhoea begins at an earlier hour of the morning, so that patients may be awak- ened at four or five o'clock in the morning with pain and ACUTE CAJARRIIAL EN'rKK/TIS. 443 an urgent desire for stool. In long-continued cases there may be developed a sense of impending movement of the bowels whenever any food is taken into the stomach. Treatment. — A change of climate is frequently followed by a most brilliant result, which in the majority of cases is permanent. The general health should be built up ; various modifications of diet should be tried, such as diets from which the starches and sugars are excluded, or a diet of meat alone. The treatment by drugs is not satisfactory, but salol, naphthaline, and the subgallate of bismuth may be used. Delafield finds his best results to have followed castor oil in doses of from 5 to 10 drops. ACUTE CATARRHAL ENTERITIS. Synonyms. — Acute ileo-colitis ; Acute entero-colitis ; Acute intestinal catarrh ; Acute diarrhoea. While certain portions of the small intestine may be in- flamed more than others, it is not usually possible during life to say which portion is especially involved. In the great majority of cases the small intestine throughout its length is affected, together with the upper portion of the large intestine, and to this condition the names of " enter- itis " and " entero-colitis " are applied. Duodenitis causing catarrhal jaundice will be considered under the latter heading. Etiology. — The causes may be primary or secondary. Primary Causes. — i. Error in food, either in quantity or in quality. The commonest cause is the ingestion of unripe fruit or of food or milk in which decomposition-changes have taken place before its ingestion. Individual peculiari- ties play a considerable part in the causation of the disease, for what is food for one may be poison for another. 2. Impurities in drinking-water often cause epidemics of enteritis. Strangers are more susceptible to such impurities than are those who are accustomed to the water. 3. Toxic causes, such as irritant food or drugs, either alkaline, acid, or corrosive. 4. A sudden fall in temperature or the chilling of the surface after excessive perspiration may induce an attack. 444 -V.LVr.lZ. OF THE PRACTICE OF MEDICIXE. 5. Changes in the intestinal secretions may theoretically give rise to conditions leading to catarrh, but of these changes we know practically but little. Secondary Causes. — i. Enteritis is often secondary to any gastric cause allowing fermenting or undigested food to pass into the intestine. 2. Peritonitis or any organic disease of the intestine, such as ulcer, hernia, or cancer. 3. Enteritis is favored by any chronic congestion of the intestinal blood-vessels from chronic heart or lung disease, or by any cause producing obstruction in the portal circu- lation. 4. Enteritis often occurs in the course of acute infectious disease ; it may attend chronic cachectic conditions, such as those occurring with cancer, tuberculosis, Bright's disease, or anjumia. Pathology. — The mucous membrane is red, swollen, con- gested, and covered with mucus. These pathological ap- pearances often disappear after death, leaving the mucosa pale and sodden. The solitary and agminated glands are swollen and prominent, especially in children. Follicular and catarrhal ulceration may occur. Symptoms. — There is pain of a colicky character, which ma\- be diffused or ma}- be localized at the umbilicus. It is usually worse before an evacuation, and is generally relieved by firm pressure. A tendenc}- to straining indicates that the lower portion of the colon is involved. Tjmipanites and gurgling noises or borborygmi usually accompan)' the attack, being due to the presence of fluid and gas within the intes- tine and to increased peri.stalsis. If the inflammation be con- fined to the small intestine, there need be no diarrhoea. If the colon be involved, there is a loose fecal diarrhoea, the thin, gruel-like stools often containing portions of undigested food (lienteric diarrhoea) and flakes of brownish mucus. The color of the stools varies from dark brown to yellow, or even to gray, according to the amount of bile with which they are mixed. The number of evacuations varies from three or four up to twenty in the course of the day. There is usually loss of appetite, with occasionally nausea or vomiting. Fever CHRONIC C.rrARRHAL KNTKRITIS. 445 may be absent, or there may be a rise of temperature of a few degrees. The prognosis is perfectly good, the attack lasting from five days to a week and terminating in recovery. Relapses are frequent from repetitions of the original exciting cause. Treatment. — In mild cases rest and a restricted diet suf- fice. The dietetic rules to be observed in chronic gastritis are applicable to these cases. In more severe cases a milk diet during the acute attack may be indicated. The patient should be kept warm, and a flannel band over the abdomen is of service, particularly in children. A cathartic is usually indicated at the onset, despite the existence of diarrhoea. The best drug for this purpose is castor oil or calomel. It is not wise to check diarrhoea for forty-eight hours. After this time astringents may be given, combined with opium in small doses. Bismuth subnitrate in gr. xx— xxx doses every two hours is usually efficient. Pain may be controlled by hot applications to the abdomen, by small doses of opium, or by spirits of chloroform in .5ss doses. CHRONIC CATARRHAL ENTERITIS. Etiology and Synonyms. — Chronic catarrhal enteritis rarely occurs as a primary disease. It may follow repeated acute attacks, or may be due to the continuance of improper food and hygiene. In these cases, however, there is usually a chronic gastritis or atony to which the enteric catarrh is secondary. It follows chronic congestion of the portal circulation and chronic lung and heart diseases. It may follow a great variety of gastric disorders, and it occurs with chronic lesion of the intestine, such as cancer or tuber- cular inflammation. Cachectic and debilitated conditions predispose to the disease, and it seems to be more common in those with a gouty tendency. Synonynns : Chronic intes- tinal catarrh ; Chronic diarrhoea ; Chronic catarrhal entero- colitis. Pathology. — The lesion is a chronic catarrhal inflamma- tion of the small, and usually of the large, intestine. The mucous membrane is generally congested and covered with mucus, and the wall of the intestine is thickened by hyper- 446 M.lXr.lL OF THE P/^.tCT/CE OF MEDICIXE. troph}' of all its la\'or.s. In other cases the wall of the in- testine is thinned, the glandular elements undergo atrophy, and the mucous membrane is grayish or lead-colored. The lymph-follicles are swollen and pigmented. Pigmentation of the villi also occurs. Catarrhal or follicular ulceration is seen in severe cases, the latter form being especially well marked in the lymph-follicles of the descending colon and the sigmoid flexure. The close approximation ofthe.se con- ical ulcers often gives to the colon a sieve-like or honey- combed appearance. These ulcers ma\- perforate or be the seat of hemorrhage. The symptoms of chronic catarrhal enteritis resemble those of acute entero-colitis, but are more protracted. As the large intestine is almost regularly involved, diarrhcea is a prominent symptom in most cases. In other patients diarrhoea alternates with periods of constipation. The stools usually are thin and fecal, containing undigested food mixed with mucus. If mucus be evenly admixed with the stool, its source is probably the small intestine ; if it coat the stool, it comes from the large intestine. The patient frequently passes lumps or strings of glairy mucus, which may com- prise the entire stool. Blood or pus may be present in the dejecta, the presence of the latter being a sure indication of the existence of ulceration. The number of stools varies from one to eight in the course of the day. In some cases the diarrhoea occurs in the early morning hours ; in other cases it is induced by eating. Pain to some degree is usually present. It ma}' be dif- fused, or localized at the umbilicus and of a colicky cha- racter. It is most common in from one to three hours after eating. In other cases there is only a sense of oppression and fulness. Borborygmi and flatulence accompany the disease, and there may be symptoms of an associated gas- tritis or of functional disturbance of the liver. In aggra- vated cases the general health fails, the patient becoming thin and weak, and the emaciation and prostration may be extreme. Hypochondriasis or melancholia may occur. In- dicanuria is very frequently present. The prognosis for perfect recovery is usually bad, although PHLEGMONOUS ENTER IT IS. ^^-J much may be done to relieve the patient. There arc usually periods of temporary improvement, even if the case be not treated. The disease may be fatal in debilitated and a,e,^ed patients and in children. The rare accident of perforation should not be forgotten. Treatment depends upon the primary disorder. In every case careful examination for gastric disorders should be made, and these should be appropriately treated. The diet should be regulated to suit the particular needs of each case, and determined by the results of gastric analysis. Cathar- tics are absolutely contraindicated, but if constipation exists, the bowels should be regulated by diet, massage, or faradi- zation. If diarrhoea is present, astringents with intestinal dis- infectants are indicated. Among these may be mentioned subnitrate of bismuth, 3ss-j ; subgallate of bismuth, gr. x-xx; naphthaline, gr. x-xv ; salicylate of bismuth, gr. x-xx ; or salol, gr. v-x, — these doses being repeated three or four times in the day. Opium should not be given as a routine treatment. If the diarrhoea depend upon ulceration of the colon, large colon injections should be used. The hips being elevated, the injection should be allowed to flow in gradually from a fountain bag ; in this way from two to four pints of injection are to be introduced, and it may be retained for some time. Simple water containing 3) of soda or borax or salt to the pint may be used ; the addi- tion of an astringent is seldom, if ever, necessary. In all cases care should be taken to build up the general health and to avoid exposure to cold. A flannel abdominal band- age should be worn constantly. In some cases the best results are obtained by sending the patient to spend the winters in a warm, dry climate. PHLEGMONOUS ENTERITIS. This affection is exceedingly rare as a primary disease, but it may occur in connection with ulceration of the intes- tine, strangulated hernia, and intussusception. The puru- lent infiltration may be localized or diffused. Symptoms. — The primary cases run a peracute course, with pain, tympanites, constipation, and fever, and terminate 44^ .V.-LVC.IA OF THE PRACTICE OF MEDICIXE. by septic peritonitis. These cases appear to be clue to in- fection by the bacterium coh commune. The symptoms of the secondary cases may be obscured by those of the primary disease, so that the diagnosis is seldom made. Prognosis. — The disease is rapidly fatal. PSEUDO-MEMBRANOUS ENTERITIS. Btiolog-y and Synonyms. — Pseudo-membranous enteritis occurs {ci) as a secondary process in acute infectious dis- eases, especially typhoid fever, scarlet fever, and cholera; (/^) as a complication of dysentery or of intestinal obstruc- tion ; {€) in conditions of advanced cachexia; (^/) as the result of poisoning by mercury, lead, and arsenic, and in urajmic conditions. Symviyms : Diphtheritic or Croupous enteritis. Pathology. — The pseudo-membranous inflammation is usually more marked in the colon, but, especially in the mercurial and uraemic forms, the small intestine may also be involved. Necrosis, ulcerations, perforation, or hemor- rhage may result, or cicatricial obstruction may ultimately develop. The symptoms are latent in many cases secondary to acute infectious diseases and to cachectic states. In other cases, especially in the mercurial form, the symptoms of a violent entero-colitis are developed. Stools consisting of a thin, purulent liquid containing blood and shreds of the pseudo-membrane are fairly characteristic of this affection. Hemorrhage and perforative peritonitis are common com- plications. This disease should not be confounded with membranous or mucous colitis — an entirely distinct disease. The treatment is that of a severe acute entero-colitis. Opium should be given to limit peristalsis and to diminish the danger of perforation or hemorrhage. MUCOUS COLITIS. Etiology. — This affection regularly occurs in neuras- thenic and hysterical patients. Over 80 per cent, of cases occur in women, especially in those who have suffered from MUCOUS COL/T/S. 449 uterine disease or from dyspepsia. It is essentially a dis- ease of adult life, but a few cases occur in children. It is frequently associated with gastroptosis and a sagging of the large intestine (coloptosis), and in many of the cases a gastric anacidity exists. Synonyms: Mucous colic ; Membranous colitis; Mucous diarrhoea ; Membranous enteritis. Patholog-y. — There are no evidences of inflammation, but the disease seems to be due to a derangement of the mucous follicles of the colon. The exact nature of the dis- ease is, however, unknown. The symptoms appear in attacks characterized by severe colicky pain with tenderness over the abdomen, followed by the passage of mucus in flakes or strings or as casts of the lining of the bowel. Mucus is not, however, passed with every paroxysm. The attacks may last for several days or weeks ; they may be produced by errors in diet or by mental worry, and they often occur in the early morning hours. The strings of mucus frighten the patients into the belief that the " lining of the bowel is ulcerated and is coming away," so that they become hysterical and hypo- chondriacal. Between the attacks the symptoms of neur- asthenia are regularly present ; they become more marked before and during the paroxysms. Symptoms due to gas- troptosis and to gastric atony are almost regularly present, and there may be the symptoms of anacidity. The course of the disease is often chronic, the attacks recurring at intervals for years. The diagnosis is easily made if the mucus be not mis- taken for other substances, such as intestinal parasites and shreds of undigested food. The long continuance of the disease, the absence of fever, and the exciting role played by neurasthenia and the emotions serve to distinguish the disease from diseases of an organic basis. If due to an or- ganic basis, mucus is regularly present in the wash-water of an intestinal irrigation, while in the purely neurotic form the bowel-washes are clear between the attacks. The prognosis is good if the neurasthenia can be relieved. Treatment consists primarily in the cure of the neuras- thenia. The Weir Mitchell rest-cure should be tried in 29 450 M.t\L:u. OF THE practice of medicixe. obstinate cases, while in all instances the nutrition should be improved in e\'ery way. Forced feeding, especially by cream and cod-liver oil, is often beneficial, and it can be said that tlie prognosis is good if the patient can be made to gain in weight. Gastroptosis and atony require their especial treat- ment. If there be coloptosis, a tight-fitting supporting belt should be advised. Morphine is not to be used during a paroxysm, for fear of the habit being formed. High enemata of w-arm salt-solu- tion (3j : Oj) ma>- be given ever\- day to cleanse the colon and to bring awa\' the mucus. At least two quarts of the solution should be allowed to enter the bowel slowh', the patient lying on the left side with the hips elevated. Astringent and irritating enemata should not be used. DIARRHOEAL DISEASES OP CHILDREN. General Etiology. — Diarrhoeal diseases occur with espe- cial frequency among artificially fed children between the ages of six and eighteen months, and tenement-house and asylum children are more apt to be attacked. Owing to the small size of the child's stomach and to the deficiency in the saliva and in the proper acidit)' of the gastric secre- tions, dietetic errors result in graver consequences than in adults. The food may be given too freely or at irregular intervals, or the child may partake of food suitable only for adults, and the result of these dietetic errors is intensi- fied by teething and by hot weather. Decomposed milk teeming with bacteria is perhaps the most common cause of infantile diarrhcea. The relation of bacteria to the diar- rhoeal affections of children has received careful attention. The healthy stools of children contain a number of micro- organisms, the most important of which are the bacterium coli commune and the bacterium lactis aerogenes, the latter being present only after a milk diet. These two bacteria are alone constantly present. In infantile diarrhoea there appear, in addition to the above-mentioned bacteria, a great number of micro-organisms, as many as fort)' varieties hav- ing been described. Acknowledging that these diarrhoeal diseases have a bacterial origin, no one germ can be re- nrARh'IKKAf. DISEASES OE CIIIf.DR EN. 45 I gardcd as the specific cause, but a large number of different kinds are concerned. Classiflcation, — Three distinct forms of acute infantile diarrhoea arc to be described: I. Acute dyspeptic diar- rhoea ; 2. Acute entero-colitis ; 3. Cholera infantum. Acute Dyspeptic Diarrhcea. Acute dyspeptic diarrhcea, which is caused by the irrita- tion of undigested or tainted food, is due to increased in- testinal peristalsis. Symptoms. — The stools, which are rarely more frequent than five or six in the twenty-four hours, consist of lumpy masses of undigested milk or food. They are not watery, and they contain no mucus. Their color is yellow, mixed with green, usually changing to green on exposure to the air. There may be vomiting of food and of mucus. Col- icky pain usually precedes each stool, and the abdomen may be distended with gas. Convulsions or carpopedal spasms may occur in nervous children. In mild cases there may be no fever, but in the severer forms and in the case of children naturally feverish the temperature may reach 104° or even 105° F. The attack usually terminates when the intestine has been relieved of its irritating con- tents ; it may, however, prove fatal in sickly children. In hot weather and in neglected cases the disease may develop into entero-colitis. Treatment. — The bowels should be moved freely by castor oil or calomel, even if the condition of diarrhoea persist. Food should be withheld for a time until the stomach is settled, but cracked ice or cool water may be given. After the bowels have been moved by medication, bismuth and chalk mixture may be given. Acute Entero-colitis. Acute entero-colitis is the ordinary form of summer diar- rhoea in children. It is the dreaded scourge of tenement- house children in their second summer, and it often appears as a sequel to the specific diseases of children. The ileum and the colon are the seat of a catarrhal inflammation, the 45- M.lXL'.iL OF THE PKACTICE OF MEDICIXE. follicles being especially involved, and frequently ulcerated, so that the name " follicular enteritis " or " follicular dysen- tery " is sometimes applied to these cases. In severe cases the inflammation may be of the pseudo-membranous variety. Symptoms. — The disease usually follows acute dyspeptic diarrhcea. The general condition of the child becomes worse. The temperature rises and remains constantly high, although extreme hyperpyrexia is but seldom observed. The stools become small in size, vary between twelve and thirty in the twent)'-four hours, contain a large quantity of mucus frequently mixed with blood, and are acid and offensive. They may be passed painlessly, or with straining and tenesmus if the rectum be involved, or colicky pain may precede the movement. Flatus is usually passed in considerable amount, and the abdomen is distended, hard, and usually tender along the line of the colon. Vomiting may occur, but it is rarely a marked feature of the disease. The attack may last for several weeks and may terminate by recovery or by death from inanition and exhaustion, or the affection may become protracted. In this form the acute symptoms disappear, but the diarrhoea continues and nutrition does not improve. From this subacute enteritis the child may convalesce in from six to eight weeks, or the disease may become chronic. In some cases of entero-coHtis the follicular glands of the colon are extensively involved, leading to the symptoms frequently spoken of as the "acute dysentery of children." The onset is sudden, with fever, convulsions in the severer forms, and frequent small passages almost entirely com- posed of mucus and blood, and not containing feces. There are incessant abdominal pain and rectal tenesmus. In mild cases the bowels can be opened within two or three days by castor oil, and recovery rapidly ensues ; but if the bowels cannot thus be moved, the case is apt to continue from three to six weeks, or even to become chronic. There is a rare form of entero-colitis, of great severity, characterized by high fever, dysenteric symptoms, convul- sions, stupor, and collapse. DIARRIKBAL DISEASES OF CHILDREN. 453 Treatment. — Attention to the proper feeding of the child is of the utmost importance. The diet should consist of sterilized or peptonized milk or of albumin-water. Cream and water are often better borne than milk. After the irri- tating cause has been removed, bismuth and chalk mixture should be given, to whicli any of the intestinal antiseptics may be added. Of these, bismuth salicylate, bismuth sub- gallate, and salol are perhaps the most reliable. Large enemata of salt-solution (.tJ : Oj) should be used to flush out the colon ; they are of the greatest service. The addition of astringents to these enemata is not to be recommended. Should dysenteric symptoms occur, the bowels should be opened with castor oil, and this medication should be repeated every other day. Medicated enemata may in these cases be used, as in the dysentery of adults. Cholera Infantum. The term " cholera infantum " has been applied loosely to any diarrhoea of childhood with vomiting and prostration, but it should be limited to a special group of symptoms resembling cholera morbus of the adult. The term beingf limited in this way, cholera infantum is rather a rare disease, occurring in only 2 or 3 per cent, of the summer diarrhoeas of children. Cholera infantum is essentially a bacterial dis- ease, the symptoms being due to poisoning by the ptomaines generated by the action of the bacteria upon milk or other intestinal contents, although no one organism can be de- scribed as a specific cause. Pathology. — There is an acute gastro-enteritis, although the appearances of inflammation may disappear after death, leaving the mucous membranes pale and sodden. The lymph-glands of the intestine may be swollen, and in rare instances may soften and break down to form follicular ulcers. Various micro-organisms may be found in the mes- enteric glands and in the lymphatic vessels of the intestinal wall. The symptoms of cholera infantum may begin abruptly, or there may be a preliminary diarrhoea for several days. The first regular symptom is purging. The stools, at first 454 MAXCAL OF THE PRACTICE OF MEDICINE. acid and fecal, later become alkaline, serous, and either colorless, brownish, or of the " rice-water " appearance. The passages are abundant, often are expelled with force, and in some cases amount to a constant discharge. The purging is supposed to result from paresis of the blood-ves- sels of the intestinal wall from the toxic action of the pto- maines, resulting in the abundant transudation of serum. There is, as a rule, neither abdominal pain nor tenderness, although in some cases colicky pain may precede the purg- ing in the earlier stages of the disease. Vomiting is not as constant as purging, but it may be violent and incessant, so that no food can be retained. The vomited matters consist first of food ; later they are of a brownish or bile-stained serum, and may be like rice-water. The skin is cool and clamm}% but the rectal temperature shows an increase to 103°, 105°, or even 107° F., there being no disease of in- fancy regularly attended by so high a temperature. The pulse is rapid and thready. The skin may be firm and hard — a condition to which the names "sclerema" and " frozen skin " have been applied. The appearance of the child is rapidly altered : the face is thin, drawn, and of an ashy paleness, the eyes are sunken, the fontanelle is de- pressed, and the loss of weight is evident. The urine becomes diminished or even suppressed, and urjemic symp- toms may develop. Course of the Disease. — i. A considerable number of the children die in from one to three days, from exhaustion, collapse, or with cerebral symptoms. These " hydrocepha- loid " symptoms, or " pseudo-hydrocephalus," consist of drowsiness merging into coma, muscular twitchings or con- vulsions, retraction of the head, and subnormal temperature or hyperpyrexia; the respirations become shallow and ir- regular, and may be of the Cheyne-Stokes variety. The pulse becomes irregular and flickering. The vomiting and purging usually cease for some hours preceding the fatal termination. 2. Other patients begin to improve in from twenty-four to thirty-six hours, and the improvement is either rapid and DIARRIKI'.AL DISEASES OF CI! J ED REN. 455 complete or is complicated by a recurrence of the former symptoms. Chronic furunculosis may appear as a sequel. 3. In some children improvement progresses only to a certain point, but the child still continues sick, with vomiting, diarrhoea, and prostration. In this condition the child may remain for weeks and then slowly recover ; or the symptoms may continue, prostration and emaciation may become more and more marked, and the child may ultimately die from marasmus. The prognosis is always serious, especially in bottle-fed babies and in asylum and tenement-house children. A guarded'prognosis must always be given, however mild the case may appear at the onset. Treatment. — The most important indication for treat- ment is the reduction of the hyperpyrexia. This should be accomplished by baths of 90° F. gradually reduced to 80° F. by the addition of cool water. Irrigation of the stomach and the colon is indicated in every case, to remove toxic products and to supply water to the tissues. For the purging, opium is almost indispensable, but the drug should be given to children with extreme caution, as they are pecu- liarly sensitive to its action. Morphine gr. j^q- is a fairly large dose for a child of one year. As a practical rule, opium should not be given to babies under six months of age unless it be absolutely necessary to do so.' All nourishment should be discontinued for twelve to eighteen hours, and then feeding by small quantities of bar- ley-water, albumen- water, or expressed beef-juice ma}' be permitted. Intestinal antiseptics should be given if they do not add to the vomiting. Of these, bismuth salicylate (gr. v q. 2 h.) is perhaps the most useful. Small doses of mercurial prep- arations often are of service in controlling the vomiting. Calomel (gr. jV). mercury with chalk (gr. j^), or bichloride of mercury (gr. ^-g-g") may be given in these doses every two or three hours without danger of salivation. Stimulants may be given if indicated, and, should collapse appear, subcutaneous injections of a i per cent, saline solution (sterilized) may be given as in x\siatic cholera. Iced drinks 456 M.l.VL'AL OF THE I'RACTICE OF MEDJCLXE. may be given even if the}' are not retained. If the case be protracted, it is of the utmost importance to move the child to the country, where the air is cool and fresh. These httle patients • stand travel well, and the improvement is often striking within a few hours after the change has been made. The dietetic rules are those applicable to acute entero-colitis. Cholera iiifatituin in incat-fcd children presents certain peculiarities by which it differs from cholera infantum of milk-fed babies. The stools are not as watery, as frequent, nor as profuse as in the ordinary cases, but are grayish or yellowish-green and highh' offensive. Tympanites is a con- stant symptom, but vomiting is more frequently absent. The general symptoms arc those of sepsis, and death usually re- sults in from forty-eight to seventy-two hours. Mild cases may recover. CHOLERA MORBUS. Etiolog-y and Synonym. — Cholera morbus is most com- mon in young adults and in the summer months. The attack may be induced by improper or partially decayed food, by unripe fruit, or by impure drinking-water. At times the disease assumes such epidemic proportions that it seems as though some specific micro-organism must act as the exciting cause. Synonym : Cholera nostras. Pathology. — The lesion consists of a catarrhal inflam- mation of the stomach and of the large and small intes- tines. The submucosa is infiltrated to some extent by fibrin, serum, and round cells, and the intestinal glands are swollen. It is impossible to differentiate cholera morbus from Asiatic cholera except by post-mortem examination, the comma bacillus being found in the latter disease. Symptoms. — The attack is usually sudden, although it may be preceded by oppression and by vague abdominal distress. The patient is usually attacked during the night or the early morning. There are nausea and faintness with violent and incessant vomiting, the ejected matter consist- ing at first of food and later of fluid, either colorless or tinged with bile. Following or coincident with the vomit- ing is severe purging. The stools at first arc feculent, but COLITIS. 457 later become watery and odorless ; they consist of serum with flakes of desquamated epithelium, giving to the stools the so-called " rice-water " appearance. The color of the passages is usually greenish or yellowish, and the fluid is sufficiently acrid to irritate and excoriate the anal parts. Cramps in the abdomen cause tearing, lacerating pain, usu- ally referred to the umbilicus, but in some cases the purging is painless. There may be violent muscular cramps, espe- cially in the calves of the legs, due to the dryness of the tis- sues. Prostration appears early in the attack. The face is drawn and anxious ; the pulse is rapid and thready ; the skin is cold and clammy, but the internal temperature reaches ioi° or I02° F., or even higher than this. The duration of the attack varies from a few hours to several days. The prognosis is good. The disease may, however, be fatal in debilitated subjects, so that the whole mortality is between 2 and 3 per cent. The diagnosis from Asiatic cholera cannot be made with certainty without bacterial examination of the stools. Treatment is entirely symptomatic. As drugs cannot be retained when given by the mouth or the rectum, hypo- dermic medication alone is to be relied upon. Morphine in gr. y^ doses should be given, and repeated if necessary, to check the pain, vomiting, and purging. Hot poultices applied to the abdomen afford relief For the attendant thirst cracked ice may be allowed if it does not increase the vomiting. It is well to give no food by the mouth until the attack is well over, and then food may be allowed in small quantities at first and at frequent intervals. COLITIS. Etiology. — Under the term colitis are embraced a variety of inflammations of the large intestine from the caput coli to the anus. When the inflammation involves the lower portion of the bowel and is accompanied with straining and frequent small passages containing mucus, it is commonly known as dysentery. Colitis is essentially a disease of the tropics, where "it 453 MAXr.lL OF THE PRACTICE OF MEDICINE. destro)'s more lives than cholera, and it has been more fatal to armies than powder antl shot " (Osier). Under imperfect hycjiene sporadic and endemic cases occur in Northern cities, and even epidemics ma}' occur, but with improved sanitation the disease is much less common than formerly. The cx- citin^]^ cause has been supposed to be drinking-water con- taminated by animal matter, while in the tropics one form of dysentery appears to be due to infection by the amoeba coli. Colitis attacks patients of all ages, and there is no racial exemption. The majority of cases occur in the late summer and early fall months. Varieties. — The following \arieties are to be described : I. Acute catarrhal colitis; 2. Amcebic or tropical colitis; 3. Acute croupous colitis ; 4. Chronic colitis. Acute Catarrhal Colitis. This form is the one usually seen in temperate climates. Pathology. — The intlamniation is limited to the large intestine, especially to the sigmoid flexure and the rectum, but the lower portion of the ileum may also be involved. The mucous membrane is swollen, congested, and covered with tenacious blood-stained mucus. The solitary glands are prominently enlarged, and in severe cases may ulcerate. In the gravest form of the disease the follicular ulceration may deepen and spread, more extensive ulcerations being formed. In children the inflammation and ulceration of the follicles are more marked than in adults, so that the disease is often spoken of as " acute follicular dysentery." The symptoms differ according to whether the rectum or the upper colon be involved. I. If the rectum be involved, as it is in the vast majority of cases, there may be a preliminary diarrhoea with griping pains ; in other cases the disease begins abruptly. An initial chill is rare. Diarrhoea is usually the first symptom. At first fecal and painless, the stools change their character within from twenty-four to thirty-six hours, becoming cha- racteristic of the disease. The dysenteric stools are first composed of mucus with a {^\s! scybalous fecal masses, but finally they consist only of mucus and blood (" bloody COLITIS. 459 slime "). The presence of pus in the stools indicates fol- licular ulceration. The stools are frequent, varying from ten to two hundred in the twenty-four hours, and are small in quantity, rarely exceeding half an ounce. They are passed with a straining, bearing-down pain referred to the rectum. This tenesmus is more marked during and after a move- ment, but it may be more or less continuous, amounting to a constant desire to go to stool, and the patient may com- plain of burning pains referred to the rectum. Preceding each stool there is apt to be severe colicky pain in the abdo- men, with possibly some tenderness along the descending colon. The temperature is not high, varying from ioi° to 103° F. at the outset. There are apt to be nausea and vom- iting with incessant thirst. Prostration may be extreme. Strangury may attend the rectal tenesmus, and in severe cases the urine may contain albumin and casts. As the patient improves the number of passages diminishes, the mucus be- comes opaque and less discolored by blood, and fecal matter begins to be passed. Rectal tenesmus finally disappears. 2. If the inflammation involve the upper colon, and not the rectum, the clinical picture is different. The patient passes not mucus and blood, but large, watery, feculent stools with- out tenesmus. In severe cases blood may be admixed with the stools. Colicky abdominal pain precedes each passage. The constitutional symptoms are not severe, and the prog- nosis is that of the first form. In children this form is ac- companied by extreme prostration and febrile disturbance, so that the case may be mistaken for typhoid fever. The prognosis for the attack is good except in the ex- tremes of life. If the bowels can be opened within two days by castor oil, the attack will probably not be severe. It is possible for the disease to run into a chronic form. Peri- tonitis and abscess of the liver rarely occur. Diagnosis. — In children the disease may be mistaken for intussusception, while in adults- cases of fecal impaction or of cancer of the intestine are frequently treated as dysentery Tropical or Amcebic Colitis. Pathology. — The amceba coli or amoeba dysenteriae, a one-celled protoplasmic organism showing active amoeboid 460 M.LVr.-iL OF THE PRACTICE OF MEDIC EVE. motion, is from 10 to 20 micromillimctcrs in diameter. It has been pro\'en to be the inciter of d}'sentcr}- in tropical and sub-tropical countries, and it is not iincommonh' found in the Northern United States and in Europe. It probably gains access to the bod} bv the medium of drinking-water. The large intestine is involved, particularly the descending colon, but the lower part of the ileum may also be affected. The lesion consists of oedema of the mucosa, with localized areas of cellular infiltration causing little elevations upon its surface. These elevations become necrotic and are cast off, exposing a yellowish-gray gelatinous mass which sub- sequent!)' sloughs, leaving an ulcer with infiltrated and un- dermined edges extending through the submucosa and even to the serous layer of the colon. " Extensive under- mining of the edges of the ulcerations allows of the forma- tion of fistulous tracts bridged over by apparently healthy mucous membrane. The colon may be so involved that the remaining mucous membrane projects like little islands from the surrounding ulcerations. The disease extends by progressive infiltration and ulceration of the mucous coat of the intestine, and in severe cases large areas may slough and be thrown off 01 masse. A croupous inflammation of the colon complicates amoebic dysentery in some cases. The microscope shows a notable absence of the products of purulent inflammation, but reveals amoebae in large num- bers in the floors and the walls of the ulcers. Healing of the ulcerations by cicatrization may lead to subsequent stricture of the intestine. One-fifth of the cases are com- plicated by lesions in the liver. There may be areas of necro- sis of the parenchyma of the liver, or there may be single or multiple abscesses, consisting of necrotic liver-tissue with a small amount of pus. Amoebae are constantly found in the contents of the abscesses. Rupture of an abscess of the liver into the right pleura or lung is not infrequent. Symptoms. — The onset of the disease is usually gradual, beginning as a diarrhoea; in severe cases, however, the dis- ease may begin abruptly. The temperature is but moder- ately raised, if at all. Pain and tenesmus may be present at the outset of severe cases, but they are not constant COLITIS. 461 throughout the disease. The principal symptoms are diar- rhoea and a progressive loss of flesh and of strength. At the onset the stools may be mucoid and blood-stained as in catarrhal dysentery, but the characteristic stools are fluid, contain mucus and possibly blood, are of a yellowish-gray color, and in them are to be found actively moving amoebae. The number of the passages varies from six to twelve in the twenty-four hours. The diarrhoea runs an irregular course of from four to eight weeks, with periods of temporary im- provement. Prog-nosis. — Recovery is usually slow and tedious from anaemia and muscular weakness, and convalescence may be interrupted by relapses. The disease has a greater mortality than catarrhal dysentery, and shows a tendency to become chronic. Death may result from the severity of the local inflammation, from exhaustion in the prolonged cases, or by reason of the liver complications. Acute Croupous Colitis. This form of colitis may occur in a primary form or may appear as a terminal complication of chronic heart disease, of chronic Bright's disease, of profound cachectic states, or of lobar pneumonia. Pathology. — The colon is thickened and infiltrated by fibrin, serum, and pus-cells, so that the mucosa, from the ileo-caecal valve to the rectum, appears as a yellowish exu- date without trace of glandular structures. In mild cases the tops of the folds of the colon are covered with a thin yellowish or grayish pellicle. The mucosa thus infiltrated undergoes necrosis, and sloughs, leaving large irregular ulcers which may involve the submucosa and even the mus- cular wall. Perforation of the ulcers is not uncommon. In some cases the lower portions of the colon alone are in- volved. Peritonitis may complicate the disease even with- out actual rupture, and ulcer of the liver may result from infective thrombosis of one of the mesenteric veins. Should the patient recover, the ulcerations will cicatrize and stricture of the intestine may result ; but the healing of the ulcers is very slow, and in many cases chronic ulcerations are left. 462 M.l.VC.-iL OF THE PRACTICE OF MEDICINE. The symptoms of acute croupous colitis resemble those of the catarrhal form, but are more severe. If the rec- tum be iiuolved, tormina and tenesmus are extreme, the stools are numerous, are composed of mucus, blood, pus, and shreds of sloughing membrane, the temperature is high, prostration is extreme, and the patient is seriously ill from the onset. If the rectum be not involved, there is no tenesmus; the stools are diarrhoeal in character, contain blood, pus, and shreds of membrane, and are accompanied by severe abdominal pain. The constitutional symptoms are severe, closely resembling those oi t\'phoid fever. In the secondary cases the patient is already ill from the primary disease, so that the course of the dysentery is in- sidious. There is usually a moderate diarrhoea, with the occasional passage of blood and mucus. The prognosis of croupous colitis is exceedingly grave. Death may result from the severity of the inflamma- tion, from peritonitis or perforation, or from abscess of the liver ; or the patient may pass into the typhoid condi- tion or may die exhausted. Should the patient recover from the acute attack, the condition may become chronic. Complications. — The course of the disease may be com- plicated by septic arthritis, endocarditis, pericarditis, pleu- risy, and pyaemia. Peripheral neuritis with paraplegia is a rare complication. The occurrence of pylephlebitis and abscesses in the liver has already been alluded to. Chronic nephritis has in some cases followed the disease. Treatment of Acute Colitis. Of the Catarrhal Form. — The patient should be put to bed, no matter how trifling the attack may seem, and should be kept on a milk or liquid diet. It is important that the bowels should be moved at the beginning of the attack, castor oil being the preferable laxative. An estimate of the probable duration can often be made with reasonable accu- racy by the promptness of the response to the laxative remedies. The bowels should be opened every second day, if possible. Opium should be given by the mouth or by suppository, to control the tormina and the tenesmus. COLJ'l'IS. 463 Much relief is often afforded by rectal medication. y\n enema of hot starch-water containinc^' from 10 to 15 drops of laudanum may be given after every jjassage. As the enemata are seldom retained for any length of time, poisoning is not likely to occur. Suppositories containing^ grain of cocaine hydrochlorate, or injections of from 5 to 10 drops of a 4 per cent, solution of the drug, are ser- viceable in mitigating the pain, but the absorptive power of the rectum is so great that toxic symptoms may occur unless the case is watched with care. Quinine (gr. x-xv daily) should be given if there be a malarial history. Bichlo- ride of mercury (gr. j^q) may be given every two hours, and large doses of bismuth subnitrate (.^j q. 2 h.) are often of great service. Astringent rectal injections are not recom- mended in acute cases. In severe cases ipecacuanha may be given in large doses. This drug, without doubt, is of great service, especially in the cases occurring in the tropics. A hypodermic injection of morphine should be given, followed in half an hour by from 20 to 40 grains of powdered ipecacuanha in capsule. A second injection of morphine should be given if vomiting threaten. No food should be given for six hours after the dosage. If vomiting occur, the dose may be repeated with- in a few hours. Amoebic Colitis. — Besides the above-mentioned treatment, colon-irrigation of quinine (i : 2500) may be used, the amoebae being rapidly killed by the drug. Medication should be continued in these cases until the amoebae are no longer present in the stools. For cro7ipo7is colitis the treatment is that of the catarrhal form, except that opium is required in larger doses, and stimulants are needed to support the strength of the patient. Should extensive ulceration exist, purgatives must be admin- istered with caution. Chronic Colitis and Chronic Dysentery. Etiology. — Chronic colitis may be chronic from the first, or may follow an acute attack. When the inflammation is a part of a general gastro-entero-colitis, the name o( chronic 464 MAXCAL OF THE PRACTICE OF MEDICLXE. colitis is given to it. For the etiology and s)'mptonis of this difTused inflammation the reader is referred to the article on Chronic Enteritis. When the inflammation involves the rectum alone, the clinical picture is different, and the condition is known as chroiiic dysentery. The following article embraces only this latter form. Pathology. — The mucosa is thickened, pigmented, and presents an irregular puckered surface. The submucosa and the muscular coats are usually hypertrophied, and the. lumen of the colon may be diminished. Cystic degenera- tion of the glandular structures may be visible to the naked eye. Ulcerations are generally present in all stages of development ; they are usually pigmented. Symptoms. — Tormina and tenesmus are uncommon unless during acute exacerbations. The stools vary from three to fifteen in the twenty-four hours, and are not always of the same character; they may be composed of mucus, occasionally stained with blood, or they may be liquid and frothy, consisting of feces, mucus, and undigested food. Blood and shreds of tissue are not common except during the acute exacerbations. There may be constipation alter- nating with diarrhoea. From time to time will appear acute exacerbations in which the stools assume a more character- istic appearance of dysentery and are accompanied by tor- mina and tenesmus. Pain and tenderness along the colon are usually present. The patient rapidly loses flesh and strength ; the tongue resembles raw beef; digestion is inter- fered with ; flatulence is common ; anremia and emaciation reach finally an extreme degree. Care should be taken to exclude carcinoma. Digital or instrumental examination 6f the rectum should be made in every doubtful case. Prognosis. — The course of chronic dysentery is pro- longed for months or possibly for years, the patient usually dying from exhaustion and inanition. Treatment. — Proper diet is of prime importance. The patient should be put to bed and be given a milk diet. Should curds appear in the stools, moat broths or scraped Arpi-:xj)jcrj-js. 465 beef may be given, and only such food be allowed as may be digested thoroughly. Inspection of the stools should then govern the diet. Colon-irrigation should be employed daily, simple salt-solution (.^j ; Oj) being the preferable solu- tion. Medicated and astringent injections are painful, and are not more efficacious than simple cleansing solutions. APPENDICITIS. Etiology. — Appendicitis is more common in the young than in the old, one-half the cases occurring before the twentieth year. Males are affected in three-fourths of the cases. In a little less than half the cases hard fecal con- cretions or foreign bodies, such as grape-seeds, orange-pips, etc., are found in the diseased appendix; on this point, how- ever, statistics are misleading, the percentage of cases in which concretions are found being estimated as low as 6 per cent, by some observers, while the concretions are said to be present in 10 per cent, of presumably healthy appen- dices. The question as to whether foreign bodies and con- cretions can originate an attack of appendicitis is still un- answered. It would seem, however, that foreign bodies, concretions, exposure to wet and cold, injury and over- straining, and previous inflammations of the appendix or the narrowing of its lumen by stricture or by twists, render the appendix more susceptible to the infection of micro- organisms, so that they may be considered as causes pre- disposing to a bacterial infection. Acute Catarrhal Appendicitis. Patholog-y. — The mucous membrane lining the appendix is in a condition of catarrhal inflammation ; the walls are swollen and are infiltrated by serum and leucocytes, so that the appendix is enlarged and its lumen becomes contracted, especiall}' toward the cascal end. The peritoneum covering the appendix is congested, is coated with fibrin, and is ad- herent to neighboring peritoneal surfaces. In this, the mild- est and commonest form of appendicitis, there is no general peritonitis, no abscess, and no perforation. Symptoms ma}' begin gradually or suddenly. If gradu- 30 466 AfJXL'AL OF TJIE PRACTICE OF MEDICINE. ally, there is a preliminary diarrhoea, or diarrhoea alternating with constipation, and a pain which is either of a colicky character or is localized in the right iliac fossa. Cases with a sudden onset are in- itiated by a chill or by chilly feel- ings. When the disease has de- veloped there is fever, usually of Fig. 44. — Cai;\rrli.il aiipcMidicitis ; 1 . • , •. _ • 1 locahzed fibrinou. pcritonms: no moderate intensity, running be- pus-format.on ; no general peri- tWCCn IOI° and I03° F., rCmain- tonitis. • /- 1 r ^ 1 ing for three or lour days and then slowly subsiding. It is of the greatest importance to keep accurate records of the temperature of each patient, as it is impossible at the onset to distinguish between the mild and the severe forms, and the exact diagnosis, the presence of complications, and the indications for operative interference are all determined, in great measure, by the char- acter of the temperature curve. With the fever there are head- ache, loss of appetite, nausea and vomiting, and prostration. It is even more important in every case to have a careful estimation of leukocytosis made daily. In the catarrhal form the number of leukocytes is usually under 12,000. Local symptoms consist of pain, tenderness, and position in bed. Pain, which is localized in the right iliac fossa, may be steady or paroxysmal. Should the appendix be abnormally situated, the pain may be felt in the right lumbar region or nearer the median line in front. In some cases the pain cannot accurately be localized. Tenderness is usually elicited by firm continuous pressure at McBurney's point, situated from one and a half to two inches from the right anterior superior spine, on a line drawn between this bony prominence and the umbilicus. If the appendix be displaced behind the caecum, tenderness may not be elicited at McBurney's point, but may be detected by vaginal or rectal examination ; hence, in doubtful cases, these methods of ex- amination should always be resorted to. The thigh is usually flexed to relax the anterior abdomen ; it may be adducted from irritation of the obturator nerve within the pelvis. A/'P/'i/vn/c/r/s. 467 Physical Examination. — Tenderness is produced by pres- sure at McBurney's point or by rectal or vaginal examination. There is usually considerable rigidity of the abdominal wall in the right iliac region. There may be a feeling of resist- ance in the right iliac region, and slight dulness on percus- sion, but no defined tumor can be appreciated. The detec- tion of resistance and dulness on percussion depend upon the position of the vermiform appendix (not being appre- ciable should the appendix be behind the caecum) and upon the extent of the localized peritonitis. Should several coils of intestines be matted together and adherent to the appen- dix, the resistance and dulness may be as well marked as in cases of the suppurative form. Course of the Disease. — After from two to four days the patient begins to improve, showing that the case is one of the mild form, and in about a week convalescence is thoroughly established. Pain, tenderness, and irregular action of the bowels may, however, persist for some weeks, owing to the resulting peritoneal adhesions, and relapses may occur at any time. Acute Suppurative Appendicitis (Ulcerative Appendicitis). Pathology. — In this form of appendicitis the wall of the appendix is infiltrated by fibrin, serum, and pus, and in severe cases the wall may slough in some part, so that the contents of the appendix escape into the peritoneum. The ad- jacent peritoneal surfaces are inflamed, coated with fibrin and pus, and become adherent, so that there is formed a cavity containing pus. This circum- scribed intraperitoneal abscess may remain localized or may fig. 4S— Suppurative appendicitis : rupture into the general peri- "'"'^'"^ adhesions; localized intra- '■ 01 peritoneal abscess. toneal cavity, producing acute peritoneal septicaemia ; or diffuse suppurative peritonitis may result without actual rupture. Suppuration may ex- 468 .U.l.VC.tL OJ- JI/Jl PKACnCE OF MEDICI XE. tend along the connective tissue in the mesentery of the appendix and invade tlie retroperitoneal tissues. This for- mation of an extraperitoneal abscess is not common, and occurs only in connection with the intraperitoneal abscess previously described (Figs. 45. 46). The peritoneum divid- ing the intraperitoneal from the extraperitoneal abscess ulti- mately becomes absorbed, so that one large abscess-cavity results. The pus may be abundant and creamy, or the quantity ma\' be small and surrounded by a large amount of inflam- matory tissue. The pus is usually grayish in color, exceedingly offen- sive, and, should sloughing of the vermiform appendix occur, may be admixed with the contents of the in- testine. Bacterial examination usu- ally reveals pure cultures of the ba- cillus coli commune. The position of the abscess varies according to the position of the ap- pendix. The usual situation is in the angle of the ileum and the caecum, lying on the psoas muscle. In other cases the abscess lies behind the cae- cum or extends into the pelvis. Rupture of the abscess may occur at any time, either into the perito- neum, the intestine, or the bladder, or, less frequently, through the abdominal wall, the pleura, the portal vein, or the iliac artery. When the retroperito- neal tissues become infected, the so-called " pcrityphlitic " abscess may burrow under the iliac fascia and appear below Poupart's ligament, or may extend to the perinephritic tissues. Suppuration may extend along the psoas fascia or may involve the perirectal connective tissue. Burrowing through the ob- turator foramen, the pus may appear as a gluteal abscess. The symptoms begin like those of the catarrhal form, but they are more severe. The temperature ranges between 102° and 104° F. ; pain and tenderness are well marked; Fig. 46.— Cross-section of appendix with suppurative inflammation, showing ex- tension of the infection along the connective tissue of the mesentery to the retroperi- toneal connective tissue, and the formation of an extra- peritoneal abscess. The peritoneum separating the intraperitoneal from the ex- traperitoneal suppuration is here shown intact ; it, how- ever, subsequently disap- pears. APPKND/C/TfS. 469 the thigh is flexed and adducted; the bladder and the i-ectum may give evidences of irritabihty. The physical signs during the earher stages of the dis- ease depend upon the position of the abscess. {a) If the abscess be in the inner side or in front of the caecum, there will be tenderness in the right iliac fossa, especially marked over McBurney's point. There may be some bulging in the right iliac fossa, in which region a percussion-note of dulness is obtained. The abdominal wall on the right side is rigid, and there is an indistinct tender mass to be felt in the region of the appendix. {b) If the abscess be small and be situated behind the caecum and the distended intestines, tenderness on palpation will be elicited, but no tumor can be detected, although there may be a sense of resistance to palpation. The per- cussion-note is tympanitic, and some oedema may be noticed in the right lumbar region. {c) If the abscess encroach upon the pelvic space, the physical signs may not be elicited by external abdominal examination, but rectal or vaginal examination detects the presence of the abscess. Instead of the disease subsiding in three or four days, as does the catarrhal form, the symptoms become aggravated. The temperature becomes irregular and remittent, and septic symptoms appear on the third or fourth day and are strik- ingly developed by the end of the first week. In some cases there are added the symptoms of intestinal obstruc- tion from septic paralysis of the intestinal wall. In the suppurative form the leukocytes vary^ between 12,000 and 30,000, with about 18,000 as the average of operable cases. Physical examination by the seventh or tenth day may reveal, by palpation through the abdominal wall, the rectum, or the vagina, an indistinct wave of fluctuation in the tumor- mass. The fluctuation is most marked in extraperitoneal abscesses, and is detected above Poupart's ligament or above the crest of the ilium. The abscess may, however, be small, and may be in a locality where it cannot be felt, so the diagnosis may still be doubtful. The aspirating-needle 47 O M.IXL'AL OF THE PRACTICE OF MEDICLNE. should never be used for diagnostic purposes unless a marked tumor with dulness is present in the ca;cal region, and even then it sliould be used with extreme caution. Course of the Disease. — i. Some patients gradually re- cover. The temperature declines, pain and tenderness sub- side, and the physical signs clear up. These are the cases of mild infection in which the peritoneal exudate is chiefly fibrino-serous without much admixture of pus, so that absorption of the effusion is possible. 2. Other cases go on with the symptoms of sepsis and of a localized peritoneal abscess. {a) Some cases are operated upon and the pus is evacuated. -■715 Day of Disease 1 2 3 4 107° 106° 105° f 104° ■S . 103<: •| r 102° s A / 101° 100° y' y : : Fig. 47. — Suppurative appendicitis : rupture of abscess into peritoneal cavity ; acute peritoneal sepsis. ij)) In some cases the abscess ruptures. If the rupture occur through the abdominal wall or into the bladder, the rectum, or the intestine, the pus will appear externally, the temperature will fall, and the general symptoms will im- prove. If drainage be good, a spontaneous cure will result, but if drainage be poor, the abscess-cavity will fill up again and the old symptoms will reappear. Fistulae may result, and there may be a resulting cystitis which, if the bladder be perforated, may prove fatal. {c) Burrowing may occur, so that pus will rupture into distant parts, even into the pleural cavity. ArPENDIC/'J'/S. 47^ id) Acute progressive peritonitis may develop. This is the greatest danger, and usually begins in the second, third, or fourth day, before the limiting adhesions have become firm enough to prevent general infection of the peritoneum. Spreading abdominal pain, tympanites, and an increase in all the constitutional symptoms indicate the onset of the peritonitis. In some cases there is a pro- gressive increase in the size of the tumor. {e) The abscess may rupture and discharge its contents into the peritoneal cavity, so that acute peritoneal sepsis may result. The temperature falls, but subsequently rises to a higher point than before, and collapse symptoms appear. Death may occur in from twelve to fifteen hours from col- lapse, with high ante-mortem temperature, or the symptoms of a general peritonitis will develop from which the patient will die in two or three days (see Fig. 47). 3. The course of the disease may be modified by compli- cations. Among these may be mentioned thrombosis of the femoral vein, and thrombosis of the portal vein which may be infective, leading to pyaemia with multiple abscesses in the liver. Pyaemia or septicaemia may develop in neglected cases. Gangrenous Appendicitis. Under the above heading are included the rather rare cases in which primary gangrene or necrosis of the appen- dix-wall occurs, so that the contents of the appendix are discharged into the peritoneal cavity before there is time for limiting peritoneal adhesions to be formed. The patient usually has suffered from previous at- tacks of catarrhal or suppurative appendicitis, with resulting ad- hesions, so that the appendix becomes distorted and twisted. Usually the exciting cause is a foreign body or a fecal concre- tion which enters the appendix and induces a pressure-necrosis on its wall. There maybe a Fig. 48. — Gangrenous appendicitis ; sloughing of the wall ; escape of con- tents into peritoneal cavity ; absence of limiting adhesions. 4/2 .i/.i.vr.i/. (V' r///-: pkact/c/-: of medicixk. local peritonitis, but no adhesions are formed, so that the sloughing appendix lies free in the peritoneal cavity. Acute peritoneal sepsis develops, and usuall>' runs a fatal course. The symptoms begin like those of the suppurative form, but the patient is evidently more sick. Peritoneal sepsis and death usually result before a tumor can be appreciated. Pi'ognosis of Appendicitis. In the catarrlial fonii the prognosis is good. It should be remembered, however, that the appendix is left adherent and predi-sposed to recurrent attacks. In the suppurative form the prognosis is good, de- pending less, however, upon the intensity of the inflam- mation than upon the skill of the surgeon. When gen- eral peritonitis occurs, the prognosis is most unfavorable. Rupture of the abscess into the general peritoneal cavity is almost regularly fatal. Spontaneous cure ma\' occur by absorption or by perforation through the abdominal wall or into the bladder or the rectum, but aside from these cases the prognosis is bad unless the case be treated sur- gically and the abscess-cavity be drained. Gangrenous appetuiicitis, unless operated upon very early in the course of the disease, before actual perforation has occurred, is rapidly fatal. Treatment of Appendicitis. No disease requires more judgment for its proper treat- ment than appendicitis, as no routine plan of treatment is applicable to all patients. In every case a surgeon should be called into consultation, as the disease is, properly speak- ing, a surgical one. The treatment is both medical and surgical. Medical Treatment. — The patient should be put to bed, no matter how mild the case may appear, and be put upon a liquid diet. Opium is to be given, to quiet the patient and to allay pain, but large doses to the point of semi- narcotization are not to be recommended. Cathartics are absolutely contraindicated, because of the danger of ruptur- APJ'ENDJCJ y y.s' 47 3 ing limiting peritoneal adhesions by the increase of intes- tinal peristalsis. The bowels should, however, be moved every second day by enemata of tepid water containing salt (3j : Oj). An ice-bag should be applied to the cascal region, or a Leiter cold coil may be used. Hot poultices are not recommended. Surgical treatment consists in evacuation of the pus, removal of the diseased appendix, and drainage of the ab- scess-cavity. Operative interference is indicated under the following conditions: (i) In catarrhal appendicitis with severe con- stitutional symptoms, especially if the attack be recurrent ; (2) whenever symptoms of pus-absorption are present, whether the tumor can be felt or not ; (3) whenever the patient is more than ordinarily sick, and does not seem to be standing the disease well; (4) should septicaemia develop; (5) in cases of spreading peritonitis; (6) in case of rupture and peritoneal sepsis ; (7) in case of burrowing of the ab- scess ; (8) in all cases in which a tumor presents itself; (9) in case of rupture into the bladder, the intestine, or the rectum, the drainage being imperfect; (10) whenever there is an increasing leukocytosis. If the leukocytes vary between 15,000 and 18,000, the case should be closely watched, but not necessarily operated upon. When leukocytosis amounts to 18,000 or over, an operation is indicated. Chronic Appendicitis. This form of appendicitis occurs in patients who have had previous attacks of acute inflammation of the appendix. Pathology. — The appendix is usuall}' enlarged and of a sausage shape. Its walls are thickened, the outlet is ste- nosed, and its cavity is filled with mucus. The appendix may be sharply bent upon itself or displaced. The peri- toneum adjacent to the appendix is thickened and adherent. There may be collections of serum or of sero-pus encapsu- lated by the peritoneal adhesions. Symptoms. — In some cases there are recurring attacks of acute appendicitis, in the intervals of which the patient 474 .y.Lyr.iL oj-' tj/e practice of medicine. is perfectly free from trouble. To these cases the name " recurring appendicitis " is frequently applied. In other cases the patient suffers more or less in the intervals from the chronic inflammation of the appendix; to these cases the terms " chronic appendicitis " and " chronic relapsing appendicitis " are more properly applied. The sy))iptovis bctivcoi acute attacks consist of localized pain and tenderness, disturbances of digestion, and irregular action of the bowels. There is usually progressive loss of flesh and strength. Physical examination usually reveals tenderness over McBurney's point, a tumor or a sense of resistance, and a dull tympanitic note on percussion. The sy})iptoi)is of the acute exacerbations resemble those of the primary attack. These acute exacerbations may occur at any time, so that the patient becomes afraid to travel from home, being apprehensive of the increasing severity of future attacks, or may become unable to pur-' sue business or laborious occupation. The duration of the disease varies from one to ten years ; the acute attacks vary in number from two to twenty or thirty. The prognosis depends upon the character of each acute attack. The treatment is surgical. The question whether to operate during an interim or to wait until the symptoms of an acute attack call for surgical interference should be left to the surgeon to decide upon the merits of each indi- vidual case. ULCERATION OF THE INTESTINE. The following intestinal ulcerations may be described : I. Round ulcer of the duodenum resembles gastric ulcer in its cause and appearance, but is much less common (as 40 to i). The ulcer is usually single and situated near the pylorus. Localized peritonitis with adhesions, local- ized peritoneal abscess, perforati\e peritonitis, and hemor- rhage are the most frequent complications, while stenosis of the pylorus, of the orifices of the common bile-duct, ULCERA'J'JON OF '////■: /N77-:S77NF. 475 or of the pancreatic duct may result frf)m cicatricial con- traction. Four-fifths of the cases occur in adult males. The symptoms closely resemble those of gastric ulcer. Pain is referred to the right hypochondriuni, is rarely severe, and appears later after eating than does the pain of gastric ulcer. There may be only irregular, ill-defined feelings re- ferred to the hypochondriuni, with localized tenderness. Dyspeptic symptoms and vomiting are exceedingly rare. Hemorrhage occurs in one-third of the cases. The blood may be vomited or be passed in an altered condition by the bowel, or the patient may die before the blood has time to appear externally. Many cases run a latent or obscure course, and in these cases death from hemorrhage or from perforation may be the first indication of serious disease, although in the latter case severe continuous pain usually precedes the rupture by several days. The prognosis is more serious than that of gastric ulcer. The treatment is that of ulcer of the stomach. 2. Duodenal tdceration may occur after extensive burns of the skin. The duodenum is congested and ulcerated in patches of an irregular form, the lesions appearing in from seven to fourteen days after the injury. The exact patho- genesis of these cases is unknown. Hemorrhage and per- foration are the chief symptoms, and the patient almost invariably dies. 3. Embolic ulcers may result from embolism or throm- bosis of a branch of the mesenteric artery. The emboli may arise from endocardial vegetation or from atheroma of the aorta, while the occurrence of thrombus is favored by atheroma of the mesenteric artery itself The mesenteric vessels being terminal arteries, embolism or thrombosis leads to hemorrhagic infarction of a section of the intestinal wall, which rapidly undergoes necrosis. The peritoneum over the affected area is inflamed and may be the seat of perforation, and the intestine itself in the vicinity is con- gested and infiltrated with blood. The diagnosis is to be made by attention to the following points : (i) The presence of a cause for embolism ; (2) the presence of emboli in other organs ; (3) symptoms of intense enteritis ; (4) symptoms 476 MAXr.lL OF 7UE PKAC'JICK OJ- MEDICIXE. of pcritonitis>. If the embolus be septic, exten.si\e suppu- ration of the intestinal wall Avill result. Mnibolic ulcers of the colon are exceedingly rare. 4. Ulcers due to avtyloid degoicratioii may be found in any part of the intestinal tract, being due to local disturbances of nutrition consequent upon the diminished supply of blood that necessaril}' results from the waxy changes in the wall of the terminal arteries. These ulcers show no disposition to heal. 5. Catarr/ial and follicular ulcers result from acute and chronic enteritis. Catarrhal ulcers are usually found in the colon, either as slight erosions or involving large areas by their extension and confluence. The floor and the walls of long-continued ulcers become greatly thickened. The natu- ral termination is by cicatrization. Follicular ulcers may be found in either the large or the small intestine. They are of round shape, with undermined edges. The\' may be so numerous that the bowel is studded by them. Follicular ulcers may extend by ulceration of neighboring parts or may perforate. Cicatrization seldom results unless the lesion be extensive. 6. Stercoral Ulcers. — The pressure of hardened feces leads to necrosis and subsequent purulent infiltration of the mu- cosa. Stercoral ulcers occur in situations in which fecal accumulation is h'able to occur, as in the caecum, the rectum, the flexures of the colon, or above the point of stricture in intestinal ob.struction. 7. The ulcers of typhoid fever, diphtheria, variola, and anthrax have elsewhere been described. 8. Tubercular idccrs are of common occurrence. They may appear as a primary infection from the ingestion of tubercu- lar meat or milk, especially in children, but they are more common as the result of secondary infection complicating pul- monary or genito-urinary tuberculosis. The process begins first in the ileum, extending thence to the re.st of the small and the large intestine. Tubercles first develop in the solitary or agminated follicles, undergo cheesy degeneration, and break down to form ulcers. These follicular ulcers extend by suppuration and by extension of tubercular de- L7.CEA'.l7VOX OF TI/J'. fXTKS'/fjVE. 477 posits along the line of the lymphatic vessels, so that " girdle " ulcers are formed, encircling the intestine at right angles to its long axis. The peritoneum covering the site of the ulcer is studded with tubercles, is coated with fibrin, and is adherent to adjacent surfaces. Perforation may occur; it is usually prevented, however, by the formation of peritoneal adhesions. The mesenteric glands are al- most invariably enlarged and tubercular. The girdle shape of the ulcer distinguishes it from typhoid ulcera- tion. A differential diagnosis in the earlier stages can be made by the fact that in typhoid fever ulceration of a Peyer's patch is uniform, whereas in tubercular disease separate follicles are involved, while others entirely escape. Cicatri- zation is rare, but it is possible. 9. Leiikceniic ulcers result from necrosis of lymphoid de- posits in the wall of the intestine. They are rare, however, except during the course of acute leukaemia. 10. Scorbutic ulcers may follow hemorrhages into the mucosa. 11. Syphilitic ulcers are rare in the small intestine except in new-born syphilitic children. Gummata of the intes- tinal wall may occur, and ulcers may result from their breaking down. Syphilitic ulceration of the rectum is not uncommon, especially in women ; it leads to progressive fibrous stricture. 12. Urcentic ulcers may occur with advanced nephritis in several ways : {a) Ulceration of solitary and agminated folli- cles, with catarrhal entero-colitis ; {b) as a result of a pseudo- membranous enteritis ; {c) gangrenous ulceration may occur. 13. Mercurial ulcers follow pseudo-membranous enteritis from poisoning by mercury. 14. Cancerous ulcerations may result from the breaking down of submucous nodules. 15. Ulceration from external perforation may occur from ulceration and erosion of new growths or by the perforation of a neighboring abscess into the intestine. The symptoms of ulceration of the intestine depend upon 478 MA.Vr.-tL OF THE PKACTICE OF MEDIC/XE. the position and extent of tlie ulceration and upon its patho- logical character. Diarrhoea is a frequent s\-niptoni, being regularly present with ulcers of the lower portion of the colon and the upper portion of the rectum. Ulcers limited to the small intestine, the caecum, and the ascending colon do not of themselves cause diarrhoea. Hemorrhage varies in amount, the largest hemorrhages occurring with duodenal ulceration, typhoid fever, and per- foration from without the intestine. If the origin of the hemorrhage be in the upper portion of the intestine, the blood is usually dark and altered and mixed with feces ; heniatin-crystals may alone be detected. Pus in the stools is rare unless from ulceration, and hence its presence is of great diagnostic importance. Large evacu- ations of pus indicate rupture of a neighboring abscess into the intestine. Usually the quantity of pus is small, necessi- tating for its detection close scrutiny, and even microscopical examination, of the feces. Pus with blood and mucus usu- ally indicates dysentery or an ulcerating carcinoma of the colon or the rectum. Shreds of tissue, if proven not to con- sist of undigested food, afford conclusive proof of rapid and extensive ulceration. Tubercle bacilli in the stools are usually, but not invariably, found in cases of tubercular ulceration. Pain is frequently absent. It may be of the nature of a colic, or there may be steady pain due to a complicating localized peritonitis. Tenderness, which may be constant over a small area, is of value in localizing the seat of ulcera- tion. Tenesmus occurs only if the rectum be ulcerated. Fever depends upon associated conditions. Emaciation depends upon the extent and pathological character of the ulcers, and is more pronounced when the small intestine is affected. Not infrequently ulcers of the intestine run an entirely latent course, and are unexpectedly found at post-mortem examination. The complications of ulceration comprise localized peri- tonitis, peritoneal abscess, purulent or perforative peritonitis, CANCER 0J< 'J-JIl-: /N'/'ES'/VNE. 479 and hemorrhage ; should cicatrization occur, intestinal ob- struction may result. Treatment. — The diet should be easily digestible, nutri- tious, and unirritating. A milk diet is indicated in severe cases, and prolonged rest in bed may be necessary to accom- plish good results. For ulceration of the small intestines antiseptics by the mouth should be given, to keep the intes- tinal tract disinfected so far as possible. Bismuth salicylate and subnitrate (each 15 grains every three or four hours) are of great value, but salol, bismuth subgallate, naphthalin, and resorcin may be used. For ulceration of the colon large injections of warm salt-solution are to be given to cleanse the bowels. The addition of astringent or irritating drugs, such as nitrate of silver, salicxdic acid, or thymol, does not seem to increase the medicinal value of these in- jections, and certainly renders them painful and annoying. Ulceration of the rectum can be treated, if within reach, by the methods pursued in treating external ulcers, CANCER OP THE INTESTINE. Carcinoma of the intestine usually occurs as a primary growth, and comprises from 4 to 8 per cent, of all cases of cancerous disease. Four varieties are encountered, which, in order of frequency, are cylindrical-celled epithelioma, encephaloid, colloid, and scirrhus. Growths in the large intestine are nine times as common as those of the small intestine, the seats of selection being the rectum (80 per cent, of all intestinal cancers), the sigmoid flexure, and the caput coli. Next in frequency comes cancer of the duodenum. Patholog-y. — Scirrhus usually produces a hard infiltra- tion of the intestinal wall, narrowing the lumen of the gut. The encephaloid and cylindrical-celled epithelioma form annular constrictions, large fungoid masses projecting into the cavity of the intestine, and are very prone to ulceration and hemorrhage. The colloid form produces a gelatinous infiltration of the intestinal wall, without much tendency to ulcerate or to cause obstruction. Secondary deposits are not uncommon, especially in the liver, the general rule be- ing that when secondary cancer of the liver develops, the 4S0 .U.I.Vr.lL OJ-' J HE rRACTlCE OF MEDICI XE. primary cancer in the intestine ceases to grow and often gives no further s\-mptoms, so that the case will resemble on€ of primary cancer of the liver. From' the ulceration of the cancer perforation may occur into the peritoneum or into hollow viscera, forming fecal fistuUv ; or extensive hemorrhage may result. The intestine becomesvmore or less occluded, the obstruction being often rendered more complete by fecal accumulation at the [joint of stricture. Cancer of the Rectum. Symptoms. — Pain is usually more marked than that pro- duced by cancer in any other part, excepting cancer of the tongue. The pain is not always of the same kind, {a) In some cases the pain is the same as that produced by cancer in any other part of the bod}'- — dull, boring, and continuous, {p) The pain may be neuralgic, and is due to pressure on the sacral plexus. These cases are frequently treated for sciatica. {c) The pain may be due to obstruction of the rectum, being paroxysmal and straining in character. These cases are often treated for chronic dysentery, for fecal impaction, or for hemorrhoids. Malignant disease of the rectum should be suspected in every case of constipation and hemorrhoids in an old person whose bowels have been previously regular. Hemorrhage is usually in small amounts ; it is brought on by straining attempts at stool. Occasionally, however, the bleeding is profuse. In nearly all cases there is an irritating discharge which excoriates the anus and the neighboring parts. Should the sphincter ani be relaxed, as often happens, the condition of the patient is rendered more uncomfortable. There are regularly changes in the action of the bowels : {a) There may be diar- rhoea accompanied by pain and tenesmus ; (/;) the stools may be deformed by being forced through the constricted rectum, so as to be ribbon-shaped or as small in diameter as a lead- pencil ; (r) there may be constipation with symptoms of intestinal obstruction. Should the obstructing growth ulcerate, the con.stipation will suddenly give way. Cancer- ous cachexia intervenes, and the symptoms of secondary CANCKK OF Tllli JA'-J'/iST/NE 481 deposits in adjacent viscera or in the liver may complicate the latter stages of the disease. Physical Examination. — There may be a hard ring felt Fig. 49. — Physical examination of cancer of the rectum two or three inches from the anus, usually just large enough to admit the finger (Fig. 49, a). In some cases the bowel is invaginated, so that the ring is pushed down by the accumulation of feces above (b), and the orifice of the constriction may be tilted so that it is found with difficulty (c). In either case there are felt projecting into the rec- tum large friable masses which bleed readily (d), or ulcera- tions with hard edges and floor may be detected (e). In cases of colloid carcinoma the wall of the rectum loses its soft, velvety feeling and becomes dense and thick, but no obstruction and no ulceration can be appreciated (f). In examination for rectal carcinoma the patient should stand up and bear down, to bring the growth within reach. If nothing can then be felt, examination under an anaesthetic is indicated. Prognosis and Treatment. — An early diagnosis should be made if possible. Neglected cases run a fatal course of from two to four years, but life may be prolonged by an early excision of the neoplasm, as by Kraske's operation. In some cases a radical cure has thus resulted. Lumbar colot- omy with the formation of an artificial anus may be indi- cated to relieve the constipation and to modify the pain. Cancer op the Caput Coli. The symptoms of cancer of the caput coli begin gradu- ally and are at first obscure. There is a gradual loss of flesh and strength, with varied digestive disturbances. In other 31 48j M.l.VUAL OF THl: PRACTICE OF MEDICINE. cases pain is the first symptom noticed. The pain may be dull and boring or sharp and colicky. If there be obstruc- tion, pain is increased and s}-mptonis of intestinal obstruc- tion gradually appear. Physical examination reveals a tumor in the caecal region — a tumor hard and irregular, either globular in shape or ovoid, its long axis agreeing with the course of the ascending colon. The tumor, which is usually adherent to the posterior abdominal wall, so that it is not apt to be movable, is most liable to be mistaken for fecal impaction or for a chronic appendicitis. The patient be- comes cachectic, loses flesh and strength, suffers from diar- rhoea or constipation, and dies exhausted or from intestinal obstruction. Treatment of cancer of the caput coli is merely palliative in cases in which the diagnosis is made too late to allow of resection of the intestine. Cancer of the Duodenum. Caticer of the duodoiiim usually presents itself as a mova- ble tumor which cannot be differentiated from malignant growths of the pylorus. The tumor may be displaced into the lower abdominal region by reason of the weight. Dila- tation of the stomach usually results, and the pancreatic duct and the bile-ducts ma)- be obstructed. The treatment is palliative. Non-cancerous Tumors of the Intestine. Non-cancerous growths are so rare that they possess only pathological interest. Mucous polypi may occur, especially in children and in the rectum ; or there may be found pediculated fibromata. Lipoma, sarcoma, lymphangioma, and myoma have been described. INTESTINAL OBSTRUCTION. Etiology and Pathology. — i. Inlcnial strangulation, or " internal hernia," is the cause in one-third of the cases, and is the most frequent cause of obstruction in adults ; 70 per cent, of the cases occur in males. The strangulation may be /N77CS77N/1/. OBS77x'UC770N. 483 produced in various ways : A loop of intestine may be con- stricted by passing- between peritoneal adhesions or by passing through apertures in the mesentery or the omen- tum, through the foramen of Winslow, or even through the diaphragm. Should the tip of Meckel's diverticulum be adherent to the mesentery or to the abdominal wall, a ring will be formed, through which a coil of intestine may pass. In 90 per cent, of all cases the ileum is the portion of the intestine involved. Strangulation results in obstruction, ulceration, sloughing, and eventually in perforation. 2. Intussusception^ or invagination, which occurs in one- third the cases, is the most frequent cause of obstruction in children, one-third of the cases occurring during the first year, and one-half of the cases before the tenth year. This condition arises whenever one portion of the intestine slips into an adjoining part as a tuck may be taken in the finger of a glove; it appears to be due to irregular peristalsis, the receiving layer being drawn up by contraction of the lon- gitudinal fibres. In each intussusception three layers of intestine are brought in apposition : an outermost or re- ceiving layer (the intussuscipiens), the middle or returning layer, and the inner or entering layer. The outer and mid- dle layers are in contact by their mucous surfaces, the middle and the inner by their serous surfaces. There is thus formed a longitudinal tumor varying in length from several inches to as many feet, and the invagination extends at the expense of the outer layer. The intussusception is invariably downward. The affected parts become swollen, congested, and perhaps ecchymotic. In recent cases the peritoneum is merely congested and the intussusception may readily be reduced, but in cases living for two or three days the peritoneal surfaces become so agglu- tinated by fibrinous adhesions that reduction is no longer possible. The invaginated portion may slough and be passed by the rectum, so that spontaneous cure may result. Three- fourths of the cases of intussusception are of the ileo-caecal variety, in which the valve slips into the large intestine, gradu- ally inverting, appearing at the rectum in extreme cases. In- tussusception of the ileo-caecal variety or confined to the large 4S4 .u.i.vc'.i/. (>/■' /'///■: PA'AC/vcF. o/-' .)//:n/c/.\/:. intestine may last in rare instances for months witlunit i;iving rise to acute s\-mptoms. 3. Volvulus, or twist of the intestine, is the cause of the obstruction in one-seventh of the cases. Two-thirds of the cases of volvulus occur in men, and the condition is most frequent between the ages of thirty antl forty. The twist, which is usually in the long axis of the intestine, is favored by a long mesentery, but one loop may be twisted around another or may be bent sharply upon itself. In one-half the cases the volvulus occurs in the sigmoid flexure, next fre- quently in the Cciecal region. The twisting interferes with the circulation of blood and leads to necrosis of the affected portion of the intestine. 4. Acute obstruction from strictures and tumors may occur, but the obstruction is more apt to be chronic and progressive, although never complete. Narrowing of the lumen of the intestine may be due to the following condi- tions : {a) Congenital stricture as the result of fatal peri- tonitis, in which case the obstruction is usually in the rectum or the lower ileum ; or there may be congenital malformation resulting in imperforate anus or rectum, {b) Cicatricial stenosis may result from previous ulceration. {c) New growths of the intestine, especially epithelioma, {d) Compression of the intestine by abdominal or pelvic tumors, (r) Contraction of inflammatory exudate, especially with tubercular peritonitis. 5. Obstruction may be due to foreign bodies within the intestine. Gall-stones may enter the intestine through the duct, or there may have been a communication between the intestine and the gall-bladder. Enteroliths may be formed by the phosphates of lime and magnesia being deposited about a central nucleus ; or the foreign body may be a tangled mass of worms. Fecal accumulation is a common cause of obstruction, and will elsewhere be described. Symptoms. — The three cardinal symptoms are pain, vomiting, and constipation. The pain may begin suddenly, while the patient is in apparently good health, and is usually localized, intermittent, and colicky. It soon becomes more intense and continuous, and spreads ov^er the abdomen, being, IN'J-JCST/NAL OBSV'A'IJCT/ON. 485 however, more severe in its original situation. Tenesmus oc- curs only if the rectum be involved. Vomiting is constant and distressing. The vomited matters are at first gastric, then bilious, and finally stercoraceous. The higher up the ob.struc- tion the earlier does the fecal vomiting occur; but true fecal vomiting cannot occur with obstructions above the upper third of the ileum. The vomiting may cease at the approach of the fatal issue, or it may be replaced by distressing and obstinate hiccough. Constipation is usually preceded by the emptying of the intestine below the seat of obstruction. There is also an absence of flatus. In intussusception there may be discharges of mucus and blood. If the obstruction be low down in the intestinal tract, the abdomen is greatly distended and active peristalsis is visible, but if the obstruc- tion be higher up these symptoms are not present. At first the abdomen is insensitive; later, exquisite tenderness is developed. The face becomes pallid and anxious ; there is incessant thirst ; the pulse is feeble and either rapid or slow; the urine is diminished or suppressed. There is not apt to be fever ; on the contrary, the temperature may be subnor- mal. Symptoms of collapse or of peritonitis appear, and the patient rarely lives beyond the fourth or the sixth day. Diagnosis. — The determination of the seat of the lesion is often extremely difficult. If the obstruction be in the duodenum or the jejunum, vomiting occurs early, collapse is rapid, there is no tympanites, and the urine is usually suppressed. If the lower ileum or caecum be obstructed, the abdomen is distended in the umbilical region, the flanks are flattened, and active peristalsis can be seen. If the colon or the rectum be occluded, the flanks become likewise distended, there may be tenesmus, and the symptoms are not as severe as in the preceding forms. If four quarts of water can be injected slowly so as to fill the colon and the caecum, the obstruction must be in the small intestine. Diagnosis of the Course of the Obstruction. — Intiissiisception is essentially a disease of children. A sausage-shaped tumor usually occurs before the third day in the region of the ascending or transverse colon. There is usually tenes- mus, with the passage of bloody mucus. Examination by 486 MAXUAL OF THE PKACTICJ: OF MEDICINE. rectum may reveal the lesion. Fecal vomiting; is not com- mon, and abdominal distention occurs, in t)nl\- one-third of the cases. Strangulation is not common except during adult life. There is usually a history pointing to the presence of peri- toneal adhesions. Pain is excessive ; vomiting is incessant and soon becomes fecal ; prostration rapidl)' becomes ex- treme. There is absolute constipation, but no tenesmus, and there is no tumor to be detected. Volvulus is diagnosed with great difficulty, although it may be suspected if the sigmoid flexure be involved. As twists of the sigmoid flexure are often produced b\' the weight of accumulated feces, a history of fecal accumulation often precedes the accident. Foreign bodies usually lodge at the ileo-ca^cal valve. There may be the history of some bulky object swallowed, or of the passage of previous gall-stones. For the diagnosis o{ fecal impaction see pp. 490, 491. The diagnosis should also be made from functional obstruction occurring in h\'sterical patients, and usually following blows upon the abdomen, peritonitis, or the reduction of a hernia. The lesion seems to be a tempo- rary cessation of peristaltic movements, as the result of which the downward advance of the intestinal contents is checked. In every case external strangulation by hernia must be excluded by careful search. Acute hemorrhagic pancreatitis may so closely resemble intestinal obstruction that a differential diagnosis cannot always be made. The prognosis of every case of obstruction is grave, and usually is absolutely unfavorable unless the obstruction be relieved by surgical measures. Spontaneous cure of intus- susception has been mentioned, but few children live long enough for the result to take place. Spontaneous cure may result in exceptional cases of strangulation b\" the formation of a fistula between two coils of intestine. Treatment should be prompt and energetic. Purgatives are absolutely contraindicated. The patient should be put under the influence of opium almost to the point of semi- narcotization, the respirations being kept between 10 and ///CMC A' A' ///I GE FROM 'J'lIE INTESTINE. 487 14 by its repeated administration. By this treatment all peristaltic action is checked, so that the j^ut will have a chaiice to untwist or to free itself from obstructing bands or from its invagination. The vomiting and pain are also checked, and the danger of collapse is lessened. Washing out of the stomach with warm water may be repeated three or four times a day. In some cases this treatment has been useful in diminishing peristalsis and in lessening the abdominal pressure above the ob- struction. The colon should be flooded with warm water, the patient being in the knee-chest position and preferably under the influence of an anaesthetic. Inflation of air may be practised, the air being introduced by a Davidson syringe, or the rectal tube may be attached to a siphon of carbonated water. These latter methods are most useful in cases of intussusception, but they are not devoid of danger, as rup- ture of the bowel has resulted when undue force has been used. Inflation and injection of water are of no service should the intussusception last longer than forty-eight hours, as by that time inflammatory fixation will have occurred. These medicinal measures should not be continued after forty-eight hours, nor in any case in which the symptoms are rapidly becoming urgent, but laparotomy should be performed at once. Laparotomy should be done as early as possible in cases of strangulation, volvulus, and impaction of foreign bodies, before the interference with the circulation has led to sloughing of the intestinal wall. HEMORRHAGE FROM THE INTESTINE; ENTERORRHAGIA. Etiolog-y. — Hemorrhage from the intestine is a symptom that may be produced in a variet}' of ways : 1. By ulceration of the intestines of any form. 2. By irritant and corrosive drugs. 3. By local injuries, such as those inflicted by foreign bodies, by hardened fecal masses, and by intestinal parasites, especially by the anchylostoma duodenale and the distomum haematobium. 488 .U.IXC.IL OF THE PKACT/CF. OF MEDICIXE. 4. By active congestion in severe inflammations, in intus- susception and volvulus, and following the reposition o{ an incarcerated hernia. 5. B}' passive congestion with disease of the heart and lungs, with obstruction in the portal circulation and with hemorrhoids and venous varices. 6. By diseases of the blood-vessels, especially amyloid degeneration, or by aneurysm or embolism of a branch of the mesenteric artery. 7. B\' tumors of the intestine, especially cancer and polypi. 8. By causes without the intestine, as when blood enters the intestine from the stomach or from a ruptured aneurysm of the abdominal aorta. 9. By constitutional diseases, especially pernicious anae- mia, leukaemia, pseudo-leukaemia, scurvy, purpura haemor- rhagica, septicaemia, profound jaundice, yellow fever, acute yellow atrophy of the liver, and poisoning b}' phosphorus. Hemorrhage may also occur in conditions of hunger and inanition. 10. Hemorrhages in the new-born (melasna neonatorum) may be due to acute fatty degeneration or to s\'philitic degeneration of the blood-vessels, to haemophilia, or to puerperal infection. Symptoms. — The blood may be vomited or be passed by the bowel, or the patient may die before the blood ap- pears (concealed hemorrhage). Blood from the rectum or the sigmoid flexure is bright red, and its passage is accom- panied by straining. Blood from the lower bowel is also smeared over the fecal masses. Blood from the ileum is usually dark red, the normal color generally being restored by adding water to the stools, and its passage is accompanied by increased peristalsis and diarrhoea. Blood from the jeju- num and the duodenum is dark and tarry from the change of the haemoglobin into haematin. These dark stools may resemble those produced by eating huckleberries or by taking iron or bismuth, but the differential diagnosis is to be made positively by the spectroscope and by the finding of h^ematin-crystals in the stools. The general symptoms are those of hemorrhage in gen- FECAL ACCUMb'LAJ-fON. 489 eral. Following the hemorrhage the bowels may be obsti- nately constipated and there may be a high temperature (septic fever or resorption-fever). Treatment. — Absolute bodily and mental rest must be enforced, and no food should be allowed for from twenty- four to forty- eight hours. Opium should be given in doses sufficient to check peristalsis ; this drug is also of service in controlling restlessness and collapse-symptoms. Ice applied to the abdomen, so often recommended, is not only useless but actually harmful, tending, as it does, to stir up peristaltic action. For large hemorrhages astringent drugs by the mouth do no good, but in repeated small hemorrhages ergotin, turpentine, erigeron, hydrastis canadensis, acetate of lead, gallic acid, and large doses of bismuth subnitrate are of great service. If the bleeding come from the rectum or low down in the colon, astringent injections may be em- ployed, but they should not be resorted to as a routine measure, because of their tendency to quicken peristalsis. Tamponage of the rectum causes retention of gas, straining efforts, and increased intestinal peristalsis, and it should not be employed except in cases of bleeding from the lower portion of the rectum. FECAL ACCUMULATION. Etiology. — Fecal accumulation may be primary, or sec- ondary to stricture of the intestine. In the primary cases there is usually the history of previous constipation, although at the time of examination the bowels may be loose. In other cases the accumulation results from weakness of ex- pulsive efforts, and is common after prolonged illnesses, as typhoid fever. Patholog-y. — The situation of the impaction is usually in the caecum or in the rectum, but it may be at an\' part of the large intestine. The fecal masses may totally occlude the lumen of the gut, or they may be packed in the lateral pouches of the colon, leaving a passage through which nor- mal stools may pass. If the accumulation be large, a tumor will be formed, which may give rise to pressure-symptoms, especially if the rectum be the seat of the impaction. The 490 u.i.vc.i/. OF riiE practke of Mrnicfxii. lon^^er the fecal masses are retained, the harder they become^ .so that they may even resist the edije of a knife. The accumuhition varies in amount, in extreme cases exceed- ing fifteen or twenty pounds in weight. Symptoms. — Two distinct types of fecal accumulation are observed — a complete and an incomplete form. COMPLKTE FeCAI. IMPACTION. {d) If the fiCiKlll be the seat of impaction, the patient will suffer from the effects of constipation and will complain of pain and tenderness in the c?ecal region. To these cases the term " stercoral typhlitis " is often applied. Examination will reveal the presence of a tumor — not soft, baggy, painless, and sausage-shaped, as ordinarily described, but hard, irregular, and more or less tender, so closely resembling the characteristics of a morbid growth that a diagnosis is impossible by examination alone. At some particular time the obstruction becomes complete. Constipation is absolute, not even gas being passed ; the temperature rises to from ioi° to 104° F. ; the pul.se is rapid and feeble. The abdomen becomes tender and tym- panitic, and there is pain, either paroxysmal and colicky or like the exquisite pain of peritonitis. Respirations are rapid and thoracic. The case closely resembles one of appen- dicitis with general peritonitis, but in fecal impaction exam- ination reveals a greatly increased peristalsis of the intestine, whereas in peritonitis all peristaltic action is checked. Un- less relieved, gastric, bilious, and stercoraceous vomiting occurs; the patient is more and more prostrated, and dies with all the symptoms of intestinal obstruction. The prognosis of this form of impaction is good if the case be properly treated. - Relapses, however, are likely to occur. Treatmoit. — In this form of impaction purgatives are absolutely contraindicated. as by the violent expulsive efforts of the bowel produced by their action the hardened mass is jammed more tightly into the distended intestine. Exactly the opposite treatment is indicated : opium is to b^ given in doses sufficient to check peristalsis and to relax the intes- tinal .spasm at the seat of the impaction. Under this treat- ment the tumor can be felt to move along the colon from day to day. When the mass reaches the transverse colon. FI'ICAL ACCUMIJJ.ATION. 49 I copious salt-water irrigations will bring away large quan- tities of hardened feces. When the impaction is once broken up opium should be discontinued and the use of laxatives should be begun, the best of these being castor oil in small repeated doses. Faradism and massage applied along the course of the colon are often of service in pro- moting the passage of the fecal masses. To prevent reac- cumulation, strjxhnine must be given for months to coun- teract the enfeeblement of the intestinal wall, and the bowels should be kept freely open by appropriate medication. [b) If the rcctiiui be the seat of the impaction, there will result ineffectual attempts at defecation, with straining and tenesmus, so that fecal impaction should be suspected in every person, especially the aged and those who are con- valescing from a long, weakening illness, in whom the symptoms of dysentery appear. Pressure on the uterus may cause uterine symptoms. There may develop neuralgia from pressure on the sacral nerves, seminal emissions, or nocturnal enuresis. The diagnosis is readily made by rectal examination, which reveals the presence of hard scybalae in the rectum. Treatment consist in breaking the impaction mechan- ically and in removing the scybalae by the fingers, by the handle of a spoon, or by repeated enemata. Incomplete Fecal Impaction. — This form of impaction is usually seen in elderly persons with atony of the colon. The fecal masses are packed in the lateral pouches of the colon, leaving a passage channelled through the centre. The prominent symptom is diarrhcea, the loose stools aris- ing from the irritation of the large intestine above the im- paction. Some patients become poisoned by the accumu- lation, run down, and become so prostrated that the case may actually resemble typhoid fever. The condition is to be suspected in every case of chronic diarrhoea in old people. Examination may reveal scybalae in the rectum, or there may be a sense of resistance with some dulness over the descending colon. Treatnie7it consists of purgation and colon-irrigation to 49- .V.l.YC.lA OF THE PRAC'IICE OF MF.DfCIXE. bring away the fecal masses. Checking the diarrhcea with astringents regularly aggravates the condition. AMYLOID DEGENERATION OF THE INTESTINE. Etiology. — Ani}loid degeneration of the intestine occurs as a secondary change in phthisis, in prolonged suppura- tion, especially of the bones, and in constitutional syphilis. Pathology. — The lesion involves the large and the small intestine and is especially marked in the lower ileum. The am\-loid degeneration begins first in the walls of the smaller arteries, and in advanced cases may involve the whole thickness of the intestinal wall. Ulceration of the mucous membrane is not unconmion. Symptoms. — The principal symptom is a chronic diar- rhoea without fever (unless from the primary disease), pain, or tenderness. Blood and pus, if appearing in the stools, are indicative of ulcerations. The diagnosis is aided by the presence of the causative disease and by the finding of amy- loid changes in other organs, as the liver and the spleen. 4. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Etiology. — Peritonitis may be primary or secondary. 1. Primary or idiopathic peritonitis is exceed ingh' rare. It may develop after exposure to wet and cold, or as a terminal event in Bright's disease. 2. Sccojidary peritonitis follows infection from inflamma- tion or perforation of any of the organs covered with peri- toneum. It thus may follow — {a) Penetrating wounds and laparotomies. (<^) Rupture or perforation of any of the abdominal viscera, ic) Rupture of an abdominal abscess, such as appendicitis or suppurating inflammation of the Fallopian tubes. It has also followed rupture of an appar- ently normal Graafian follicle or extra-uterine gestation. It has also occurred after perforation of the diaphragm in em- pyema, [d) Extension from inflammation or ulceration of ACU'J'J''. J'J:lsfJ ON/'J'/S. 493 the stomach or intestines, cancer or suppurative inflarnma- tions of the spleen, liver, pancreas, and retroperitoneal tis- sues, or strangulated hernia, [e) Pelvic conditions — septic uterine conditions, decomposing thrombi, etc. Infection may be carried, as in the case of gonorrhoea, through the Fallopian tubes without the tubes being involved. Bacteriolog-y. — The bacterium coli commune is one of the most frequent micro-organisms found in the peritoneal exudate, and is met with especially in peritonitis due to intestinal perforation. Next in frequency are the pyogenic micrococci, the streptococcus being usually associated with puerperal peritonitis, while the staphylococcus pyogenes aureus or albus is usually found in cases following lapa- rotomy. The diplococcus pneumoniae and the gonococcus have been found ; the amoeba coli may occur in the peri- tonitis accompanying amoebic dysentery. Varieties. — There are three distinct varieties of peritonitis: I. Acute peritoneal -sepsis; 2. Acute diffuse peritonitis; 3. Acute circumscribed peritonitis. Acute Peritoneal Sepsis. In this form of sepsis, which is also termed "acute peri- toneal septicaemia " and " perforative peritonitis," we have a simultaneous and rapid infection of the whole peritonea cavity after perforation of the stomach or the intestines, after rupture of large abscesses, or after septic penetrating wounds or laparotomies. Patholog-y. — The peritoneum may appear normal, or may be injected and without its normal lustre. In the peri- toneal cavity is a small quantity of sticky, non-purulent effusion, consisting chiefly of micro-organisms. This exu- date may be found on the surfaces of the peritoneum, and cocci may be found in the lymph-spaces. Feces, contents of the stomach, or pus from a ruptured abscess may be present, according to the nature of the primary cause. If the patient live long enough, purulent inflammation follows and the lesions of acute diffuse peritonitis are found. The symptoms are due to shock and to toxaemia from rapid absorption of ptomaines. There is usually a sudden 494 MANUAL OF THE PRACTfCE OF MEDICINE. sharp pain in cases of rupture or perforation, the pain ceas- ing as the patient passes into the condition of shock. The pulse becomes rapid and feeble ; the breathin<^" is rapid and shallow; the skin is cold and clammy. Slight cyanosis appears, and the patient is restless. The temperature at the onset falls, only to undergo a subsequent rise before death to 105° or 106° F. Death from tox?emia results in from twelve to fifteen hours in the majority of cases. In cases of milder infection the patient may survive long enough to develop the symptoms of diffuse peritonitis. Acute Diffuse Peritonitis. This form of sepsis, which is also termed " acute general peritonitis," "purulent." "progressive," " progredient," or "exudative peritonitis," occurs when a general infection is not severe or sudden enough to cause death from toxjemia, or when successive areas of the peritoneum become in turn affected. Patholog-y. — The intestines are inflated with gas and pro- trude through the post-mortem incision. The peritoneum is congested or pale and soggy in appearance, and is covered with fibrin or with fibrin and pus which render opposing peritoneal surfaces adherent. There is an exudation of serum in cases of mild infection, or of pus if the infection be more severe, the pus being thin and yellowish or thick and creamy or putrid. The amount of the exudate varies from half a liter to twenty or thirty liters. There may be admixed contents of stomach or of intestines in cases of perforation. Blood is not found except after penetrating wounds or laparotomies. If the patient recover, the serum is absorbed, the fibrin and pus undergo emulsification and absorption, and the exudate becomes organized, so that the peritoneum becomes thickened and adherent. These connective-tissue adhesions interfere with peristalsis and may lead to internal strangu- lation. Symptoms. — Tympanites is usually marked; it is due to the paralytic condition of the intestine. The inflation of the intestines may be so marked that the thoracic viscera are ACUTJ'. J'/'lRI'JVNrJJS. 495 displaced upward, interfering with the breathing and the action of the heart. The abdomen in these cases is usually protuberant, but in some cases it is of natural size, although the abdominal wall is tense and hard. In other abdominal diseases, such as intestinal obstruction, tympanites is also present, but is associated with active peristalsis, whereas in peritonitis the association of tympanites with absence of peri- stalsis is distinctive. Over the distended abdomen a tym- panitic note is obtained by percussion. Tympany over the normal liver-area is suggestive of gas within the peritoneal cavity. Pain and tenderness are usually at first limited to the local- ity first inflamed, but later they become more general. The pain is very severe, with acute exacerbations. The patient lies motionless on the back, with the knees drawn up to relax the abdominal wall, and the breathing is rapid and thoracic. Restless movements of the arms are often in sharp contrast to the immobility of the body and the lower extremities. In progressive peritonitis fresh encapsulations of pus are marked by an extension of the pain, and over these freshly involved areas the note is dull on light percus- sion. It is important to examine the patient frequently and to remember the extent and location of these areas of dul- ness. In rare cases it is possible for peritonitis to exist without either pain or tenderness. Vomiting is a frequent symptom. In some cases the vomiting appears to be due to irritability of the stomach or the diaphragm, and is accompanied by the muscular efforts of vomiting. The vomited matters are composed of food and bile-stained mucus. In other cases there is a re- gurgitation of gas from the intestine into the stomach, so that, without muscular effort, the gas is raised with a brown- ish or bilious fluid. In other cases, as death approaches there occurs, without effort, a regurgitation of a brown fluid which may possess a fecal odor. This sign is of serious import. Constipation is the rule, and results from diminished peri- stalsis. In some cases, however, diarrhoea may exist from the transudation of serum into the cavitv of the intestine. 496 .U.t.Vr.lL O/-' THE PRACTICE OF MEDICINE. This diarrhcea is more common with circumscribed peri- tonitis, especially if it has lasted for some time. The tcjiipcraturc is usually raised and runs an irregular course bearing no direct relation to the severity of the dis- ease. As a rule, a high temperature indicates an extensive peritonitis, but a low temperature does not necessarily in- dicate a mild attack. The fever may rise to 102° or 104° F., but in some cases there occurs a sudden fall in the temperature with the appearance of collapse-symptoms, indi- cating the intervention of an acute peritoneal sepsis. Death soon occurs in these cases, and the temperature may be high again at the time of the fatal issue. A steady rise in temperature usually indicates a spreading peritonitis. In some cases with encapsulated collections of pus the temper- ature may become markedly remittent. Absence of fever is noted as a rare exception, especially in peritonitis of such acuteness and intensity that the symptoms merge into those of acute peritoneal sepsis. The pulse is rapid and " wiry," being more rapid than can be accounted for by the fever. As a rule, the pulse gives reliable information as to the general condition of the patient. The appearance of the patient is characteristic. The face is drawn and pinched ; the nose is sharp and cold. The tongue has a tendency to become brown and dry even if the fever be moderate. The intellect remains surprisingly clear even to the last, but there may appear periods of muttering delirium asso- ciated with the symptoms of the " typhoid state." The duration of the disease is usually between two and seven days. The prognosis is exceedingly grave. Spreading infection of the peritoneum may be recovered from after laparotomy and drainage; recovery without operation may follow cases of mild infection in which the effusion is chiefly fibrino- serous without much pus ; but in all cases of diffuse peri- tonitis, however mild the inflammation may appear, a most guarded prognosis must be given. Cases of streptococcus infection usuallv die. ACUTE J'ERlTONf'J'JS. ^cjy Diagnosis. — The following conditions are most apt to be mistaken for acute peritonitis : 1. Hysterical peritonitis. Here every symptom of peri- tonitis may be reproduced exactly, even the collapse, the tympanites, and the fever, but other hysterical manifesta- tions are usually present, the duration of the attack is longer, and there may be recurrences. 2. Intestinal obstruction. Here the cause is usually pres- ent (fecal accumulation, intussusception, or malignant growth), the temperature is not usually elevated, the vomit- ing is often stercoraceous, and intestinal peristalsis is in- creased. 3. Acute lieinorrJiagic pancreatitis may exactly simulate peritonitis, so that a diagnosis between the two conditions cannot be made. 4. Ruptured tubal pregnancy gives a previous history of cramp-like pains and cessation of menstruation. 5 . Rupture of an abdominal aneurysm usually gives rise to rapid collapse and intense anaemic symptoms. Acute Circumscribed Peritonitis. Etiology and Pathology. — Acute circumscribed peri- tonitis, which occurs in cases in which adhesions are suffi- ciently resistant to limit the infection, is more apt to occur with infection in the lower abdominal zone. The most frequent cases occur from inflammation of the appendix or from puerperal or gonorrhoeal infection of the uterus and the Fallopian tubes. The rupture of an ulcer of the stomach may lead to a circumscribed peritonitis within the lesser peritoneal cavity. There may thus form beneath the dia- phragm a large air-containing abscess to which the name " subphrenic pyo-pneumothorax " has been applied. If the localized abscess be small, the pus may eventually be ab- sorbed, encapsulated, or calcified ; extensive collections may burrow or perforate. Gradual infection of the peritoneal cavity results in progressive peritonitis, and acute peritoneal sepsis may result from the internal rupture of the abscess. Symptoms are local and general. Local symptoms con- sist of pain, tenderness, and the presence of an inflamma- .32 498 MAXi'AL OF THE PRACTICE OF MEDICIXE. tory tumor. General symptoiiis at first are those of an in- flammatory character — prostration and continuous fever. Later appear the septic symptoms of pus-absor})tion, irregu- lar fever, chills, cold sweatings, diarrhoea, emaciation, and delirium at night. Ultimately septicii^mia develops, with the s)'mptoms of the t\'[3hoid condition. The s\'mptoms of the disease may at any time merge into those of acute peritoneal sepsis or of progressive peritonitis. Treatment of Peritonitis. Peritoneal Sepsis. — The treatment is that of surgical shock — by stimulation, external application of heat, and small doses of opium. If the patient's condition justifies the risk, laparotom}' may be performed, perforations closed, and the peritoneal cavity cleansed with warm sterilized boric-acid solution. Diffused Peritonitis. — Mild cases may be treated medicin- ally at the start, but it is advisable for a surgeon to be in constant consultation in the case, so as to be ready for sur- gical interference should the medical treatment be unsuc- cessful. The object of the medical treatment is to prevent intestinal peristalsis, so as to allow of the formation of adhe- sions to limit the infection. The drug par excellence is opium, and the amount in which it can be given is remark- able, as in peritonitis there exists a tolerance of the drug. Alonzo Clark's method was to give such doses as would keep the patient semi-narcotized, repeated doses being given as soon as the respirations exceeded twelve to the minute. In ordinary cases from 4 to 8 grains daily sufficed, but as much as 420 grains have been given in a single day. It is said, however, that the same tolerance does not exist for hypodermic doses of morphine as when the drug is given by the mouth. It is not now considered necessary to employ such heroic doses, but only as much morphine is given as will suffice to keep the patient free from pain. Larger doses than ^ grain every two or three hours are rarely required. Morphine even in these doses should always be given hypodermically. CHRONIC j'KRrroNiT/s. 499 Concentrated saline laxatives, however, may be given at the onset in cases following operations or septic conditions. Local applications are often of great comfort and of un- questionable utility. For the earlier stages cold ice-bags or the cold Leiter coil is serviceable, but after five or six days hot applications seem to be preferable. The tym- panites may be relieved by turpentine stupes or by the passage of a rectal tube. Lavage of the stomach may re- lieve the distention of the upper portion of the abdomen. Fitz recommends the frequent puncture of the distended bowel with a small hollow needle in extreme cases of me- teorism, stating that the danger of extravasation or of the escape of gas into the peritoneal cavity is comparatively slight. The use of saline purgatives has been recommended by Lawson Tait and decried by others. Certainly it would seem that the increased peristalsis would rupture fine lim- ited adhesions, and the general use of laxatives is to be deplored. No harm results from constipation in peritoneal cases. Rectal injections may, however, be given to relieve the large intestine. In all cases of spreading peritonitis with urgent symptoms, surgical treatment is the only one that affords the patient any hope. There is more danger in waiting too long for operative interference than there is in operating too early in the disease, when surgical treat- ment may not be necessary. Acute cirainiscribcd peritonitis calls for surgical treat- ment to open and drain the abscess. The operation may be deferred in many cases until the limiting adhesions have had time to become firm. CHRONIC PERITONITIS. Etiology. — Chronic non-tubercular peritonitis may suc- ceed an acute attack or may be chronic from the first. The most frequent cause appears to be repeated tappings for the removal of ascitic fluid ; but the condition may occur with chronic diffuse nephritis or with long-continued abdominal or pelvic abscesses. The disease is more common in alco- holic patients. In some cases no definite cause can be 500 .UAXi:i/. OF 77 IE PRACTICE OF MEDICIXE. assigned, but many of the so-called " idiopathic " cases ulti- mately are proven to be tubercular. Pathology. — The peritoneum is thickened by connective tissue, and opposing surfaces are matted and massed to- gether by firm, thick adhesions. In extreme cases the peri- toneum is between one-fourth and one-half inch in thickness. In places there are congested patches cov^ered with recent deposits of fibrin. The omentum, which is usually much thickened, is rolled up to form a sausage-shaped tumor lying tran.sversely across the abdomen. The capsule of the liver or of the spleen may be thickened, contracted, and the volume of these organs correspondingly reduced. The mesentery is thickened and contracted. There may be but little serum, so that the process is described as " adhesive " or "proliferative peritonitis," but in other cases ("ascitic peri- tonitis ") there is a quantity of liquid exudation, either free or encapsulated by adhesions. The ascitic form seems to be espe- cially common in children. Chronic peritonitis may be dif- fused, or the process may be limited to a circumscribed area. Symptoms are general and local. General Syuiptoms. — There is a progressive loss of flesh and of strength by which the patient becomes finally re- duced to semi-invalidism. The temperature may at times be slightly elevated. Local Symptoms. — Pain in the abdomen is constant and annoying rather than actually severe. There is usually considerable tenderness on palpation. Disturbances in digestion are almost constant. The bowels are usually con- stipated, although periods of diarrhoea may occur from time to time. Distortions and flexions of the intestines may re- sult in obstruction, or the common duct may be so twisted or compressed as to cause persistent jaundice. Acute ex- acerbations of the inflammation may occur, with moderate fever and a marked increase of the pain and tenderness. In children between two and ten years of age a chronic peritonitis which cannot be traced to any cause is not un- common. The ascites is considerable, but the symptoms are not extreme and recovery usually ensues. The results of a physical examination are not always uni- C//KON/C IIJiMONRIIAG/C PPIK I'rONITJS. 501 form, and depend upon the amount of the thickening and adhesions, the rolHng up of the omentum, and the presence or absence of a serous exudate. If there be much thicken- ing with matting together of the adhesions, the abdomen yields a doughy resistance to palpation, totally unlike the soft feeling of a normal abdomen. The whole abdomen may even appear to be filled with a resistant nodular tumor. If the omentum be rolled up, it may be felt as an irregular mass lying across the abdomen, and may be mis- taken for the nodular edge of an enlarged liver. If there be free effusion, the abdomen will be distended, and dulness or flatness will be obtained over the dependent portions of the abdomen, as well as over the flanks in the dorsal decu- bitus, with a tympanitic note over the uppermost portions. By changing the position of the patient there is a relative, change in the position of the percussion-notes. Fluctuation can readily be appreciated. Small encapsulated collections of fluid, surrounded by thickened and adherent intestines, may so closely resemble tumors that a differential diagnosis from cancerous peritonitis is not always possible. The duration of the disease is months or years. For the diagnosis from tubercular and cancerous peri- tonitis, see the articles treating of these diseases. The prognosis is bad, the patients usually dying ema- ciated ; but in some cases the disease may cease progress- ing, or recovery may follow operative treatment. Treatment is properly surgical. Ascitic accumulations should be withdrawn by puncture of the abdominal wall. Laparotomy, with the breaking down of adhesions and the drainage of encapsulated serous effusions, is often of cura- tive value. Medicinal treatment is symptomatic. It is claimed that benefit is derived from abdominal inunctions of mercurial ointment. CHRONIC HEMORRHAGIC PERITONITIS. This rare condition is analogous to chronic internal pachymeningitis. The peritoneum is thickened by con- nective tissue, and on its free surface are wide, thin-walled blood-vessels. By successive hemorrhages fibrin is de- 502 M.i.yr.iL or the pa'.ict/ce of medicine. posited in layers, so that the thickening is increased. The process, which is usually circumscribed, is most frequent in the pelvic region. TUBERCULAR INFLAMMATIONS OP THE PERITONEUM. The following forms of tubercular inflammations of the peritoneum are described: i. Acute tuberculosis of the peritoneum; 2. Acute tubercular peritonitis; 3. Chronic tubercular peritonitis. Acute Tuberculosis of the Peritoneum. In this form of inflammation the peritoneum is studded with tubercles as one of the lesions of acute miliary tuber- culosis. The peritoneum is otherwise normal, and shows no coincident inflammatory change, although there may be an effusion of clear serum. The clinical symptoms are latent or obscure. Pain and tenderness are rarely observed. The abdomen may be distended and may present the evidences of a peritoneal effusion. Acute Tubercular Peritonitis. Etiology. — This condition is seldom primary, but ex- tension of the disease to the peritoneum usually takes place from the intestines, the lungs, the pleura, the mesenteric glands, the Fallopian tubes, or the genito-urinary tract in either sex. Pathology. — There is a miliary tuberculosis accompanied by the ordinary products of inflammation. The peritoneum is studded with tubercular granules or plates. Elsewhere the membrane is congested and coated with fibrin or with fibrin and pus. There is usually an abundant effusion of either clear or turbid serum, occasionally hemorrhagic, rarely purulent. The symptoms usually begin abruptly. There are more or less severe abdominal pain and tenderness, with the other local symptoms of a general peritonitis. The temperature runs an irregular course varying between iOi° and 105*^ F., TUBERCULAR RJ'.R rrONf'JfS. 503 and is usually higher at night, although there has been ob- served an " inverse " temperature with evening remissions. The pulse becomes increasingly rapid and feeble. There is a progressive loss of flesh and of strength. There may be diarrhoea or constipation, or these conditions may alternate with each other. The " typhoid condition " ultimately develops. Physical Examination. — The abdomen is distended and tympanitic. Fluctuation is detected in one-third of the cases, especially in the earlier stages of the disease. Irreg- ular masses may be detected on palpation in protracted cases ; these masses may be due (i) to a thickened and rolled-up omentum, (2) to encapsulated exudation, (3) to tubercular mesenteric glands, or (4) to retracted and thick- ened intestinal coils. Diagnosis. — The symptoms are not equally prominent in all cases, but there is considerable variety in their relative pre- ponderance. If the general outweigh the local symptoms, the case may closely resemble one of typhoid fever. The diagnosis may be rendered even more definite by a rose- colored eruption over the abdomen, resembling typhoid spots, which occasionally appears in tubercular peritonitis. If the local symptoms are the more prominent, the case may be regarded as one of non-tubercular peritonitis ; but the diag- nosis is to be made from the latter condition by the absence of a cause for non-tubercular infection, by the presence of tubercular disease elsewhere, especially in the organs enu- merated under the heading of Etiology^ and by the more protracted course of the disease. The duration of the disease is from four to six weeks. The prognosis is exceedingly bad, but is not absolutely hopeless. Treatment should be surgical. The abdomen should be opened and drained. Operative treatment is more effectual in chronic cases, but in a few acute cases cure has resulted from such peritoneal drainage. Medical treatment is en- tirely symptomatic. 504 j/.i.vr.l/. of t/if. practjcr of medicixe. Chronic Tubercular Peritonitis. Etiology. — The etiology of tlie chronic is the same as that of the acute form of tubercular peritonitis. Pathology. — Two types are recognized : 1. Ti(bcn'ular Ascites. — The peritoneum is thickened and is studded with fibrous or cheesy tubercles in granules or in larger masses. The omentum is thickened and rolled up; the mesenter\' is retracted. There are but icw adhesions. There is, however, an abundant serous effusion, giving rise to the symptoms and physical signs of ascites. The effu- sion is usually serous, but in rare instances it may be hem- orrhagic or milky. 2. Tubercular Peritonitis with AdJiesious. — All the viscera are matted together in one boggy mass, either by connective- tissue thickening and adhesions or by soft gelatinous fibrin. Fluid effusion is usually scanty and may be encapsulated. The retraction of the omentum and the mesentery is the same as in chronic non-tubercular peritonitis. Throughout the thickened peritoneum are old tubercles and cheesy masses. Fibroid transformation of tubercle is more com- mon in the peritoneum than in any other locality of the body. The symptoms of the tubercular resemble those of the non-tubercular form. There are, however, tubercular lesions elsewhere that modify the clinical picture of the disease, and the course of the tubercular form is more severe and uncompromising than that of the non-tubercular form. Some cases run a latent or an insidious course, and are acci- dentally discovered at a laparotomy or at the post-mortem table. In these cases the peritonitis is more apt to be cir- cumscribed, and usually it is found in the pelvis, from infec- tion through the Fallopian tubes. Malignant disease of the peritoneum, as a rule, progresses more rapidly than tubercular peritonitis, and is secondary to malignant disease of some one of the abdominal organs that can readily be diagnosed. The prognosis is grave, but is not so hopeless as might be expected. The brilliant results following laparotomy and drainage have made a favorable prognosis the rule. CANCl'.R 01' 'J'l/I': I'KRJ'J'VNI'JJM. 505 Treatment. — It is claimed that from 70 to 80 per cent, of the cases operated on have been cured, but evidence is wanting that even the majority of these cases were actually- tubercular. In some cases merely an exploratory laparotomy in which the abdomen has been opened, inspected, and sewed up again at once has been productive of good results. The medicinal treatment is essentially constitutional and symptomatic. CANCER OP THE PERITONEUM. Etiolog-y. — Primary cancer of the peritoneum is exceed- ingly rare, although cases of primary colloid growths of large size have been described. Secondary growths occur in connection with malignant disease of any of the abdomi- nal viscera. The disease, which is more common in women than in men, occurs during advanced life. Pathology. — The peritoneum is studded with carcino- matous nodules of various sizes, the favorite seats for the deposits being the omentum and the mesentery, the perito- neum near the umbilicus, and Douglas's fossa. The nodules may be small and discrete or larger and confluent, so that tumors of considerable size may form. Unaccom- panied by coincident peritonitis, the process is spoken of as " carcinosis." Usually, however, the peritoneum is the seat of a chronic inflammation ; it is thickened, the omentum is rolled up, and the peritoneal cavity contains an effusion which may be serous, hemorrhagic, or milky from the fatty degeneration of the cancer-elements. In rare cases the effusion may become purulent. To this form of malignant deposits with associated inflammation the term " cancerous peritonitis " is given. The retroperitoneal and mesenteric glands are usually involved, and the inguinal glands may be enlarged. Perforation or fistulse may result from the ulcera- tion of the cancer-masses, and fatal hemorrhage may occur from ulceration within the bowel. Colloid carcinoma involves the peritoneum diffusely, converting it to a thick, gelatinous mass, often of enormous size. Symptoms. — i. There are s}^mptoms due to the primary 5o6 m.i\l:il of the practice of medicjxe. growth. Cachexia is usually' evident before the peritoneum becomes involved. 2. Symptoms of chronic peritonitis are present. In many cases ascites and progressive emaciation are the prin- cipal complaints. Fever is usualh' present, but its course is similar to tliat of tubercular peritonitis. Pain and tender- ness are usually more marked than with ordinary chronic peritonitis, but in rare instances the course of the disease is painless throughout. 3. Severe hemorrhages may result from ulcerations with- in the intestinal walls, or rapidly spreading peritonitis from perforation may develop. Cachexia, waxy pallor, and weakness increase with the progress of the disease. Physical examination yields no distinctive signs by which a positive diagnosis may be made. If there be much effusion, the tumors may be so obscured that a diagnosis from chronic peritonitis is impossible. Usually^, after tap- ping, multiple nodules may be felt, but these nodules may be mistaken for the encapsulated exudate of a chronic tubercu- lar peritonitis. According to Osier, multiple nodules, if large, indicate cancer, particularly in persons above middle life, whereas nodular tubercular peritonitis is more common in children. The rolled-up omentum may be appreciated as an irregular mass lying across the upper abdominal zone ; it has, however, no diagnostic value, as the same condition occurs in chronic tubercular or non-tubercular peritonitis. Examination by the rectum or the vagina should be resorted to in doubtful cases, as Douglas's fossa is frequently in- volved early in the course of the disease. Secondary nodules about the navel are highly suggestive of cancer. The diagnosis will be confirmed if cancerous fras^ments be removed through the trocar at the time of tapping. A milky appearance of the fluid is suggestive, but is not absolutely diagnostic. The further diagnosis from tubercular peritonitis has been spoken of under the latter disease. If the growth be colloid, the results of physical examina- tion are altogether different. There are no nodules and no ascites. The abdomen is symmetrically enlarged, often ASCITES. 507 reaching enormous proportions. On palpation the abdomen is apparently filled with a semi-solid mass. The prog-nosis is absolutely bad. As cancerous peri- tonitis usually complicates pre-existing visceral cancer, the duration of the disease is seldom more than a few months. Cases of primary growth run a longer course. Treatment is entirely symptomatic. The fluid may be relieved by tapping if it produce discomfort, but the ascites rapidly returns. Opium should be given in doses sufficient to quiet pain. ASCITES; HYDROPERITONEUM ; ABDOMINAL DROPSY. Etiology. — A serous exudate within the peritoneal cavity is common in all forms of chronic peritonitis, whether simple, tubercular, or cancerous. The term " ascites," how- ever, should more properly be limited to a serous transuda- tion from stasis, without inflammatory changes. The ascites may thus be due — {a) to obstruction of the portal vein, either in the terminal branches within the liver, as in cirrhosis of the liver, or in a larger trunk without the liver as from thrombus-formation, from external pressure by pro- liferative peritonitis, new growths, or abdominal aneur- ysms ; (/;) to general venous congestion arising in the course of chronic heart disease, emphysema, or interstitial pneu- monia; (r) to hydraemic blood-conditions, as in Bright's disease or in advanced ansemia. The ascitic fluid is pale yellow, with occasionally a green- ish tinge, and is usually clear. The specific gravity varies between loio and 1015, although in cases due to cancer of the liver the gravity may be as high as 1023. The fluid contains albumin, has the chemical characteristics of blood- serum, and may form a delicate fibrinous clot on standing. Ascitic fluid may at times present a milky appearance. If this appearance be due to the admixture of chyle ('' chylous ascites "), the fat is molecular ; if due to layers of fat-globules, the name " adipose ascites " is often applied to the fluid. Chylous ascites is due to injury to the thoracic duct by perforation, rupture, or by the filaria sanguinis hominis, or 5o8 M.lXf.lL OF THE PRACTICE OF MEDICIXE. to its thrombosis or obliteration. In adipose ascites the fat originates from the fatty degeneration of cells, usually the product of. a cancerous or tubercular peritonitis. The symptoms of ascites are due to the mechanical weight and pressure of the transudation. In ascites due to portal obstruction the fluid accumulates within the peritoneal caxity, sinking into the most depend- ent portions, while the abdominal organs that contain air float upon the fluid as far as their peritoneal attachment will allow. The fluid is freely mo\'able, occupying the most dependent portions of the abdomen with every change of position. If the fluid does not thus move freel)-, but changes its position slowly and incompletely or remains immovable, inflammatory exudation is indicated. Pressure upon the iliac veins will cause secondary oedema of the lower extremities. In ascites due to diseases of the heart and the lungs or to hydrjtmic blood-conditions the abdom- inal effusion is but an added symptom of a general dropsi- cal condition, and is associated with oedema of the lower extremities, and usually with h}'drothorax. Physical Signs. — In the dorsal position the abdomen is flattened in the umbilical region and bulges in the flanks. In the upright position the lower abdominal region is alone prominent. In extreme distention the whole belly is rounded and the skin of the abdominal wall is tense, shin- ing, and may present pinkish striae as in pregnancy. The navel is usually protuberant. Enlarged anastomosing veins are usually seen coursing over the abdominal wall. Percussion gives dulness over the fluid and tympany over the overlying intestines. By changing the position of the patient the relative areas of these percussion-notes becomes correspondingly altered. Percussion is important in' differentiating between the distention of ascites and that of extreme meteorism. In cases of moderate effusion dul- ness appears in the umbilical region when the patient assumes the knee-chest position. Fluctuation is obtained by the transmission of a wave from one side of the abdomen to the other by one hand being placed over one flank while the other flank is lightly ASCITES. 509 tapped. In this way even a small amount of fluid maybe detected with great accuracy. The sign, however, may fail when there is great effusion under high pressure. In fat subjects a fluctuation-wave may run across the lax, flabby abdominal wall, but this superficial wave may be checked by pressing the ulnar edge of the hand firmly upon the linea alba. The prognosis of ascites is dependent upon its cause. The treatnaent is that of the primary cause. Stimulants should be given to sustain a failing circulation. Anaemic conditions require appropriate treatment. The fluid may be diminished by the free use of diuretics and cathartics, should the patient's strength allow of such treatment. Eventually tapping becomes necessary for the comfort of the patient, although the operation may have to be repeated frequently, as the accumulation tends to recur. Care should be taken before tapping to exclude a distended blad- der. The skin having been scrupulously sterilized, the puncture should be made with a straight trocar, in the median line midway between the symphysis and the navel, provided that previous percussion has not revealed an intes- tinal coil lying directly under the site of puncture. When the fluid ceases to flow the trocar is to be withdrawn, the opening being closed by a suture over which is applied an antiseptic pad. A tight many-tailed bandage applied dur- ing the tapping will facilitate the flow, and after the trocar is withdrawn will yield support to the relaxed abdominal wall ; this application should never be omitted. The dangers of tapping are syncope, perforation of the intestine, infection of the peritoneum with unclean instruments, and hemorrhage from puncture of an artery of the abdominal wall. 5IO MAXr.-iL OF THE PRACTICE OF MEDICIXE. 5. DISEASES OF THE LIVER. FUNCTIONAL DISTURBANCES OF THE LIVER. To appreciate the various symptoms caused b\' functional disturbances of the liver it is necessary to consider the normal functions of the liver, and to see what symptoms will necessarily arise from the perversion of each function. 1. From disturbed glycogenic function the bodily heat is lowered, so that the patient becomes susceptible to cold ; glucose may pass the liver unchanged and may appear in the urine (glycosuria). 2. Destructive metamorphosis of albuminoid matter not being properly performed, uric acid and sub-oxidized urea compounds are retained in the body, giving rise to head- ache, vertigo, mental dulness, and despondency. Muscular or articular pains are common. The kidneys may become irritated by the uric acid and the oxalate of lime, and a chronic nephritis may develop. In some cases renal calculi result. 3. Defects in the quantity or the qualit\- of the bile allow of general malnutrition. Fats not being easily absorbed, the patient becomes thin. There are constipation and intestinal flatulence. 4. From the failure of the liver to destroy the poisons arising in the normal processes of digestion (pepto- toxines), or the alkaloids of intestinal fermentation, these toxic products pass the liver unchanged, and a general toxajmia is the result. Etiology. — Functional disturbance of the liver may be primary or secondary. Primary cases arise — (i) From errors in diet. The food may be too rich, too excessive, or too abundant in fatty and saccharine ingredients, or there may be an over-indulgence in malt liquors. (2) From want of exercise and from deficient oxidation-processes. Secondary cases arise — (i) From structural changes in the liver. (2) From disorders of gastric or intestinal diges- tion. (3) From disorders of the heart and the lungs, inter- FUNCTIONAL DISTURBANCES OF THE LIVER. 5 I I fcring with a proper circulation of blood within the liver and with oxidation-processes. (4) Some cases seem to be due to mild malarial poisoning. Symptoms. — Individual symptoms may be inferred from the consideration of the preceding paragraphs. Clinically the cases may be divided into two groups : 1. The whole nutrition of the patient is below par; he looks anaemic and imperfectly nourished, and the com- plexion has a muddy, sallow tinge. The tongue is furred and flabby. The appetite is generally lost, especially dur- ing the earlier portions of the day. The bowels are con- stipated, the stools being dryish and clay-colored. There is a disagreeable taste in the mouth, especially in the morn- ing, variously described as "bitter" or "pappy." The breath is usually offensive. Headaches are frequent ; they may be so persistent and severe as to suggest organic disease of the brain. Attacks of " sick headache " incapacitate the patient from time to time. The mental condition is one of apathy, with periods of irritability and depression. The urine generally shows deposits of urates, of oxalate of lime, or of uric acid. These patients are commonly described as " bilious." 2. Patients of the second group of cases do not become emaciated nor do they lose strength. The intestinal symp- toms are slight, but the cerebral symptoms are prominent and distressing. Vertigo is often so pronounced that the patient is afraid to leave the house alone. There is loss of memory, with failure of the mind to concentrate itself for any length of time. Headache is frequent and distressing. There are alternate pallor and flushing of the face, with a sense of throbbing fulness in the head. The urine may contain oxalate of lime, uric acid or the urates, or may be normal. In these cases the symptoms are due to the vaso- motor disturbances of the vessels of the brain, due to their irritation by toxic products of body- waste or of intestinal digestion. The prognosis depends largely upon the will-power of the patient to carry out the necessary treatment. Treatment. — hxxy dietetic error should be corrected. 512 MA.VCAL OF THE PK.ICT/CE OF MEDICLXE. The food should be simple and wholesome, and fatty and starchy food should be reduced in quantity. Alcoholic stimulants should, in general, be interdicted. The most benefit is to be derived from active exercise in the open air to the point of moderate fatigue. The exercise, once begun, should be systematic, should be graded to suit the individual strength of the patient, and should be of such nature as to afford pleasure and enjoyment. The drug- treatment consists chiefly in controlling dyspeptic condi- tions, in giving laxatives when required, and in the use of cholagogues. Of the latter, podophyllin, rhubarb, ipecac, magnesium sulphate, hydrochloric acid, and salicylic acid are the most serviceable. The modified rhubarb and soda mixture, while unpleasant to the taste, is of great value: I^. Pulv. rhei, gr. ij ; Sodii bicarb., gr. v ; Pulv. ipecac, gr. \; Tinct. nucis vomicae, TTLv ; Aq. menth. pip., ,^j. — M. Sig. One teaspoonful three times daily, before meals. CIRCULATORY DISTURBANCES OF THE LIVER. Anaemia. — This condition, frequently found post-mortem, is not accompanied by any symptoms. Active congestion was formerly regarded as a more im- portant condition than at the present time. Physiological congestion occurs after a hearty meal. Acute congestion may occur with infectious diseases, especially malaria, typhoid fever, and dysentery. The syinptovis are not characteristic. There may be slight enlargement of the liver with tenderness on palpation. Treatment is by active purgation. Passive congestion (Chronic congestion; Nutmeg liver). — This condition occurs whenever there is a mechanical obstruction to the outflow of blood from the liver, during the course of heart disease with a failing right ventricle, with diseases of the lungs interfering with the flow of blood from the right to the left heart, and with pressure on the vena cava by thoracic tumors. DISEASES OF TI/E CAPSdlJi OF 'J'J/E LIVER, 513 Pathology. — The central vein of each hepatic lobule is dilated, and the liver-cells in its neighborhood become pig- mented and atrophied. The cells at the periphery of the acinus become fatty. The mottling of the reddish-brown depressed centre and the yellowish periphery of each acinus gives rise to the term " nutmeg " liver. In long-continued cases connective tissue may be deposited in and between the lobules, starting usually from the central vein. In the earlier stages the liver is enlarged, but the longer the conges- tion lasts, the smaller and denser the liver tends to become. The symptoms are chiefly those of the primary lesion with the attending venous congestions. There may be added symptoms of a moderate degree of portal obstruction (see Cirrhosis of the Liver). Nausea, vomiting, and even vomiting of blood may occur, and slight jaundice may be evident in the conjunctivae and in the urine. The treatment is that of the original disease. Depletion of blood from the liver is accomplished by vegetable or saline laxatives. An occasional mercurial purgation by cal- omel or by blue pill is recommended. DISEASES OP THE CAPSULE OP THE LIVER. Acute Perihepatitis. Etiology and Synonyms. — The cause of acute peri- hepatitis may be direct violence, but usually there is found perforation of an ulcer of the stomach or the duodenum, or infection or rupture of a neighboring abscess, especially of the liver, the gall-bladder, or the right kidney. Synonyms : Subphrenic abscess ; Subphrenic pyo-pneumothorax. Patholog-y. — The peritoneum of the liver and of the corresponding surface of the diaphragm is congested and covered with fibrin and pus. Adhesions form, allowing of a circumscribed peritoneal abscess (subphrenic abscess). The pus may be yellowish-red in color, from the presence in it of bilirubin, and it may contain crystallized fatty acids. If the cause be a perforation of an ulcer of the stomach or of the duodenum, the pus may be mixed with air (subphrenic pyo-pneumothorax j, 33 514 M.l.yr.tl. OF THE PRACTICE OF MEDICINE. The sjrmptoms of acute perihepatitis are those of a local-" ized peritonitis. There are pain and tenderness with the general symptoms of fever. In perforative cases the onset is abrupt and may be accompanied by shock. In general, the course of the disease is that of an empyema or an ab- scess of the liver. Drainage or evacuation of the pus may be followed by cicatricial contraction of the abscess-wall, so that compression may be produced upon the liver, the vena cava, the bile-duct, or the portal vein. The physical signs resemble those of empyema or of an abscess of the liver. The right hypochondrium is dis- tended and motionless. There may be a friction sound detected early in the disease. Later the friction disappears and is replaced by dulness or flatness and absence of voice and breathing. Subphrenic pyo-pneumothorax may giv^e physical signs similar to those arising from a like condition above the diaphragm. The diagnosis of perihepatitis is readily made, should the aspirating-ncedle draw ochre-colored pus containing bili- rubin and fatty acids. The etiology of the condition also gives a clue to the correct diagnosis. Treatment is entirely surgical, consisting in opening and draining the abscess. Chronic Fibrinous Perihepatitis. Etiology. — This condition may follow acute perihepatitis or may be chronic from the start, as the result of a chronic irritation of a neighboring inflammation or of long- continued pressure over the liver. Patholog-y. — The peritoneum covering the liver is thick- ened and is adherent in places to opposed surfaces. Shrink- age of the fibrous capsule may result in atrophy of the liver or in constriction of the veins or the ducts. Symptoms.— ^There are no characteristic symptoms. A friction rale may be heard over the liver during inspiration, but this sign is inconstant. The treatment is that of the causative disease. ACUTE rARENCIIYMATOUS lUWATITIS. 515 Syphilitic Perihepatitis. The various syphilitic lesions of the liver will be consid- ered under the heading of Syphilitic Diseases of the Liver. ACUTE PARENCHYMATOUS HEPATITIS. Synonyms. — Acute yellow atrophy ; Malignant jaundice. Etiology. — Secondary acute fatty degeneration of the liver may occur with many of the infectious diseases, in the latter stages of cirrhosis or of biliary retention, with yellow fever, and with phosphorus-poisoning. Primary cases are exceedingly rare. Individuals under thirty years of age are more frequently attacked, and women, especially during pregnancy, are especially liable to the disease. At times several cases occur in one family or in barracks, showing an epidemic tendency. The actual cause of the disease is unknown, although it is supposed to be due to an unknown bacterial infection. Pathology. — The liver is reduced from one-third to one- half in size, and its capsule is in folds and wrinkles. The organ is jaundiced or mottled yellow and red, the latter color representing the more advanced stages of the lesion, in which all fat has been absorbed from the liver-tissue. Microscopically are found extensive fatty degeneration and necrosis of the liver-cells, ending in their ultimate absorp- tion. Crystals of leucin, tyrosin, and bilirubin may be found, and in most cases there is seen a small-celled infiltra- tion of the stroma. The body-tissues are deeply jaundiced. The spleen is large and soft in about half the cases. The heart-muscle shows granular degeneration. There is acute degeneration of the kidney. There are numerous hemor- rhages throughout the body. Symptoms. — In the majority of cases there is a premoni- tory gastro-duodenitis, with nausea, vomiting, and jaundice. The onset of the disease itself comes suddenly and severely. Nervous Symptoms. — There is violent headache. Active delirium, amounting to mania, may be so marked as to require physical restraint. The attacks of delirium become less and less severe and alternate with periods of stupor 5l6 MAXr.lL OF THE PA'.tCT/CE OF MEDIC/XE. until finall\' the patient passes into the typhoid condition, with low. muttering delirium and extreme prostration. Jaundice, if not developed during the preliminary period, now becomes noticeable. Its absence is rare. The sudden occurrence of jaundice with violent cerebral sj'mptoms is suggestive of this disease. Honorrliagcs occur in the subcutaneous and submucous tissues, from mucous surfaces, and into internal viscera. Pregnant women abort with violent post-partum bleeding. Urinary syviptonis are somewhat characteristic. The urine is diminisl^ed, jaundiced, and contains albumin and casts. Urea is markedly diminished, and ma}' be altogether absent in the latter stages, and in its place are found crystals of leucin and tyrosin. The former, occurring in the form of globules resembling fat, is seen only upon evaporation of the urine ; the latter, in the form of needles, occurs as a spontaneous deposit. Leucin and tyrosin are not, however, constantly present in the urine of this disease. General symptoms are not characteristic. The tempera- ture may be normal, subnormal, or slightly elevated. A high ante-mortem temperature, however, is almost always observed. Vomiting is usually a prominent symptom, and blood may be raised. The bowels are constipated ; the stools are clay-colored or may consist of blood. The pulse becomes rapid and feeble, the typhoid condition becomes more profound, and the patient dies, usually within a week, although the case may be somewhat more protracted. Physical examination shows a rapid diminution in the size of the liver. As the flabby liver tends to drop back, there may finally be only a slight line of liver-dulness in the axillary region, and no dulness at all in front. If the disease attack a previously enlarged liver, the diminution will be less marked and the diagnosis will be more difficult. The liver is usually tender on palpation or percussion. The diagnosis is further aided by the presence of an enlarged spleen, by the jaundice, and by the hemorrhages. The diagnosis may be made positively upon the associa- tion of severe jaundice, cerebral symptoms, diminished size CfRRIIOSJS OF THE L/l'AA'. 517 of the liver, and the presence of leucin and tyrosin in the urine. The case may be mistaken for one of phosphorus-poison- ing, but in the latter condition there is the history of poison- ing, the presence of phosphorus in the vomited matters, the onset is more sudden, gastro-intestinal symptoms are more marked, and leucin and tyrosin are absent from the urine. The latter stages of hypertrophic cirrhosis may resemble acute yellow atrophy, but the liver is enlarged and the course of the disease is essentially chronic. Conditions of profound jaundice with cerebral symptoms (cholaemia) may so closely resemble acute yellow atrophy that a differential diagnosis is very difficult. Prognosis. — The disease is invariably fatal. The treatment is symptomatic. CIRRHOSIS OF THE LIVER. Synonyms — Chronic interstitial hepatitis; Fibrous cir- rhosis. Three forms of cirrhosis of the liver are recognized : i. Atrophic cirrhosis ; 2. Hypertrophic cirrhosis ; 3. Syphilitic cirrhosis. The " Glissonian cirrhosis " has been described under the heading of Chronic Perihepatitis. Atrophic Cirrhosis. Etiology. — Fibrous disease of the liver is almost regu- larly due to the action of irritants brought to the liver by the blood-vessels. In over two-thirds of the cases the im- mediate cause is alcohol, especially the stronger liquors. There may be the history of excessive indulgence, or the habit of " nipping " may be confessed. In some cases indul- gence in the lighter wines or in malt liquors may lead to the disease. Other irritants entering the liver by the portal vein may be adduced as causes of the disease — highly-spiced food and the ptomaines and other alkaloids of intestinal digestion — but upon this point satisfactory evidence is lack- ing. Cirrhosis may follow rickets, scarlet fever, or typhoid fever, or may result from long-continued passive hyper?emia of the liver. In coal-miners the disease mav follow the 5l8 MAXL\AL OF THE PRACTICE OF MEDICLVE. swallowing of coal-dust, which is deposited as solid pigment in the liver. There has been described a senile form of cirrhosis analogous to other arterio-sclerotic changes in the different viscera. Cirrhosis of the liver is far more common in men tlian in women, because of their more frequent indulgence in alco- hol. It usually occurs between the ages of thirty-five and sixty years, and it is far less common in children than was formerly supposed, although in them the majority of cases are of syphilitic origin. It is a peculiar fact that cirrhosis is exceedingly rare in the negro, although in this race in- temperate habits are common. Two autopsies only of this disease have been made at the Colored Hospital in New York during the past twenty-five years. Pathology. — The liver is small, hard, and dense. Its weight may not exceed a pound or a pound and a half The surface. is granular, and the capsule is usually thick- ened. On section the organ ma\' be bile-stained or may present grayish-white streaks of connective tissue. It was owing to the yellow appearance of the organ that the name " cirrhosis " {xefjf)o^, yellow) was first applied by Laennec. A primary increase of the size of the liver does not occur. Upon close examination the essential lesion is seen to con- sist of the -formation of connective tissue within the liver, either loose and cellular or dense and fibrillated. The fibrous tissue usually extends about the radicles of the por- tal vein at the periphery of the acinus, giving the organ a finely granular appearance ; or the connective tissue may surround groups of acini, resulting in a coarsely granular appearance. The tissue may extend into the liver from the capsule in large irregular streaks and bands, although this arrangement is more common in .syphilitic cirrhosis. Pressure-changes are seen in the liver-cells, the blood- vessels, and the gall-ducts. The liver-cells, especially at the periphery of the acini, undergo fatty degeneration and become atrophied or flattened by pressure. The rootlets of the portal vein between the lobules are pressed upon and obliterated. This interference with the portal circulation gives rise to the important lesions of CIKRIJOSIS OF THE I.IVhR. 519 portal obstruction. There is usually an increase in the size of the hepatic artery furnishing blood to the new fibrous tissue. The gall-ducts may be the seat of a catarrhal inflammation or may become obliterated. In some cases there occurs an irregular production of new gall-ducts. Secondary lesions result directly from the portal obstruc- tion. The spleen becomes congested and hyperplastic. The stomach and the intestines are congested or show chronic catarrhal inflammation. Ascites results from the stasis, may reach an extreme degree, and may be accom- panied by a mild form of chronic peritonitis. Hemorrhoids result from congestion of the veins of the rectum. There are evidences of collateral circulation between the branches of the portal veins and those of the vena cava, at the junc- tion of the oesophagus and the stomach, along the sigmoid flexure and rectum, in the retroperitoneal plexus, and about the umbilicus. The radiating varicose veins about the latter situation have received the name of " caput Medusae." The branches of the internal mammary and epigastric veins also become dilated and tortuous. Associated lesions are not due directly to the cirrhosis, but are frequently found in the same patient, and arise from the same etiological factors as does the fibrous disease of the liver. These lesions comprise endocarditis, atheroma of the aorta, endarteritis, emphysema, and chronic diffuse nephritis. Acute tuberculosis is a not infrequent compli- cation. Symptoms. — There may be an antecedent alcoholic gastritis. When cirrhosis develops, the symptoms present themselves in four groups : 1. Symptoms of functional disturbance of the liver. The various intestinal, urinary, cerebral, and nutritive symptoms are present as in the cases previously described, and cir- rhosis should be suspected if these symptoms occur in an alcoholic subject. 2. Symptoms of obstructed portal circidation are more dis- tinctive. Gastro- intestinal symptoms are those of conges- tion or chronic inflammation, dyspepsia, vomiting, haema- temesis which may be profuse or even fatal, constipation, and 520 .y.lXl'.IL OF THE PRACTICE OF MEDIC L\'E. hsemorrhoids. Ascites gives rise to enkirgement ut the abdomen and to dyspnoea ; the transudation may press upon the ihac veins, causing oedema of the lower extrem- ities. As long, however, as compensatory circulation is maintained, the obstructive symptoms are slight or absent, 3. Symptoms of jaundice are due to the obliteration or catarrhal inflammation of the bile-ducts or to gastro- duodenal catarrh. The jaundice is rarely marked at first, amounting only to a nuidd\', sallow tinge. The facies is fairly characteristic : the skin is dry and of an icteroid hue ; the nose and the cheeks show distended veins ; the eyes are sunken and watery. From time to time attacks of more severe jaundice occur, and in some instances, espe- cially toward the termination of the disease, the jaundice becomes extreme and is accompanied by cerebral symp- toms. 4. Symptoms of toxczmia may develop at any time. The patient may become actively delirious, noisy, and talkative; or he may become stupefied, with periods of semi-coma and muttering delirium, or may even develop convulsions. These symptoms may be due to intense jaundice, to alco- holism, or to urc-emia, while in other cases the exact nature of the toxaemia cannot be ascertained. The course of the disease is usually afebrile throughout, except that a moder- ate temperature may occur as a terminal symptom. At no time is there pain or tenderness over the liver. Physical examination shows a diminution in the size of the liver, an enlargement of the spleen, and the presence of ascites and of ana.stomosing veins. A positive assurance that the liver is actually diminished in size is often lacking, as an apparent but not a real, diminution may be caused by the overlapping of the liver by an emphysematous lung, or by the liver being tilted upward by a distended stomach or colon ; or the lower line of liver-flatness may be obscured by tympany from intestinal distention. In other cases the cirrhosis may occur in a liver previously enlarged by waxy or fatty change. The liver is thus rendered smaller than its previous size, but still may be larger than normal (see Hypertrophic Cirrhosis). The enlargement of the spleen CIRRIJOSJS OP' THE LJVJCR. $21 is best determined by palpation, as the percussion-bound- aries may be obscured by tympanites, by the solid or liquid contents of the stomach or the colon, or by the ascites. It is important to remember that the spleen may not be in- creased in size if there be continued diarrhcea or vomiting or if its capsule be thickened from perisplenitis. Prog-nosis. — The course of the disease is protracted. The exact duration of any given case cannot be determined accurately, as the onset is insidious. If the patient abstains from his alcoholic habit, the lesion may not develop further, so that he may live for years. In ordinary cases the end is reached within a year or two after the diagnosis is made. Death may result from haematemesis, from Bright's disease, from delirium tremens, from the cerebral symptoms of severe jaundice, or from toxaemia and exhaustion. In the latter instance the patient becomes anaemic and emaciated, the enlarged ascitic abdomen being in marked contrast to the emaciated chest and extremities. Cerebral symptoms develop — stupor, muttering delirium, and semi-coma. The pulse becomes rapid and feeble, and death finally results. Treatment. — The patient should abstain from alcoholic drinks and from highly-seasoned food. The diet should be of the simplest character, and the value of a prolonged milk diet cannot be overestimated. Exercise should be moder- ate and gradual ; the skin is to be kept active by baths and frictions ; the bowels should be kept open ; and all errors of digestion should receive appropriate treatment. In pa- tients with a syphilitic history mercury and potassium iodide may be given. Quinine and arsenic are indicated if the patient lives in a malarial locality. Cholagogues are indicated for the relief of the functional disturbances of the liver. When symptoms of portal obstruction appear, the indication for treatment is to deplete the engorged intestinal vessels by occasional catharsis. For this purpose from half an ounce to an ounce of magnesium sulphate may be given in a concentrated solution before breakfast, or any of the vegetable purges may be administered. An occasional dose of calomel or of blue pill is also of service. The ascites is to be relieved by diapharetics, cathartics, and diuretics. 522 MAXCAL OF THE PKACTICE OF MEDICIXE. Tapping should not be resorted to unless the ascites be distressing and be unrelieved by medicinal treatment, as the operatiori usually must be repeated frequently, and cerebral symptoms are apt to follow the withdrawal of the effusion. Repeated tappings, moreover, may result in chronic peri- tonitis. Toward the close of the disease alcohol may be necessary as a stimulant. Hypertrophic Cirrhosis. Of h^'^pertrophic cirrhosis four forms are described: 1. In the first variety the lesions are the same as in the atrophic form, but the increase of the connective tissue is greater than can be compensated for by the atrophy of the liver-parenchyma. The result is a cirrhotic liver of large size. The secondary lesions and the symptoms are identical with those of the atrophic form. 2. Biliary cirrhosis, or hypertrophic cirrhosis ivith jaundice, usually results from chronic bile-retention, and frequently follows chronic obstruction of the common duct by a gall- stone, by cicatricial contraction, or by pressure from without. A primary form of biliary cirrhosis has been described. The bile-ducts become distended and are surrounded by new deposits of connective tissue. Fatty degeneration and atrophy of the liver-cells are not marked, the lesion differ- ing greatly in this regard from that of the atrophic form. The liver is symmetrically enlarged, extending to the umbil- icus or even to the level of the anterior superior spines, is deeply jaundiced, and is resistant to the feeling and to the knife. Secondary lesions of portal obstruction are usually present, but to a less degree than in the atrophic form. Ascites is usually absent, although it may appear late in the disease. Jaundice is persistent and extreme throughout, yet the feces may be bile-stained. Hemorrhages in biliary cirrhosis are infrequent. At any time there may appear symptoms closely resembling those of acute yellow atrophy. The temperature rises to 102°, 104°, or even to 106° or 108° F., jaundice rapidly becomes more extreme, delirium and convulsions appear, and a fatal issue rapidly follows. CIRRHOSIS OF THE LIVER. 523 Lcucin and tyrosin, however, do not appear in the urine. In other cases death results from emaciation and debility. The course of the disease is from three to seven years. The treatment is that of cirrhosis in general. Good re- sults have followed the frequent use of small doses of cal- omel, one grain being given several times a day for several days, and then discontinued should too free purgation fol- low or should stomatitis threaten, to be again administered after five or six days' interval. 3. Fatty Cirrhosis. — In this form of cirrhosis fatty and cirrhotic changes are found associated. The liver is large and resembles a fatty liver, but it is firmer, more resist- ant to the feeling and to the knife, and microscopically shows an increase in the connective tissue. The clinical course is that of atrophic cirrhosis, differing only in the fact that the liver is found to be enlarged. This form of cirrhosis is very common. 4. There is a form of hypertrophic cirrhosis accompanied and usually preceded by bronzing of the skin. In many of the advanced cases diabetes has been present, and to this symptom-complex the name "diabete bronze" has been given. Whether the disease has a separate pathological entity is uncertain. It is believed, however, that the primary lesion consists in the widespread deposition of blood-pigment (haemochromatosis), with subsequent degeneration of the cells containing the pigment, especially in the liver and pancreas, which organs become the seat of a chronic inter- stitial inflammation. The great majority of the reported cases have occurred in adult males. Syphilitic Cirrhosis. Etiology. — Syphilitic disease of the liver may be the re- sult of hereditary syphilis, occurring as a congenital mani- festation or during childhood, or the liver may be affected as a tertiary lesion of the acquired disease. Patholog-y. — Pathologically, three types of syphilitic dis- ease of the liver may be described, but they are usually combined and blended with each other : 1. Syphilitic Perihepatitis. — The capsule of the liver is 524 A/.ixr.t/. 0J-' riiF. practice of medicixe. thickened and is adliercnt to opposing peritoneal surfaces. From the thickened capsule bands of connective tissue pass into the substance of the liver, forming fibrous scars that cause considerable deformity. 3. Diffuse SypJiilitic Hepatitis. — The liver is large, firm, and resistant. Its color ma\- be compared to that of sole- leather, or its appearance may resemble that of the amyloid liv^er. Microscopically the hepatitis does not present essen- tial differences from the lesion of ordinar\' cirrhosis, al- though in some instances large groups of acini are sur- rounded by fibrous bands visible to the naked eye, and extensive puckered cicatrices may be found. Gummata are usually present at some stage of the disease. The lesions of portal obstruction are regularly present. 3. GuDiviata occur as nodules varying in size from that of a pea to that of a lemon. Fresh gummata are reddish- gray and of a translucent appearance. The older gummata show at their peripher\- a connective-tissue capsule ; their centres may become cheesy, fibrous, or puriform, or they may be infiltrated with lime-salts. Smaller gummata un- dergo fibroid transformation and result in disfiguring cica- trices. Gummata alone cause neither portal obstruction nor jaundice, as a rule, unless they form in a locality where pressure on the portal vein or the bile-duct is possible. Symptoms. — i. Of the Perihepatitis. — Pain and tender- ness are commonly observed ; the movements of the liver during respiration are impeded ; and a friction sound can usually be detected by auscultation. 2. Of the Diffuse Hepatitis. — The symptoms resemble those of cirrhosis, but a primary enlargement of the liver may possibly occur. 3. Of Guunnata. — The symptoms are similar to those produced by multiple tumors. The gummata are usually situated near the suspensory ligament and on the under surface of the liver, so that an irregular lower border may be appreciated. Inequalities of the surface may be detected. The diagnosis of syphilitic disease of the liver is made by the consideration of the following points: i. The absence of alcoholic history. 2. The presence of congenital or the ABSCESS OF tup: liver. 525 late forms of acquired syphilis. 3. The patient is frequently a young- child. 4. The symptoms of cirrhosis are compli- cated by those of perihepatitis and of gummata. 5. The beneficial results of treatment. Treatment consists in the administration of potassium iodide in large doses, preferably combined with mercurials. If the treatment be prompt and vigorous, the results are often brilliant; but if the treatment be begun too late, cica- tricial bands and diffuse hepatitis may remain, for which further treatment is of no avail. In other respects the treat- ment of the case is that of ordinary cirrhosis. ABSCESS OP THE LIVER (SUPPURATIVE HEPATITIS). Etiology. — Abscess of the liver is due to infection by micro-organisms capable of causing suppuration. Of these micro-organisms the pyogenic micrococci and the amoeba coli are the most important. The infecting germ may enter the liver by several channels : 1. Through traumatism, by injuries, by foreign bodies, and by parasites. Suppurating hydatid cysts are not un- common. 2. Through the portal vein. Liver-abscess thus compli- cates intestinal ulcerations (especially those of dysentery, in which the infective agent is the amceba coli), abdominal abscesses, operations upon the rectum, and suppurative in- flammations of the portal vein itself 3. ThrougJi the umbilical vein in new-born children, fol- lowing infection of the navel. 4. TlirougJi the hepatic artery in pyaemia, in malignant endocarditis, and in gangrene of the lung. 5. Through the bile-duct. Infection through this channel is favored by the presence of cholangitis or of gall-stones. 6. In some cases no cause can be ascribed for the infec- tion, and to these cases the names " idiopathic " and " tropi- cal " abscess are given. This variety of abscess, which is most common in India, may occur in the Southern United States, but it is infrequent in Northern cities. The infecting 526 .v.-Lvr.iL OF riiE practice of medicine. agent in most of these abscesses is the amteba coh, although the symptoms of dysentery may be absent. Abscess of the Hver occurs with greatest frequency in men, and in those of adult years. Pathology. — Tlie wall of the abscess is usually irregular and jagged ; it is composed of necrotic liver-tissue infiltrated with fibroid serum and pus, and the surrounding liver-tissue is hypera^mic. In protracted cases a connective-tissue cap- sule may be formed. The pus ma)' be thick and creamy, or it may be thin, curdy, and of a reddish or brownish color, from pigment derived from blood-cells and broken-down livcr-parench}-ma, thus resembling anchovy sauce in appear- ance. In other cases the pus is yellowisli-green or brick- red in color, from the staining of bile or of bilirubin-crystals. The pus, which is usually foul-smelling, is generally shown by bacterial examination to be sterile. There may be but one abscess, as in the tropical variety, or the abscesses may be multiple, as is the case with pyaemia and with suppura- tive inflammation of the portal vein or of the bile-passages. Single abscesses may reach the size of a cocoanut ; multiple abscesses vary in size up to that of a walnut, but by their coalescence still larger abscess-cavities may be formed. Seven-tenths of all abscesses of the liver occur in the right lobe, usually toward the convexity. Abscesses in the liver evince a tendency to approach the surface and to rupture. In 5 per cent, of all cases rupture into the peritoneal cavity occurs. Usually, however, the peritoneum is shut off by adhesions, so that the abscess ruptures into neighboring organs. Rupture upward into the right lung occurs in 9 per cent., into the right pleura in 5 per cent., of all cases. Perforation of the pericardium or of the vena cava may occur. Rupture downward may occur into the liver, the intestine (3 per cent.), or the kidney. The abscess may approach the chest-wall or the abdominal wall or may open into the gall-bladder. In rare cases the abscess remains stationary. A connective-tissue capsule is ulti- mately formed, enclosing the purulent contents, which may become inspissated and cheesy. The symptoms are general and local. ABSCESS OF Til J'. IJl'J'.R. 527 General syviptoms indicate the presence of pus within the body. Chills are common at the onset, and may be re- peated throughout the disease. The chills may be erratic and may be followed by fluctuations in temperature and by cold sweating — a symptom-complex of pus-infection ; or the chills may be repeated in multiple abscesses whenever a new focus of suppuration forms. The fever is usually irregularly remittent, although in some cases the remissions are so periodic as to suggest malarial fever. In some cases, especially if long-protracted, fever may be entirely absent. Prostration is evident from the first ; the pulse becomes rapid and feeble, and the patient finally passes into a typhoid condition. The appearance of the patient is somewhat characteristic. The skin is sallow and of a slightly jaundiced hue, and the expression strongly suggests the existence of abscess. Marked jaundice is rare. The bowels may be constipated, or there may be diarrhoea. Amoebae coli may be found in the stools, giving a clue to the diagnosis. The general symptoms may be so complicated or masked by those of the primary disease that no special features may be added to the case. Local symptoms, due to localized suppuration, consist of pain and tenderness. The pain may be dull in case of a central abscess, or sharp and cutting if the peritoneum over the abscess become inflamed. In many cases the inflamma- tion extends from the peritoneum to involve the diaphrag- matic pleura, so that a true pleuritic pain occurs. Pain of a peculiarly heavy, dragging character usually develops when- ever the patient lies upon the left side. Tenderness becomes more marked when the peritoneum over the liver is involved. In deep-seated abscess there may only be some rigidity of the abdominal wall in the hypochondrium. In some cases pain and tenderness are slight or are alto- gether absent. Portal obstruction occurs only if the abscess happen to press upon the portal vein, but the symptoms are never extreme. , A catarrhal inflammation of the bile-ducts with jaundice 52S M l.yr.lL OF THE PRACTICE OF MEDICIXE. may or may not be present, but the jaundice rarely becomes marked. Physical Examination. — i. Of the Large Single Ab- scess. — The Hver is tender on palpation and is irregularly enlarged. There may be appreciable bulging over the abscess, depending upon its size and its position. A large superficial abscess may give rise to fluctuation if the perito- neal surfaces over the abscess be adherent. As the abscess is usually in the right lobe near the convex surface, the area of liver-dulness rises in the axilla, fre- quently to the fifth rib, and extends across the back on a level with the angle of the scapula. In these cases an erroneous diagnosis of empyema is frequently made. Large abscesses of the upper surface of the right lobe, extending forward, ma\' give rise to dulness as high as the second rib in front and the spine of the scapula behind, while the liver itself is displaced downward, the lower edge being fre- quently as low as the level of the umbilicus. Abscesses of the right lobe tend to point in the seventh and eighth spaces in the mammary line or below the costal arch. Ab- scesses of the left lobe usually point in the median line just below the ensiform cartilage. 2. Multiple Abscess of Pycsuiic Origin. — The liver is usually symmetrically enlarged and tender. Pointing, fluc- tuation, and bulging are not observed. In cases of doubtful diagnosis an exploratory aspira- tion of the liver may be resorted to without risk if strict asepsis be observed. A long needle, not too small in cali- bre, should be used, and should be deeply inserted in the location of the suspected abscess. The aspiration should preferably be done under ether. Course of Abscess of the Liver. — i. Some abscesses run a latent course until rupture occurs. In other cases there are found at autopsies old encysted abscesses which gave no definite symptoms during the life of the patient. 2. In some cases the constitutional symptoms are marked, but the local symptoms are slight or are altogether absent. These cases are often mistaken for typhoid fever, malaria, or tuberculosis. ABSCJ'ISS ()/'■ Till: l.lll'.K. 529 3. The course may be straightforward, with pronounced general and local symptoms. The patient dies from per- foration or from septicaemia unless the abscess be opened and drained. 4. The abscess may open into the right lung. At the time of rupture there will be raised an expectoration of a reddish-brown or brick-dust color, resembling anchovy sauce (Osier), in which amoebae coli may be found. 5. Chronic abscesses may run an insidious course, with hectic, loss of flesh and of strength, and slight localized pain and tenderness. Amyloid changes in the spleen and the kidneys are liable to occur. 6. In cases of multiple abscesses occurring in the course of pyaemia or malignant endocarditis, pain, tenderness, and moderate enlargement of the liver may be the only addi- tional symptoms. Diagnosis. — The evident causation of the abscess and the character of the pus obtained by aspiration are of prime im- portance in diagnosis. Abscess of the liver may be con- founded with the following conditions : 1. Malarial fever. Here the plasmodium is found in the blood, the spleen is enlarged, and the disease yields to qui- nine. Pain and tenderness over the liver, if present, are but slight. 2. Empyema is to be known by a consideration of its cause and by the different appearance of the aspirated pus. The heart is displaced, and attendant diseases of the lung are evident. It must be remembered that abscess of the liver may rupture into the pleural cavity and constitute a genuine empyema. 3. Intermittent hepatic fever zvith gall-stones. Here the clinical picture may closely resemble abscess ; but pain is more sudden and intense, jaundice is marked, and the fever is shorter in duration and is interrupted by periods of apy- rexia. Septic symptoms and failure in general nutrition do not occur. 4. Abscess of the abdominal wall is diagnosed by the incon- siderable depth of the abscess upon operation. 5. Stibphrenic abscess is diagnosed by its etiology (rupture 34 530 .l/.l.VrJL OF THE PRACTICE OF MEDICIXE. of an ulcer of the stomach or of the duodenum, etc.) and b\' the frequent addition of air or y;as to the purulent effusion. The progrnosis is bad unless the pus be evacuated spon- taneously or by operation. Multiple small abscesses are usually fatal. Single abscesses treated surgically show a mortality rate of only 30 per cent. Perforation into the lung or into the gastro-intestinal tract is followed by re- covery in about half the cases. The treatment is essentially surgical, consisting in the opening and draining of the abscess-cavit)\ Operative in- terference is not usual!)' justifiable in cases of multiple pypemic abscesses, and the operation may be postponed if perforation into the lung or into the gastro-intestinal tract occur, with good drainage, as in these instances spontaneous cure may follow. TUBERCULAR DISEASE OF THE LIVER. 1. Miliary tubercles in the liver occur almost constantly with miliary tuberculosis, but they give rise to no symptoms. 2. Large tubercular deposits and cheesy masses may occur, usually in connection with tubercular disease of the intestines or of the mesenteric glands, but they are chiefly of pathological interest. 3. In the chronic forms of tubercle in the liver there may be an increase of connective tissue. This " tubercular cir- rhosis," as it is sometimes called, occurs especially with chronic tubercular peritonitis and perihepatitis, and gives rise to the symptoms of portal obstruction. NE^W GRO^WTHS OF THE LIVER. 1. Cavernous angioma is not uncommon, but usually is of no practical significance. Exceptionally, in children, angioma may form a growth of considerable size. 2. Adenoma may develop ; it runs a benign course, although in some instances it seems to merge into car- cinoma. 3. Leukaemic deposits will be considered in the descrip- tion of Leukaemia. 4. Sarcoma may occur. This affection is usually second- NKIV GROWTfPS OF 77//-: LIVER. 53 I ary, the skin, tlie eye, and the bones being the favorite seats of the primary growth. Melanotic sarcoma is not infrequent. Sarcoma usually develops in small nodules generally distributed throughout the liver, and the clinical course is that of cancer. 5. Cancer of the liver may be primary or secondary. The primary form, which is exceedingly rare, arises from the epithelium of the bile-ducts. It is three times as common in women as in men, and it is usually associated with biliary calculi. Secondary cancer in the liver may follow — (i) any cancer in the distribution of the portal vein, especially in the rectum and the stomach ; (2) direct extension from cancer of the pylorus, colon, pancreas, or omentum ; (3) more rarely secondary involvement of the liver complicates cancer in other organs at a distance. Cancer of the liver is more frequent in women than in men, and is more common in advanced life. Pathology. — There may be one large growth surrounded by smaller deposits, or small nodules may be more gener- ally distributed throughout the liver. These nodules may be sharply defined or may fade imperceptibly into the sur- rounding liver-tissue. Growths near the surface may be flush with it or may project as round or flattened nodules, at times presenting a central crater-like depression, the so- called " umbilicated appearance." Hemorrhages may occur into the nodules, and there is a tendency to fatty degenera- tion of the cancer-cells. There is an infiltrating form in which small cancer-masses, varying in size from 3 to 10 millimeters in diameter, are scattered throughout the liver, surrounded by fibrous tissue. The appearance of such a liver closely resembles that of cirrhosis. Symptoms of portal obstruction may or may not be present, according to whether or not the growths happen to press on the portal vein. Large or multiple growths may thus exist without the slightest symptom of portal pressure. In a little less than half the cases there is associated a catarrhal inflamma- tion of the bile-ducts, with jaundice. Symptoms. — In cases in which the secondary growths are small neither mechanical nor functional symptoms are pre- 53- .U.l.Vr.lL OF THE PRACTICE OF .^fEDICEYE. sented. and the disease runs a latent course. This chnical form occurs especiall}' in cases in which the s\-mptoms of the primary growth are marked. Should the disease run a more classical course, the symptoms of the cancer in the liver are preceded usually by those of the primary growth. When secondary deposits occur in the liver, the primary cancer, especially if it be in the intestines or in the rectum, is apt to cease developing and may be overlooked. Many so-called "primar\-" cancers of the liver are found to be secondary to a small quiescent cancerous nodule in the rectum. The symptoms of cancer of the liver may be classified as follows : 1. There are present the symptoms oi d. functional disturb- ance of the liver. 2. Symptoms of the cancer itself Tire local and general. Local symptoms consist of pain and tenderness. The pain is usually steady and severe, with paroxysms running through the liver to the back, and at times to the right shoulder. Tenderness is usually marked. The general symptoms are those of cancerous cachexia. The temperature shows a slight elevation in some cases to iOO° or 102*^ F., and may be intermittent with rigors. There is usually some oedema of the feet, the face is of a waxy pallor, and loss of flesh and of strength becomes progressive. Should the local symptoms be slight, the general cachexia may be mistaken for that of anaemia or of nephritis. There is usually gastric disturbance, with loss of appetite, nausea, and vomiting. The cachectic condition rapidly becomes marked, as the patient has usually suffered for some time from the primary growth, and in some cases the cachexia may even precede the enlargement of the liver. 3. Symptoms of portal obstruction may or may not be present, as previously explained. Ascites is uncommon, but it may result either from portal obstruction or from can- cerous disease of the peritoneum. An enlargement of the spleen occurs in about half the cases. 4. Jaundice is present in less than half the cases. The symptom is rarely severe, except in occasional acute attacks. A'Kir GRowj'Jis oi' 77//': /./17:a'. 533 The beeswax appearance of the skin may resemble jaundice, but the conjunctiv- be included certain cases of transient albumin- uria occurring during pregnane}-. (f) Ab)ionnai Blood-iiigrcdioits, such as alcohol, bile- pigment, sugar, chronic lead- or mercury-poisoning, may induce the disease; it may also occur after the administra- tion of ether or chloroform. Hyaline casts also may be present in bile-stained urine. (f/) Neurotic causes, probably from changes in the blood- supply, may give rise to the condition, as after epilepsy, apo- plexy, tetanus, or injuries to the head, and with exophthal- mic goitre. {e) Febrile alhniniiiuria, with pyrexia from any cause, per- sisting during the period of fever. Albumin is present in small quantities, and is due to slight changes in the glom- eruli caused by the febrile process. (/) Cyclic or periodic albuminuria is a form occurring in young adults, especially in boys, in which albumin appears at certain times of the day. It seldom, if ever, occurs after rest at night, but usually after exertion or after the principal meal of the day. The quantity of albumin is usually small, although it may be considerable, and transient glycosuria or occasional hyaline casts may be present. In functional albuminuria there is neither high arterial tension nor hypertrophy of the left ventricle of the heart, unless from some intercurrent affection, and neither consti- tutional nor uraemic symptoms are present. Cases must always, howex'er, be regarded with suspicion, especially if albumin be present in considerable quantities or if it be per- sistent. Albuminuria in persons over forty years of age usually indicates changes in the kidneys. 3. Albuminuria with Gross Renal Lesions. — [a) Congestion of the kidney, either acute or chronic. (b) Organic disease, acute and chronic nephritis, amyloid disease, and tumors. Tests. — The urine should be collected for twenty-four ANOA/ALIES OF I'l/J': URINARY SECRE'JVUjV. 563 hours, and a specimen of this urine should be taken for examination. If the urine be turbid, it should be filtered, unless the turbidity be due to urates, in which case a little heat will clear the specimen. Heat-and-nitric-acid Test. — The urine is boiled in a test- tube. If opacity result, it is due either to albumin or to earthy phosphates. On adding a few drops of nitric acid the opacity disappears if due to phosphates; if due to albumin, it is permanent. This is the best routine test and the most satisfactory. Heller's Test. — Upon a small quantity of pure colorless nitric acid in a test-tube is allowed to trickle an equal amount of clear urine, so that it will overlie the acid. If albumin be present, a sharp white band will appear at the contact of the two liquids. A somewhat similar zone may be formed by the action of nitric acid on urates if in excess, so that the more insoluble acid urates are precipitated. This zone, however, is not sharply defined, diffuses itself into the urine above, and disappears on the application of heat. A haze due to mucin may also occur above the albumin zone, and may obscure the test. Picric-acid Test. — A saturated solution of picric acid may be used as in Heller's test. Mucin, peptone, and certain alka- loids yield an opalescence with picric acid, but this opales- cence disappears on heating. Esbach's test is valuable in the quantitative analysis of albumin. The test-solution is made by dissolving 10 parts of picric acid and 20 parts of citric acid in 900 parts of boiling distilled water. After cooling, a sufficient quantity of distilled water is added to make a total of 1000 parts. The graduated tube is filled with urine to the mark U, and then with the reagent to the mark R. The liquids are mixed by slowly reversing the tube, and the coagulu'm of albumin is allowed to stand for twenty-four hours. The height of the sediment read on the etched scale indicates the weight of acid-albumin in grams per liter of urine. Other tests for albumin are superfluous, and for them the reader is referred to books on urinary analysis. 564 .UJ.VC.il of the rK.lCTICE OF MEDICINE. H/EMATURIA. Blood in the urine may come from the kidney, the pelvis of the kidney, the ureter, the bladder, or the urethra. Rciial JicuiorrJiagc occurs after injuries or falls; after acute congestion or inflammation ; rarely from the atrophic form of chronic nephritis ; from toxic agents, such as can- tharides, carbolic acid, and turpentine ; from embolism, thrombosis, or aneurysm of the renal vessels ; from tuber- cular inflammation ; from new growths ; from calculous pyelitis ; with malignant forms of acute infectious fevers, as hemorrhagic small-pox or " black measles ;" with certain hemorrhagic diseases, as scurvy, purpura htnemorrhagica, or leukcXMiiia ; as evidence of vicarious menstruation; and in some )-oung adults as a simple hemorrhage without known cause. It is also caused in the tropics by the parasites filaria sanguinis hominis and the Bilharzia. Malarial haematuria is endemic in certain of the Southern States. Hemorrhage from the ureter usually implies the passage of a calculus. Hemorrhage from the bladder is caused by injuries, rough catheterization, ulcers, ruptured veins, new growths, and calculi. Hemorrhage from the urethra is caused by traumatism, foreign bodies, calculi, ulcers, chancroids, rough catheteri- zation or injury, and gonorrhoea. Diagnosis. — Blood in the urine imparts to it a red or brownish color and gives the reaction for albumin. Haema- turia is to be distinguished from haemoglobinuria by the presence of red blood-corpuscles. Microscopical examina- tion usually renders other tests superfluous. Hellers test for blood-pigment consists in boiling the urine with a solution of caustic potash until flocculi of phosphates fall ; these flocculi assume a red color from the freed haematin. The guaiae7im test consists of the addition to the urine of a drop or two of tincture of guaiacum and two minims of ozonic ether. At the junction of the two fluids a blue line forms, which becomes diffused through the ether. Spectro- ANOAIAL/ES OF 'J'HE URINARY SECRK'J'ION. 565 scopic examination may reveal the single band of reduced haemoglobin or the double band of oxyhaemoglobin. Care should be taken to exclude the admixture of men- strual blood from the specimen obtained for examination, and bloody urine should not be confounded with the stain- ing by rhubarb, logwood, and a few other dyes. Determination of the Source of the Hemorrhage. — In blood from the kidney the blood and urine are intimately mixed, and there may be blood-casts, rendering the diag- nosis positive. The color is often smoky. Blood from the pelvis and the ureter is frequently passed in clots which resemble leeches in form and color. Blood from the bladder usually is passed with the last por- tion of urine. In washing out the bladder the water comes away blood-tinged, whereas if the source of hemorrhage were from the kidney the water would come away clear. Hemorrhage from the urethra occurs in the first part of micturition, and blood frequently escapes in the intervals. Local symptoms aid in revealing the source of the hemor- rhage. HEMOGLOBINURIA. Whenever, from any cause, the red blood-corpuscles are dissolved in the blood, the coloring matter thus set free is excreted as methsemoglobin in the urine, imparting to it a reddish-brown color which may in extreme cases resemble that of porter. The urine contains granular pigment and is albuminous, but usually no red blood-corpuscles are pres- ent. If present, their number bears no proportion to the intensity of the color of the urine. Hsemoglobinuria is to be distinguished from haematuria by the absence of red blood-corpuscles ; but care should be taken not to mistake haemoglobinuria for bloody urine in which the corpuscles have been dissolved during ammonia- cal decomposition. The urine reacts to Heller's test (see page 564) and gives the spectroscopic absorption-bands of metha;moglobin or, more rarely, of oxyhaemoglobin. In all cases of haemoglobinuria that have terminated fatally a secondary nephritis has been found. Two clinical groups of heemoglobinuria are described : 566 M.lXr.tL OF THE PKACT/CE OF MEDICIXE. 1. Toxic HiC))ioglobiiiuria. — Dissolution of the red blood- corpuscles can occur from the ingestion of certain drugs, such as potassium chlorate, carbolic acid, pjTOgallic acid, naphthol, chloral, arscniurettcd h\-drogen, and muscarine. HaMiioglobinuria occurs after transfusion of blood, especially the blood of animals into the human subject, and after exten- sive superficial burns ; it is said also to occur after exposure to cold. It may occur with certain infectious diseases, such as t\'phoid fever, scarlet fever, malarial fever, j'ellow fever, and syphilis, and an epidemic form of hremoglobinuria in the new-born has been described, characterized b}' jaundice, cyanosis, and nervous symptoms. 2. Paroxysmal Hccuioglohinuria. — This form is character- ized by the passage of blood-pigment in the urine in attacks. It is more common in men than in women, and it is usually seen in adults. Attacks may be induced by exposure to cold or as the result of bodily or mental exhaustion. Patients suffering from Raynaud's disease are peculiarly susceptible. Severe malarial poisoning may cause either hrematuria or hremoglobinuria, the changes in the urine frequentl}' showing some regular periodicit}'. The attacks may be preceded by a chill and a rise in tem- perature, or the temperature may be subnormal. There may be yawning, headache, pain in the bones, vomiting, and cramp-like pains over the hepatic or lumbar region. The hremoglobinuria rarely persists for more than one day ; it then subsides, and is followed by slight jaundice in a considerable number of cases. Urticaria after the paroxysm is not uncommon. Ralfe describes cases in which parox- ysms of hat-moglobinuria alternate with the same general symptoms, but with the passage of albumin and an in- creased amount of urea. The prognosis of the toxic form of hremoglobinuria depends upon the severity of the primary disease ; other- wise the prognosis is good. Treatment is unsatisfactory. Exposure to cold should be avoided ; quinine should be given in malarial cases, and iodide of potassium is to be administered should a syphilitic history be obtained. During the parox}-sm the patient ANOMALIES OF Till': URINARY 'SECR EI'ION. 567 should be confined to bed, kept warm, and given hot drinks. Pyuria (Pus in the Urine). Etiolog-y. — I. Pyelitis and Pyelonephritis. — The pus is uniformly mingled with the urine, and the condition of the urine is unchanged after the bladder has been washed out. In calculous and tubercular pyelitis the urine is usually acid in reaction, but in pyelitis complicating cystitis the reaction is usually alkaline. Large abscesses of the kidney may suddenly discharge a large quantity of pus, and for days or weeks afterward the urine may be free. 2. Cystitis. — The urine is alkaline, often ammoniacal. The pus is passed with the last portions of the urine, and is mixed with thick, ropy mucus. The urine first obtained after the bladder has been washed out shows decided im- provement. 3. Urethritis. — The pus is passed with the first portion of the urine, and may escape from the meatus in the intervals of micturition. Local symptoms of inflammation are usually evident. 4. LeiicorrJicea. — The pus is small in quantity and is ad- mixed with vaginal epithelium. This condition may be excluded by ordering a vaginal douche to be given before micturition, and by the use of the catheter. 5. Ruptnre of an abscess into the wnnary passages is characterized by a sudden irruption of pus. Peptonuria. Peptone is never found in healthy urine. Traces of it are found in some acute diseases, in suppurative processes, and with disturbances of the digestion of albuminous sub- stances, but the peptonuria possesses no diagnostic value. Tests. — Peptone is not precipitated by heat or by nitric acid, but with picric acid there occurs a precipitate which is dissolved by heat. A supernatant layer of urine over Fehling's solution yields a rose-pink halo. 568 MANUAL OF THE PRACTICE OF MFDICIXE. PllOSPHATURIA. Phosphates occur in the urine as alkaline salts of sodium and potassium and as carlliy salts of lime and magnesium. In urine undergoing ammoniacal fermentation the am- monio-magnesium salt or the triple phosphates may appear. Phosphates are soluble only in neutral or acid urine, and are precipitated whenever the urine becomes alkaline. As they are less soluble in hot solutions, the phosphates are often precipitated by boiling, even in urine of a slightly acid reaction, and may be mistaken for albumin ; but the speci- men rapidly clears up upon the addition of acetic acid. If this acid be added to the specimen before boiling, precipi- tation does not occur. Phosphates may appear in excess (up to 7 to 9 grams, whereas from 2 to 3 grams is the normal quantity) in those suffering from debility, dyspepsia, or wasting disease. There has been described a phosphatic diabetes characterized by polyuria, thirst, loss of flesh, and an absence of sugar in the urine. In some cases glycosuria or diabetes has followed this condition. Lith/emia; UriC/Emia. The daily amount of uric acid excreted depends largely upon the diet, varying from 10 to 30 grains, the relation of uric acid to urea being normally as i : 33. As to the pro- duction and antecedents of uric acid not much is known accurately, although it is supposed to be formed in the liyer from ammonia and lactic acid. It is also unknown whether it represents a suboxidized grade of urea or whether it has an independent origin. Uric acid, being practically insolu- ble, is eliminated by the kidneys chiefly as the urates of sodium and ammonium, and to a less extent as the urates of potassium, calcium, and lithium. From these bases uric acid may be separated, forming the " red-pepper " or "brick-dust" deposits, which show characteristic appear- ances under the microscope. As conditions which cause the precipitation of uric-acid cr}'stals from the urine Roberts mentions — (i) High acidity; (2) poverty in min- eral salts ; (3) low pigmentation ; and (4) high percentage ANOMALIES OF THE URINARY SECREEION. 569 of uric acid. More commonly occurs the precipitation of amorphous urates, chiefly as the acid sodium urate, in the form of a pinkish deposit occurring as the urine cools. The urine is usually concentrated, of high specific gravity, and of excessively acid reaction. The power which the blood possesses of holding uric acid in solution depends upon its degree of alkalinity. According to Haig, the excretion or the retention of uric acid can be regulated by increasing or diminishing the alka- linity of the blood. His theory is that agents increasing the alkalinity, finding a considerable quantity of uric acid in the liver, the spleen, and the tissues, render its solubility more perfect, so that it is taken into the blood and excreted by the kidneys. Pre-eminent among the drugs that increase the elimination of uric acid is sodium salicylate. Among those drugs -causing retention, the most important are acids. Haig further believes that drugs affect only the excretion of uric acid, and have no influence whatever upon its formation. The term " lithaemia " was first used by Murchison to designate symptoms due to functional disturbance of the liver and accompanied by an increased elimination of uric acid or urates ; but it is impossible, in the present state of our knowledge, to state with any accuracy the pathology of the uric-acid diathesis. The diathesis bears a close relationship to gout, so that it has been termed " Amer- ican gout." For its etiology and symptoinatology see Irregular Gout. OXALURIA. Oxalate of lime is held in solution in the urine by the acid sodium phosphate. The crystals, which may be found deposited in small quantities under certain conditions, are easily recognized under the microscope. Oxaluria occurs after eating certain fruits and vegetables, as tomatoes, rhubarb, apples, pears, and cauliflower. It occurs also in gouty, hypochondriacal, and neurasthenic patients, as the result of imperfect oxidation-processes. Oxaluria is also said to result from acid fermentation of the urine within the urinary passages. 570 M.i.vr.iL OF THE pmact/ce of medicine. Chvi.ukia. Rare cases of chyluria result from some connection between the lymphatic vessels and the urinary passages, but the exact pathology is unknown. In the tropics chyluria is not infrequently associated with the presence of the filaria sanguinis hominis. The urine is milky in appearance and contains emulsified fat and serum-albumin. There may occur a spontaneous clot resembling blanc-mangc, or the fat-globules may rise to the surface like cream. The microscope shows fine fat-globules which dissolve in ether. IXDICANURIA. Indigo appears in the urine, not in the free state, but in combination as indoxyl-sulphate of potassium, which is a compound originally derived from indol. Indol itself is formed in the small intestine by the action of bacteria upon albumin. When concentrated acids are added to the urine containing the indoxyl-sulphate, indigo is liberated. Indicanuria is frequent in all wasting and cachectic diseases associated with the excessive destruction of albu- minoids. It may occur with tumors of the intestines and the pancreas, in intestinal obstruction, and in prolonged constipation. It is increased by a milk diet. Glycosuria. It is a generally accepted belief that sugar does not occur in normal urine. The occurrence of glycosuria with patho- logical conditions will be considered elsewhere, under the same heading. LiPURIA. Fat may appear in the urine after an excessive quantity of fat has been taken with the food, with prolonged sup- puration, with pancreatic tumors and degeneration, after phosphorus-poisoning, and in diabetic urine. The occur- rence of chyluria has already been described. Lipuria may also occur with ad\'anced Bright's disease and with pyo- nephrosis. CHRONIC CONGESTION OF THE KIDNEYS. 57 1 ACETONURIA. Acetone, according to Von Jaksch, may occur with fevers, diabetes, cancer, inanition, in certain mental conditions, and as a form of auto-intoxication. For the clinical and microscopical detection of the above- mentioned ingredients of the urine the reader is referred to books on urinary analysis. ACUTE CONGESTION OF THE KIDNEYS. Etiology. — Acute congestion of the kidneys may follow the taking of certain poisons (as cantharides), the removal of one kidney, or the sudden blocking of one ureter by a cal- culus, by over-exertion, or by surgical operations, especially on the bladder and the urethra. Pathology. — The lesion consists in the temporary con- gestion of the blood-vessels of the kidney, allowing of the exudation of serum and the escape of red blood-cells. Symptoms. — The urine, which is diminished in quantity or suppressed, according to the degree of congestion, may contain blood, albumin, and casts. Its specific gravity is not changed. The urinary symptoms may last for a few days with considerable prostration, and may then disappear; or the symptoms may continue, and the patient becomes more feeble and prostrated, passes into a typhoid state with delirium, and dies. These bad cases are those following the removal of one kidney, impaction of a calculus, or surgical operations on the bladder and the urethra. The prognosis in mild cases is good. Repeated attacks induced by over-exertion or by irritant drugs may event- ually lead to nephritis. Treatment. — The patient is to be kept warm in bed, on a liquid diet, and the bowels are to be moved freely. Sweat- ing should be induced by pilocarpine or by the hot pack or the hot-air bath. CHRONIC CONGESTION OP THE KIDNEYS. Etiology and Synonym. — Chronic congestion of the kidneys is induced by any cause preventing the free escape 57- M.l.XL.lI. OF 77/E rh'.lC77CK OF MFDICIXE. of blood from the renal \-eins, such as the pressure of ab- dominal growths or that occurrinijj in tlic course of chronic conj^estion of the viscera due to heart disease or to cmpln-- sema. Syncviyiii : Cyanotic induration. Pathology. — The kidneys are normal or increased in size and are heavy and hard. The capsule is not adherent ; the surface is smooth. The organ is congested, red, and livid, or the pyramids are red while the cortex is pink or white. A considerable number of the glomeruli are large, their capil- laries are dilated, and the cells covering the capillaries are swollen. Aside from a slight increase in the subcapsular connective tissue, the stroma is unchanged. Such kidneys are apt to develop chronic diffuse nephritis. In heart dis- ease with visceral congestions chronic diffuse nephritis occurs in 60 per cent., chronic congestion in 40 per cent. Symptoms. — The urine is diminished in quantity but is of good quality, the amount of urea to the ounce being rather increased than diminished. The specific gravity is normal or high. Albumin and casts may be present in small quantities, but are often absent. A continual precipi- tation of urates should excite suspicion of chronic conges- tion, and the heart and lungs should be carefully examined. The general symptoms are slight or unnoticed. Urremic symptoms do not occur. Treatment should be directed toward the disease causing the congestion. ACUTE DEGENERATION OP THE KIDNEYS. Etiolog-y and Synonyms. — Acute degeneration of the kidneys is always secondary to the introduction of poisons into the body. It complicates poisoning by arsenic, mer- cury, and phosphorus, or by the organic poisons which result from severe infectious diseases or from injuries. Acute degeneration is usually found in the kidneys of those who have died from infectious diseases. Synonjnns : Acute Bright's disease; Parenchymatous nephritis; Paren- chymatous degeneration. Pathology. — The kidneys are more or less enlarged ; the capsules are not adherent ; the surfaces are smooth ; the CHRONIC DEGENERATION OE THE KIDNEYS. 573 cortex is usually thickened, and it may be either pale or congested. There are changes in the renal cells, especially marked in those of the convoluted tubes. These changes consist in (i) swelling, (2) granular infiltration with albumi- noid matter and fat, (3) death of the cells, with desquama- tion, (4) a formation of hyaline masses in the cells, and (5) a o-rowth of new cells to replace the dead epithelium. In severe cases there is added congestion of the blood-vessels, with exudation of serum. There are no changes in the stroma. Symptoms. — The urine is diminished according to the severity of the disease. It may even be suppressed. Its specific gravity is unchanged. Albumin and casts are usually present, from the congestion and exudation, and blood-cells appear in severe cases. The general symptoms are usually obscured by those of the primary disease. In mild cases accompanying infectious diseases there are no symptoms, excepting the presence of albumin and casts in small amounts in the urine. In severe cases accompanying yellow fever and acute yellow atrophy of the liver, and following the ingestion of an inorganic poison, the urinary changes are marked : the patient becomes feeble, passes into the typhoid condition, and dies, apparently from the kidney-lesion. Dropsy is not noticeable in these cases. The prognosis is good except in the severe cases. Albu- min and casts may, however, persist for some time after the subsidence of the primary disease. Treatment. — There is no treatment to prevent the degen- erative changes. When exudation occurs the treatment of acute exudative nephritis is indicated. CHRONIC DEGENERATION OF THE KIDNEYS. Etiology and Synonyms. — The process is secondary to any of the mechanical causes of chronic congestion, to vicious modes of life, and to chronic alcoholism. Synonyms : Chronic Bright's disease ; Chronic parenchymatous nephri- tis ; Fatty kidney. Pathology. — The kidneys are usually increased in size, although exceptionally they may be normal or even small. 574 -V.l.vr.lL 0J-' THE PRACTICE OE MEDICIA'E. The surface is smooth ; the pyramids are red ; the cortex is white, yellow, or pink. There are swelling, granular degen- eration, and fatt>' infiltration of the epithelium of the cortex. There are no changes in the stroma. The glomeruli are normal unless the degeneration be due to venous congestion. Symptoms. — The quantit)' of urine varies in different patients and at different times ; it may be increased, normal, scanty, or the urine may be suppressed. The specific grav- ity of the urine and the proportion of urea excreted are unchanged. Albumin and casts in moderate amounts are usuall}^ present. The patient becomes anaemic and loses flesh and strength. In bad cases he may pass into the t)-phoid state, with delirium and stupor. Dropsy does not develop. The disease may be followed b\' chronic nephritis. The prognosis is not good, as the natural tendency of the disease is to progress. Treatment is not satisfactory. Vicious and alcoholic habits are to be checked. The diet and the mode of life are to be regulated. The circulatory changes inducing venous congestion are to receive appropriate treatment. ACUTE EXUDATIVE NEPHRITIS. Etiology and Synonyms. — Primary cases may occur after exposure to wet and cold, or without assignable cause. Secondary cases accompany an}- of the severe infectious dis- eases or the puerperal state. SyiionyiNs: Parench}'matous nephritis; Tubal nephritis; Desquamative nephritis; Ca- tarrhal nephritis ; Croupous nephritis ; Glomerulo-nephritis. Pathology. — The chief lesion is' in the blood-vessels. From the tuft there is an exudation of plasma and of red and white blood-cells wliich infiltrate the stroma of the kidney and collect as casts and cellular masses in the tubes, from which they may be voided in the urine. The amount of exudation varies with the severity of the case. In severe cases there may be an over-production of pus-cells. In mild cases the kidney shows no changes, the conges- tion having disappeared and the exuded material having been passed in the urine. In severe cases the kidney is large, the surface is smooth, ACUTE EXUDATIVE NEI'IIh' /I'fS. 575 the cortex is thick and white or red and white, or the whole kidney is congested and succulent. Within the tubes, espe- cially those of the cortex, are irregular masses of coagulated material, forming casts, and frequently white and red blood- cells. There may be dilatation of the cortical tubes, and their epithelium may be swollen, degenerated, or detached. The cells covering the tuft are usually swollen and increased in number. In other cases there is an excessive emigration of white blood-cells, which infiltrate the stroma and appear as small whitish foci in the cortex. The amount of serum exuded from the tuft is not proportionately increased, so that it is possible in this form to have little or no albumin and casts in the urine. Symptoms. — In mild cases the patient complains of gen- eral malaise, with slight headache, loss of appetite, and per- haps some aching in the back. The urine is slightly dimin- ished in quantity, the specific gravity is about normal, and albumin is present in considerable quantity, with hyaline, granular, and epithelial casts, sometimes with red and white blood-cells. The constitutional symptoms last for from one to two weeks ; albumin and casts persist for four or six weeks and then disappear. In severe cases there is fever, with prostration, loss of appetite, nausea, a pulse of high tension, and exaggerated heart-action. Anaemia is rapidly developed. There may appear the symptoms of acute uraemia due to contracted arteries — stupor, headache, dyspnoea, restlessness, muscular twitchings, or general convulsions. Dropsy may be de- veloped, usually appearing first in the face. The urine is diminished in quantity, and contains albumin, casts, and cells in proportion to the severity of the inflammation. Constitutional symptoms last about four weeks. Albumin and casts continue in the urine for weeks afterward. The cases zvitli abundant production of pus-cells occur in children and in adults as a primary disease or secondary to measles, scarlet fever, and diphtheria. The invasion is sudden, with fever and prostration. Restlessness, delirium, headache, and stupor appear early in the disease and con- tinue throughout its course. Dropsy is slight or absent. 5/6 MAXCAL OJ-' THE PRACTICE OE MEDICIXE. The patient loses flesh and strength, passes into the typhoid condition, and is apt to die. The urine is not much diminished in quantity; its specific gravity is normal. Albumin, casts, and red and white blood-cells are usually present in considerable quantity, but they may not appear until late in the disease. In other cases albumin and casts are scanty or are absent altogether. The prognosis of mild cases is good. The development of uraemic symptoms in the severe cases causes anxiety, but a decided majority of the cases recover completely. The cases with abundant production of pus-cells are apt to terminate fatally. It is possible for the disease to be fol- lowed by chronic nephritis. Treatment. — The patient should be put to bed on a milk diet. In mild cases the liberty of the house may be allowed. The bowels should be kept open by calomel or by sulphate of magnesium in small repeated doses, and the skin should be rendered active by hot baths, daily cleansing, and skin- friction. Applications of wet or dry cups or hot poultices to the lumbar region may be of service. The cerebral symptoms during the early part of the disease, being due to contraction of the arteries with labored heart-action, should be controlled by arterial dilators. Of these, the best are aconite, chloral hydrate, nitroglycerin, and opium, in small repeated doses before the cerebral symptoms are marked, and in larger doses, hypodermically and by the rectum, during an attack. As the nephritis subsides the milk diet is replaced by solid food, iron and oxygen are given for the anaemia, and, if possible, the patient is sent to a warm, dry inland place until convalescence is complete. ACUTE DIFFUSE NEPHRITIS. Etiology and Synonyms. — Primary cases of acute diffuse nephritis follow exposure to wet and cold. Secondary cases complicate scarlet fever, diphtheria, and pregnancy. The disease is more common in children and young adults. Synonyms: Acute productive nephritis; Acute Bright's disease; Croupous nephritis. Pathology. — The kidneys are large ; the capsule is not ACU'/7': J) //■•/-'USE NIC /'//A' /'/vs. 577 adherent unless in cases of old standing, in which event the surface may also be roughened ; the cortex is thick, white, mottled yellow and red, or congested ; the pyramids are red. The microscope shows the same lesions as in acute exudative nephritis, with two additional features : First, a growth of connective tissue in the cortex ; second, a growth of the capsule-cells of the Malpighian tufts. These changes do not occur throughout the entire kidney, but in symmet- rical wedges in the cortex, following the line of the arteries. These wedges may be small or large, few or numerous, reg- ular or irregular. Each wedge has the same general characters : First, one or more arteries which run toward the cortex, the walls of which are thickened. Second, the Malpighian bodies connected with the affected artery show an increased growth of capsule-cells, causing compression of the tufts. There is also a growth of the cells covering the vessels and within them, as in exudative nephri- tis. The tuft never returns to a normal condition, but in time the vessels are obliterated and the glomeruli are transformed into little balls of fibrous tissue. Third, a growth of connective tissue in the stroma paral- lel with the affected arteries. This connective tissue is at first composed largely of cells ; later the tissue becomes denser. If the growth of connective tissue be abundant, the tubes within the wedge become atrophied. Between the wedges are seen the lesions of exudative nephritis ; later there is developed a diffused growth of connective tissue. The disease is serious not only from the disturbed func- tions of the kidney induced, but also because of the perma- nent character of the lesion. Symptoms. — The invasion may be sudden or gradual. The acute cases begin with fever and prostration, pain in the back, and frequent, scanty micturition. There are symptoms of acute uraemia, a pulse of high tension with exaggerated heart-action, or hypertrophy of the left ven- tricle, loss of appetite, nausea or vomiting, stupor, headache, muscular twitchings, or even convulsions. The patient be- 37 5/8 M.lXC.tL OF THE PKACriCE OE MEDICIWE. comes rapidly an;uinic. and dropsy appears, usuall\' first in the face ; tlie dropsy may become general. The urine is smoky or bloody in color, scanty or even suppressed, of a low specific gravity, and contains albumin and casts in con- siderable quantities, with renal epithelium, and sometimes with pus-cells. These acute cases resemble cases of acute exudative nephritis, but the specific gravity of the urine is lower and the patient is more apt to die. At the end of about four weeks, however, the patient may apparently re- cover, although albumin and casts still persist in the urine. In course of time s\-mptoms of chronic nephritis appear. The subacute cases are more frequent. The first symp- toms are often referred to the stomach — loss of appetite, nausea, and vomiting. In other patients dropsy is the first .symptom complained of Anaemia, headache, sleepless- ness, and dyspnoea usually appear early in the -disease. The urine is diminished in quantity, is of a low specific gravity, and may or may not contain blood. Albumin and casts are present, the former usually in considerable quantity. The patient becomes gradually worse. Acute uraemia from contracted arteries is shown by high-tension pulse, exaggerated heart-action or hypertrophy, with or without some dilatation of the left ventricle, headache, restlessness, and muscular twitchings or convulsions. Chronic uremia is shown by alternating delirium and stupor, with a feebly acting heart and low arterial tension. The attack may last for weeks or months, and from it the patient ma)^ die. Other patients apparently recover, but the urine still con- tains albumin and casts and is of low specific gravity. There are usually subsequent attacks, which must be re- garded as acute exacerbations of an established chronic nephritis. The prognosis is bad, the patient dying either in the acute attack or from the chronic nephritis that follows. In many cases life may be prolonged for a number of years. Treatment. — In the acute cases the treatment is the same as that for exudative nephritis, except that more care should be employed during convalescence, and pro- CHRONIC JSKIGUT'S DISEASE. 579 longed residence in a warm inland climate should be recommended. In the subacute cases the nephritis is best treated by rest in bed on a milk diet. The milk diet should be continued for a few weeks, and should then gradually be replaced by solid food. Later, residence in a warm, dry climate for some months at least should be insisted upon. Anaemia is to be treated by iron, oxygen, and fresh air. The dropsy is best treated by rest in bed on a milk diet. If the dropsy be persistent, diuretics, cathartics, and the hot pack or the hot-air bath may be employed. The condition of the heart and the arteries should be watched continually. If the arteries be contracted, with a pulse of high tension and an exaggerated heart-action, arterial dilators should be used. Among the best of these are nitroglycerin, chloral hydrate, opium, and potassium iodide. If the heart be feeble, with low-tension pulse, and if symptoms of chronic uraemia appear, digitalis, strophanthus, caffeine, or strychnine is indicated. In all cases the patient should be watched during convales- cence, and the general health should be improved in every possible way. The selection of a suitable warm climate is of the very first importance in these cases. CHRONIC BRIGHT' S DISEASE. Although two forms of chronic nephritis are described, one with and one without exudation from the blood-vessels, practically the same lesions are found in both. The only real difference is that in one form exudation from the vessels is added. In chronic nephritis with exudation albumin is nearly constantly present in the urine, although it may be absent for short periods. In chronic nephritis without exudation albumin is generally absent, although it may be present at times in considerable quantity. The presence or absence of albumin seems to vary the clinical symptoms of the disease to some extent. Chronic Diffuse Nephritis with Exudation. Etiology and Synonyms. — Primary cases occur in young and middle-aged adults, being somewhat more common in 580 .V.I.VrJL OF THE PKACriCE OF MEDICIXE. males. The disease may follow acute diffuse nephritis, whether from cold, scarlet fever, or pregnancy, and it occurs after chronic congestion and chronic degeneration of the kidney. It may complicate syphilis, endocarditis, chronic phthisis, and prolonged suppuration, especially of bones and joints, and it is usually associated witii am)'loid degen- eration of the kidney. Synoityins : Chronic parenchyma- tous nephritis; Large white kidney; Small white kidney; Chronic desquamative nephritis ; Chronic tubal nephritis. Pathology. — The kidneys are usually large, with smooth or roughened surfaces ; the cortex is pale. This condition is spoken of as the " large white kidney." In other cases the kidney is small, with a pale cortex, forming the " small white kidney." In rare cases the kidney may appear to the eye to be normal. Microscopically the following changes are described by Delafield : " There is a very extensive growth of connective tissue in the cortex ; the renal epithe- lium is swollen, granular, degenerated, fatty, broken, or flat- tened ; the tubes contain coagulated matter, cast matter, or blood ; the cortex-tubes are atrophied in some places, dilated in others. "The glomeruli are changed in several different ways: " I. There is a growth of the capsule-cells in such num- bers that they compress the tufts. The cells covering the capillaries are also increased in size and number. The capsule-cells may finally be changed into connective tissue, and the tufts become atrophied. "2. The glomeruli are of large size; the cells covering the capillaries are increased in number, so that the outlines of the capillaries are lost, but yet the capillaries are not compressed nor are the glomeruli atrophied. " 3. There is a growth of the cells which cover the capil- laries and of the cells within them. Of the cells which cover the capillaries, the cell-bodies become very large, the capil- laries are compressed, and the glomeruli eventually become atrophied. "4. The walls of the capillary vessels become the seat of waxy degeneration, while the cells which cover them arc increased in size and number. CIIKOA'JC JSR/CJIT'S DIS/'IASK. 581 "5. If the nepliritis follows chronic congestion, the capil- laries are dilated, and there is an increase in the size and number of the cells which cover the capillaries. " The arteries remain unchanged, or they are the seat of obliterating endarteritis, or there is a symmetrical thicken- ing of all the coats of the artery, or all the coats of the artery are thickened and converted into a uniform mass of connec- tive tissue, or there is waxy degeneration of the walls of the artery." Symptoms. — i. Changes in the Urine. — The quantity varies at different times. When the inflammation is quies- cent the quantity may be normal ; during an acute exacer- bation the urine is diminished or suppressed. In some cases, when the patient is doing badly, even if there be dropsy, the urine is increased. The specific gravity and the amount of urea to the ounce slowly diminish. The gravity varies usually between looi and 1012. Low specific gravity indicates extensive connective-tissue growth in the cortex or waxy degeneration of the capillaries of the glo- meruli. Albumin and casts are almost constant in con- siderable quantities ; they are increased during acute ex- acerbations, and at other times, when the lesion is quiescent, they may diminish, and may even disappear for short periods. 2. Dropsy is a prominent symptom, and is rarely absent. It may occur early or late, or only in periods. 3. Ancemia is most marked, and may even resemble per- nicious anaemia. There is a peculiar pallor of the skin which is quite characteristic. 4; Acute nresmic symptoms, with contracted arteries, caus- ing convulsions, etc., are not as common as in the cases without exudation. 5. Chrojiic tirczmia, with soft, feeble pulse, delirium, and stupor, is common, especially toward the close of the disease. 6. HeadacJie, restlessness and sleeplessness, loss of appe- tite, nausea, and vomiting frequently occur. 7. Neuro-retinitis and nepJiritic retinitis are not as common as in the cases without exudation. 5^2 J/.I.VC.IL OF TJIE PRACTICE OF MEDICIXF. 8. Dyspihva is ne;irl>- constant. It nia\' be due to liydro- thorax, to cedema of the luntj^s, to failuie of the lieart. or to contraetion of the arteries. In many cases spasmodic d\'.spnoea occurrinij at nii;ht or in the early mornintj, and aggravated by l>'ing down, ma\- be the first symptom noticed. 9. The tciisioi of Ihc pulse is usuall\-, but not always, in- creased. There ma\- be hypertrophy or dilatation of the left \'entricle, myocarditis, or feeble heart. Course of the Disease. — The constant symptoms are (i) albumin in the urine, (2) dropsy, and (3) anaemia. 1 . In some cases the symptoms are continuous, the patient dying from chronic urcxmia or dropsy in from one to two years. 2. The symptoms come in attacks. Between the attacks the patient feels well, although the urine contains albumin and is usually of low specific gravity. The interval between the attacks may be weeks, months, or even years. 3. Some patients live for years with only pallor of the skin and albumin in the urine, feeling well otherwise. 4. There may be an attack of spasmodic dyspnoea in a time of supposed good health. Years may intervene before symptoms are developed. 5. There may be a history of chronic endocarditis, con- gestion of the kidney, or acute diffuse nephritis before the regular symptoms of the disease appear. 6. A few cases apparently recover, especialh' in children. The prognosis is bad, although life may be prolonged for years. Treatment. — The amount of urine should be increased by drugs or by so regulating the diet of food and liquids that the patient passes sixty ounces of urine a day. The dropsy is to be treated by rest in bed, diuretics, and cathartics. Arterial dilators or heart-stimulants are indicated to meet the respective errors in the circulatory system. Anaemia requires iron, arsenic, and oxygen. Prolonged residence, especially during the winter months, in a warm, dry climate is of great importance. Acute uraemia with contracted arteries requires arterial CHRONIC j: RIG I IT'S DJSEASK. 583 dilators, such as nitroglycerin, chloral hydrate, opium, and potassium iodide, or bloodletting. In chronic uraemia, with delirium, stupor, and a feeble heart, we employ the hot pack, heart-stimulants, and cathar- tics, but the results are not usually satisfactory. During the acute exacerbation the patient should be put to bed on a milk diet and treated as if he had acute nephritis. Between the exacerbations plenty of outdoor life in fresh warm air may be advised, but not to the point of fatigue. Chronic Diffuse Nephritis without Exudation. Etiolog-y and Synonyms. — This disease usually occurs in those over twenty years of age. It may appear in adults in a primary form as a gradual degeneration of the kidney ; it often runs in families having a tendency to degeneration of the arteries. It may be caused by chronic alcoholism, lead-poisoning, gout, excessive eating and drinking, lithae- mia, and constitutional syphilis. These causes are also factors in causing emphysema, endocarditis, endarteritis, and cirrhosis of the liver, with which diseases the nephritis is often associated. This form of nephritis also follows chronic congestion of the kidney, hydronephrosis, and chronic pyelitis. Synonyms : Chronic interstitial nephritis ; Cirrhosis of the kidney ; Granular kidney ; Atrophic form of chronic diffuse nephritis ; Gouty kidney ; Renal sclero- sis ; Arterio-sclerotic kidney. Pathology. — The kidneys are diminished in size ; the capsules are adherent ; the surfaces are granular ; the cortex is thinned and of a red or gray color. There may be small cysts on the surface. Rarely the kidney is normal or even increased in size. The following microscopical changes are described by Delafield : " There is a growth of new connec- tive tissue in the cortex, and also in the pyramids, which becomes more and more marked as the disease goes on. In the cortex the new tissue follows the distribution of the normal subcapsular areas of connective tissue, is in the form of irregular masses, or is distributed diffusely between the tubes. In the pyramids the growth of new connective tissue 584 J/.I.VC.IL OF THE I'RACTICE OF MFDICI.XE. is diffuse. The tubes, both in the cortex and in the pyra- mids, undergo marked changes. Those included in the maisses of connective tissue are diminished in size ; tlieir epithehum is flattened ; some contain cast matter, many are obhterated. The tubes between the masses of new connec- tive tissue are more or less dilated ; their epithelium is flat- tened, cuboidal, swollen, degenerated, or fatty. The dilata- tion of the tubes may reach such a point as to form cysts of some size which contain fluid or coagulated matter. Tiiese cysts follow the lines of groups of tubes or are situ- ated near the capsules. Of the glomeruli, a certain number remain of normal size, but with the tuft-cclls swollen or multiplied. Many others are found in all stages of atrophy until they are converted into little fibrous balls. The atro- phy seems to depend partly on the growth of tuft-cells and intercapillary cells, partly on the thickening of the capsules, partly on the occlusion of the arteries. If the chronic nephritis follows chronic congestion, the glomeruli remain large, but with a marked growth of tuft-cells ; or they be- come atrophied, but with the dilatation of the capillaries still evident. The capillaries of the glomeruli may be the seat of a waxy degeneration. The arteries exhibit the same changes as are found in chronic exudative nephritis." Complicating- Lesions. — Hypertrophy of the left ventri- cle of the heart is almost constant, and affords corroborative aid in diagnosis. The hypertrophy may be followed by dilatation, chronic degeneration, or myocarditis. General arterio-sclerosis is frequently found associated with the nephritis. Chronic endocarditis may complicate the disease. In some cases the heart-lesion is primary, being followed by chronic congestion of the kidney and by nephritis. In other cases the cardiac and renal changes occur together in the same patient and are due to the same causes, but are not directly dependent on each other. Endarteritis with h)'pertrophy of the heart may give rise to cerebral hemorrhage. Emphysema and cirrhosis of the liver may be found asso- ciated with the nephritis, all being types of chronic produc- tive inflanmiation due to the same causes. CHRONIC /!A'/C//7\S D/SI-IASE. 585 Pericarditis is not uncommon, and should be suspected in all nephritis cases dangerously sick with obscure symj)- toms. There seems to be an increased liability to gastritis and bronchitis. Symptoms. — i. Urinary. — The urine is usually increased in quantity, is of a light-yellow color, has a specific gravity ranging between 1005 and loio. and contains a diminished amount of urea to the ounce. Albumin and casts are usu- ally absent, or albumin is present only in traces, especially in the early morning urine. During the acute exacerbations of the nephritis, or in the latter stages when the heart be- gins to fail, albumin and casts may be present in consider- able quantities. In exceptional cases the specific gravity may be normal, or it may be exceedingly low, ranging be- tween 1 00 1 and 1003, with or without waxy degeneration of the vessels. During the acute exacerbations of the nephritis and during the attacks of contraction of the arteries the urine may be scanty or even suppressed. In rare cases there may be blood in the urine, or even profuse bleeding from the kidneys. 2. Cerebral symptoms appear in the majority of the cases, and are due to a variety of causes : (rt) Headache, usually frontal, and sleeplessness are com- mon ; the headache may be so severe that the patient is almost beside himself There may be in various parts of the body neuralgic pains difficult of relief Muscular twitch- ings and general convulsions are of serious import. There may be delirium, mild or furious, or stupor and coma. When these'cerebral symptoms come in attacks the arteries are contracted, the heart's action is labored, and the temper- ature is raised. To this condition the name " acute uraemia " is given. From such an attack the patient may die, or he may recover, but the attack is liable to be repeated. These attacks may occur early or late in the disease, and such an attack may even be the first symptom noticed. iU) Delirium and stupor may come on gradually in the latter part of the disease, with a feeble, low-tension pulse and a tendency to a subnormal temperature. These symp- toms are due to chronic uremia. 586 M.ix(.:ii. OF J7/J-: pa'.ictjce of mfdicixe. (r) There ma\' be the sx-niptimis of cerebral lieiiiorrhage, coma, hemiplegia, and possibly of aphasia. (-onephritis, but as the enlargement is rarely decided, it is with diffi- culty detected. 4. The co)istitiitio)ial symptouis are those of other tuber- cular diseases. Fever is rarely absent, and usually presents a remitting hectic character. Ana:mia, emaciation, and weakness increase with the progress of the disease. 5. There may be complicating tubercular diseases else- where which add their characteristic symptoms. Acute miliary tuberculosis not infrequently develops. Diagnosis. — The diagnosis from calculous pyelonephritis is made (i) by the presence of tubercular disease elsewhere, especially in the lower genito-urinary organs ; (2) by the absence of a history of renal calculi ; (3) by the presence of the tubercle bacilli in the urine. Prognosis. — The course of the disease is progressive. The great majority of cases terminate fatally within two years, but it is possible for the disease to stop and the patient to recover. Treatment. — Surgical treatment consists in the removal of the diseased kidney, and this should be done before other portions of the genito-urinary tract become infected; hence an early diagnosis is of the greatest importance, and it should be a rule to examine for tubercle bacilli in every case of persistent pyuria, so that incipient cases of tubercular kidney may thus be recognized. SUPPURATIVE DISEASE OF THE KIDNEY (SURGICAL KIDNEY). • Etiology. — The germs of suppuration may gain access to the kidney — (i) through the abdominal wall, as with penetrating wounds ; (2) by extension from neighboring abscesses ; (3) through the blood-vessels, as in pyaemia and malignant endocarditis ; and (4) through the ureter, as from cystitis or following operations upon the genito-urinary organs. The first two methods of infection are exceedingly rare. Infection through the ureter is favored by inflam- matory conditions of the urinary passages, by pyelitis, SUPPURATJl-E DrSEASE OJ' 'J'lIE KIDNEY. 593 whether simple, tubercular, or calculous, and by injuries and contusions of the kidney. Suppuration of the kidney alone is termed " suppurative nephritis," but as the pelvis of the kidney is almost regularly involved, the name " pyelo-nephritis " is often applied. Should the pelvis of the kidney be distended with pus, the term " pyonephrosis " is not inappropriately applied. The cases of suppurative pyelo-nephritis complicating tubercular disease and calculi in the pelvis of the kidney will be considered when discussing these diseases. Pathology and Symptoms. — i. Abscesses produced by emboli may occur in the course of pyaemia and malignant endocarditis. Both kidneys are large, congested, and studded with small abscesses. The blocking of small ter- minal arteries by the emboli causes pyramidal areas of white infarctions which subsequently break down to form abscesses. The symptoms of embolic abscesses in the kidney are obscured by those of the primary disease. Pus may not appear in the urine, as the abscesses seldom communicate with the urinary tubules. 2. Idiopathic abscesses occur without assignable cause, and it is unknown whether the suppuration begins first in the kidney or in its pelvis. One kidney becomes partially destroyed, and in the remaining portion abscesses are found. The pelvis of the kidney is inflamed and becomes dis- tended with pus, constituting a pyonephrosis. The sup- purative processes may extend to the perinephritic tissues. The symptoms are at first obscure : {a) Pus-symptoms are present, consisting of irregular fever, erratic chills, and cold sweatings. The symptoms of septicsemia or of the typhoid condition may become marked, or the patient will develop the waxy changes in the viscera that regularly accompany prolonged suppuration. {h) Symptoms of a localized abscess consist of pain and tenderness over the kidney. (r) Pus and broken-down kidney-tissue are present in the urine. The urine is frequently acid, the pus is uniformly mixed with the urine, and the character of the urine is unchaneed after the bladder has been washed out. From 594 M.lXr.lL OF THE PA'ACT/CE OF J/FD/C/.VF. time to time the pus escapes fiDin the dilated i)el\-is in large quantities and appears in the urine. , ('elitis may complicate t\-phoid fever, diphtheria, and the exanthemata. Chronic catarrhal pyelitis may result from cystitis, from hydronephrosis, or from the continuance of an acute attack. In some cases the cystitis may develop without apparent cause. Patholog-y. — The mucous membrane of the pelvis is thickened, infiltrated, and coated with mucus or with muco- pus. Phosphatic calculi may form as the result of the in- flammation. In some cases the inflammation spreads to the kidnc}', so that a pyelo-nephritis results. Symptoms. — Pain and tenderness are referred to the kidney. The urine is generally acid in reaction and con- tains pus, mucus, epithelial cells from the pelvis of the kidney, and occasionally blood. The pyuria ma}' be con- stant or intermittent. If suppuration extend to the kidney itself, the symptoms of suppurative pyelo-nephritis or of pyonephrosis will be developed. The diagnosis from tubercular pyelo-nephritis is made by the absence of tubercular foci in other parts of the body and by the absence of tubercle bacilli in the urine. The course of the tubercular form of pyelitis is more serious, and the disease usually terminates fatally. The diagnosis from calculous pyelitis cannot be made in all cases, but a long history of renal calculi affords an important clue to the diagnosis, and pyelitis is to be considered calculous if crystals of uric acid or of oxalate of lime be more or less continuously present in the urine. Treatment consists in giving bland alkaline mineral waters or citrate of potassium in doses sufficient to render the urine neutral in reaction. The diet should be unirritat- ing, and drugs that are capable of causing irritation or con- // y 'D R OA'K/'IJN os/s. 5 99 gestion of the kidney sliould not be given. If suppurative pyelo-nephritis occur, surgical treatment is indicated. HYDRONEPHROSIS. Btiolog'y. — When any obstruction arises in the urinary tract, interfering with the free passage of urine, the pent-up urine causes an increasing dilatation of the urinary parts above the contraction. A contraction of the ureter may result from impacted renal calculi, from bends, from cica- tricial contraction, or from external pressure, especially by new growths of the uterus or the ovaries. The lower orifice of the ureter may be stenosed in cancer of the bladder. In some cases congenital hydronephrosis results from congenital membranous obstruction or from abnormal valve-formations of the ureter. Double hydronephrosis, which results from strictures of the urethra, may also occur with enlargement of the prostate gland, or even with phimosis. Double hydronephrosis . is regularly accom- panied by dilatation of the bladder and of both ureters. The more gradually the obstruction is developed, the greater the degree of the dilatation ; and it is important to remember that a sudden complete obstruction of a ureter, as by a renal calculus, does not lead to hydrone- phrosis, but to atrophy of the kidney. Patholog-y. — The pelvis of the kidney is dilated ; pres- sure-atrophy of the kidney-tissue results, and in the com- pressed kidney a chronic nephritis is set up. In advanced cases the kidney becomes converted to a cyst, in whose wall may be seen a thin rind of atrophied and com- pressed kidney-tissue. The fluid is thin and yellowish, and contains urea, uric acid, and sometimes albumin. It may be turbid from the admixture of pus. In cases of long duration the urinary salts may disappear, so that the fluid may not be characteristic. In extreme cases the sac may contain from ten to twenty quarts of fluid. Symptoras. — The majority of cases give rise to no symp- toms except the presence of a tumor, which first appears in the region of the kidney and enlarges toward the hypo- chondrium and the median line. Fluctuation may be 6oO M.I.Vr.l/. OF THE PRACTICE OF Ml'.DICIXE. appreciated in some cases. The colon lies in front of the cyst, and may be recognized by the tympanitic percussion- note obtained over it. The size of the tumor varies from time to "time according to the amount of urine passed. In the rare cases of " intermittent" hydronephrosis the tumor may entirely disappear, with the discharge of its contents down the ureter. These cases, which are frequently con- genital, appear to be due to a valve-like orifice of the ureter, which is opened onl\- when the walls of the pelvis of the kidney are dilated and put upon the stretch. In other intermitting cases the ureter arises from the upper portion of the pelvis. Aspiration of the tumor differentiates hydronephrosis from solid growths, and the character of the aspirated fluid may confirm the diagnosis. In other cases intermittent hydronephrosis occurs with movable kidney. The growth of the tumor may give rise to pres- sure-symptoms, nausea and vomiting, and to shooting pains extending down the thigh. Ur.'emic symptoms may occur with bilateral hydronephrosis and in cases in which nephritis occurs in the dilated kidney. Suppuration may result in the formation of a pyonephrosis. Prognosis. — Death may result from the primary disease, from secondary hydronephrosis, or from uraemia. Recovery may follow if the cause of the obstruction be removed ; it may also follow operative interference. Treatment is surgical. When the sac reaches large size the fluid may be removed by aspiration, or the sac opened and drained. The kidne\' maybe extirpated as a last resort. NEPHROLITHIASIS; RENAL CALCULI. Etiology. — The solid constituents of the urine may be deposited in the kidney itself in several forms, to which the name " infarcts" has been incorrectly applied. 1. Uric-acid infarcts occur as reddish streaks at the bases of the pyramids in new-born children after the fourteenth day. They are not found in stillborn children. 2. Infarcts of sodium urate,- with occasionally ammonium urate, appear as whitish lines at the apices of the pyramids in gouty kidneys. NEPJ/K O f.n Iff. I .S7.V. 60 1 3. Lime infarcts, seen in the kidneys of old people, appear as white lines in the pyramids. The term " calculi " should more properly be confined to the concretions formed within the pelvis of the kidney. These calculi are common to all ages and are more frequent in males than in females. The occurrence of calculi of uric acid or of oxalate of lime is favored by gouty conditions and by functional disturbance of the liver. Phosphatic calculi are more commonly associated with inflammations of the pelvis of the kidney. Diet seems to exert no direct influence upon the formation of renal concretions, but the use of hard drinking-water containing lime seems to predispose to their formation. The deposition of uric acid, according to Roberts, is favored by the following urinary conditions: (i) High acidity; (2) poverty of salines ; (3) low pigmentation; (4) high percentage of uric acid. Patholog-y. — The important varieties of calculi are as follows: (i) Uric acid alone or combined with concentric layers of the urates; (2) uric acid with alternating layers of lime oxalate ; (3) lime oxalate alone (" mulberry calculus"); (4) phosphatic calculi of the magnesium salts, of the ammonio- magnesium salts, or of both ; (5) urates alone, especially in children ; (6) cystin, resulting in a soft concretion of bees- wax consistency. A central nucleus is occasionally found, consisting of mucus or of a small blood-clot. The ordinary size of the calculi varies from small gritty particles — " renal sand " — up to the size of rice-grains. In the pelvis of the kidney there may be found larger calculi of an irregular branching shape — the so-called " dendritic calculi." Calculi forming perfect stony casts of the renal pelvis have been described. Uric-acid and oxalate-of-lime calculi are more apt to be formed in both kidneys than are those of phosphatic origin. Symptoms are produced by (i) the passage of the cal- culus down the ureter; (2) its retention in the ureter; (3) its retention in the pelvis of the kidney. I. Passage of tlic Calculus through the Ureter. — Small concretions may pass without symptoms, or may give rise to twinges of pain in the side, the pain running down to the 6o2 M.IXi'.lL OF THE PRACTICE OF MEDICEXE. bhuidcr. Larsji'cr calculi, cntcriiii^ the ureter, are pushed downward in jerks In' the pressure of urine behind theni, arid give rise to the symptoms of renal colic. Syniptovis of Roial Colic. — {a) Pain is se\erc, steady, located in the side or the back, with cutting or tearing ex- acerbations which radiate downward to the groin and tes- ticle. Radiation upward does not occur. The testicle may be swollen and retracted. The pain appears suddenly, and disappears with equal abruptness when the calculus drops into the bladder. The pain is often so intense that the pulse becomes rapid, feeble, and irregular. Syncope and vomiting are commonl}^ observed. Convulsions may occur in chil- dren. In some cases there are chilly feelings with a mod- erate fever during the attack. (//>) Uruiary Symptoms. — There is a constant desire to micturate, and the act may be painful from an associated spasm of the neck of the bladder. The urine, which is usually scanty, may contain blood. It may be suppressed either from functional inhibition or from previous calculous disease with atrophy of the opposite kidney. In some ca.ses the urine is copious and limpid. After the attack dull, aching pain, with some tenderness over the kidney, continues for several days. 2. Impaction of the Calculus witJiiu the Ureter. — The attack begins as renal colic ; the cutting paroxysms of pain grad- ually cease, and the dull ache alone remains for a consider- able time, and finally disappears. (a) The calculus may finally be passed after a period of impaction. This fortunate occurrence is more common if several calculi are impacted within the ureter. The passage of the obstruction is accompanied by the symptoms of renal colic, usually with blood in the urine, and may be followed by the passage of an excessive quantity of urine, especially if the other kidney have previously been disabled by calcu- lous disease. In one case of the writer's, in which atrophy of the left kidney had taken place by a previous impaction of a calculus in its ureter, impaction in the right ureter oc- curred, with anuria of twelve days' duration. The final passage of two small calculi was followed by the excretion NKPJIROJJTJII.IS/S. 603 ot" eighteen pints of urine containing over five ounces of urea, the diuresis not being due to the drainage of a hydro- nephrosis. {6) If the calculus remain, completely obstructing the duct, urinary secretion of the kidney will cease as soon as the pressure of the pent-uj) urine equals the blood-pressure within the renal artery. The kidney undergoes atrophy, and is converted to a little cyst in whose walls may be seen a thin shell of kidney-tissue. The cyst contains from one- fourth to one-half an ounce of clear serum, or the contents may consist of inspissated pus containing calculi and lime- salts. The ureter above the impaction becomes converted to a fibrous cord. HydronepJirosis never occurs if the ob- stiniction be sudden and complete. The symptoms of such an atrophy of the kidney depend entirely upon the condition of its companion organ. If the remaining kidney be in good condition, it will be able to do the extra amount of work required of it, and no symp- toms will be developed. If the other kidney, however, be destroyed in like manner by previous calculous disease, or, as has happened, if there be but one kidney, then anuria develops. The characteristic of this obstructive anuria is that it may exist for a number of days without marked ursemic symptoms. Finally, at the end of one or two weeks uraemic symptoms develop, or the patient may suddenly die. In some cases pressure-necrosis of the ureter at the point of impaction allows of perforation and of peritoneal sepsis. If the impaction be incomplete, so that gradual back- pressure is exerted upon the pelvis of the kidney, hydro- nephrosis may be developed. This, however, is a slow and gradual process. 3. If the calcidi remain in the pelvis of the kidney, they tend to grow larger and to assume the form of the cavity in which they lie. There results from their presence either a pyelitis, mild, severe, or suppurative, or dilatation of the pelvis (pyonephrosis), or a suppuration of the kidney (pyelo- nephritis). Mild forms of pyelitis result in pain, of a dull, aching 604 M.LVi.lL OF THE PRACTK'E OF MFDICIXF. charr\cter, usually increased b\- exertion. The pain is usually referred to the kidney or to the back, but it may be referred to the opposite kidney — a point which should be remembered in operating upon such cases. From time to time there occur attacks of renal colic with its characteristic pain. Toidcnu'ss over the kidne\' is usuallx' detected by bi- manual palpation. The urine, which is generally acid in reaction, contains mucus, epithelial cells from the pelvis of the kidney, blood, pus-cells, and crystals of uric acid or of oxalate of lime. Haematuiia is not profuse, but is apt to be persistent, and is regularly increased by exercise, so that the blood inay be passed in considerable quantities. From time to time there occur acute exacerbations of the pyelitis. There may be an initial chill ; the temperature rises to I02° or 104° F. and is accompanied by severe and distressing pain in the back. Profuse sweating follows the decline of the fever. During the attack the urine becomes smokj' or bloody and contains a large number of epithelial cells. This " intermittent renal fever," which may be mistaken for malarial fever, is identical with the inter- mittent hepatic fever due to gall-stones. Severe cases of pyelitis may merge into those of suppu- rative pyelo-nephritis and pyonephrosis. The symptoms of pyelitis become aggravated, pus appears in the urine, and chills, fever, and other septic symptoms develop. If the opposing kidney be previously destroyed by calculous dis- ease, pyelo-nephritis may lead to fatal uraemia. Other cases die in a septicctmic condition. Treatment should be directed toward the following con- ditions : I. The habitual passage of uric- acid or oxalatc-of-lime crystals. Usually there is found some digestive error. The bowels should be kept regular; the functions of the liver should be stimulated by cholagogues and occasional doses of calomel. The use of dilute hydrochloric acid (TTLxv in a glass of water to be drunk during meals) is often of the greatest service, especially in cases of oxaluria. A NE/'//K(>L/77//.IS/S. 605 reduction should be ordered in fats, sugars, alcohol, and meat, but fruits, vegetables, and milk may be given freely. The most important part of the treatment is to enforce regular and systematic exercise ; unless this can be done, the effects of dietetic and medicinal treatment may not be apparent. 2. Attacks of renal colic. The indication is to relieve the pain and spasm. The patient should at once be immersed in a hot bath, or hot applications may be applied to the abdomen. Morphine is to be given in |-grain doses hypo- dermically, and is preferably combined with atropine. The same caution attends its use as in biliary colic. The pain having a tendency to cease suddenly, the tolerance for the drug will also cease, and toxic symptoms may appear if the drug be given in too liberal doses. While the patient is passing under the effects of the morphine whiffs of chloro- form may be necessary to mitigate the agony. After the attack is over the urine for some days should be filtered through gauze or through a fine sieve to find the stone, and by analysis its chemical composition may be determined. 3. If the stone be impacted in the uretei^, treatment is given with a view to relax the spasm of the wall of the ureter, and to increase the quantity of urine, so as to push the stone along. Spasm is relaxed by continuous hot applications and hot baths, during which the abdomen may be kneaded gently, and by small doses of morphine and atropine. Increased secretion of urine is accomplished by raising the blood- tension by appropriate heart-stimulants, the preferable drug for this purpose being digitalis. If medicinal treatment be of no avail, and if anuria per- sist, showing permanent disability of the other kidney, the stone may be removed surgically. If the stone remain in the pelvis of the kidney, various forms of solvent treatment have been recommended. Citrate of potash is to be given in doses sufficient to keep the urine neutral in reaction. The treatment must be dis- continued as long as the urine is alkaline or ammoniacal. According to Roberts, three conditions are necessar\" for 6o5 MAXr.-lL OF THE PA'.IC/7C/-: OF MEDJCfXF. success in this treatment : the calculus must be of uric acid ; it must be of small size ; antl the urine must not be alkaline or ammoniacal, as otherwise sodium biurate or phosphate is precipitated upon the calculus, rendering further solution impossible. Instead of the citrate of potassium, alkaline mineral waters may be given for the same purpose, but, according to Haig, the lithium waters are useless. For the oxalate- of-lime calculi there is no solvent treatment. If the pain be so severe as to interfere with the patient's earning a living, or if suppurative pyelo-nephritis or pyonephrosis develop, the ki(.lne\- ma\- be cut down upon and the calculi removed or the kidney extirpated. Care, however, should be taken that the other remaining kidney is competent, and not atrophied from previous disease or congenitall)' absent. PERINEPHRITIC ABSCESS. Etiolog-y. — Suppuration of the pennephritic tissues may result from traumatism or from extension of suppuration from the kidney, intestine (especially the vermiform appen- dix), liver, or spinal column. Burrowmg downward of a perforating empyema has occurred. Symptoms. — As the disease is, properly speaking, a sur- gical one, but a brief description of the symptoms will be given. Pain and tenderness are present in the lumbar region. The pain is somewhat relieved by keeping the body immobile and by flexing the thigh. In rare cases the pain may be altogether referred to the hip-joint or to the knee. In the lumbar region there may be detected a tender, indurated mass which in the latter stages may yield a sense of fluctuation. The abscess may appear externally, or internal rupture in any direction may occur. The constitutional symptoms are those of an internal abscess — chills, fever, and the gradual development of sepsis. Treatment consists in opening and draining the abscess. VL CONSTITUTIONAL DISEASES. ACUTE ARTICULAR RHEUMATISM; RHEUMATIC FEVER. Etiology. — Rheumatism may occur at any time of the year, but it is more common ni the spring months. Hered- ity is traced in 25 per cent, of the cases. One attack pre- disposes to successive attacks, and relapses are common. No age is exempt. It is very common in children, and it may even be a disease of intra-uterine life. It occurs espe- cially in those leading a life of exposure, and the exciting cause may be wet and cold or over-strain of a muscle or a joint. The disease is rare in the tropics. Rheumatism at certain times assumes epidemic propor- tions, and when this is the case the clinical features are apt to vary. The following theories of rheumatism have been advanced; no one of them has been satisfactorily proven : 1. The nervous theory, that rheumatism depends upon dis- turbances of the nerve-centres presiding over the nutrition of joints. 2. The lactic-acid theory, that rheumatism is due to the presence of lactic acid in the blood, due to some perverted tissue-change of muscle. 3. The 7iric-acid theory of Haig, that uric acid formed in the blood may be deposited in the joints by diminished alkalinity of the blood. It has been supposed that lactic and uric acid in combination might produce the lesions. 4. The tlieory of inicrobic infection is based upon the gen- eralization of the lesions, the involvement of the fibro-serous membranes so commonly involved in other known bacterial diseases, the constitutional predisposition seen in many patients, and the occurrence of occasional epidemics of the (i07 6o8 J/.l.VC.IL OF THE PRACTICE OF MEDICIXE. disease. No germ lias yet been isolated, althoui^jh ex- periments seem to confirni the theor\- of bacterial in- fection. Symptoms. — i. Goicral. — The onset nia>' begin acutely with a chill and f'c\'er, or subacute!)' b\' shooting pains in the joints, malaise, and moderate fever. In rarer cases the joint-symptoms are the first symptoms observed. The fever is rarel\- intense, usually under 103° F., and runs no t\pical course. Formerl)' its duration was from two to four weeks, but owing to improved methods of treat- ment it now rarely lasts more than from two to fi\e days. In children the fever is but moderate, and it may even be absent. It is important to watch the temperature through- out the disease. A rise in temperature usually means a fresh invasion of joints, or some complication, such as endo- carditis or pericarditis, while a fall generally implies a sub- sidence of the disease and modifies the therapy. The occur- rence of hyperpyrexia will be noted later. The pulse is full and dicrotic The urine is diminished, is of increased acidity and high specific gravity, and contains urates and an increased quan- tity of uric acid. Febrile albuminuria may be observed. Cerebral symptoms are not seen except in cerebral rheu- matism with hyperpyrexia or in over-dosing of salicylic acid. The blood in rheumatism becomes rapidly anaemic. In the majority of cases there occur drenching sweats of a peculiarly sour odor, and the skin may show sudaminal vesicles. 2. Inflammation of Fibro-scrous Membranes. — The joints are almost regularly involved, giving a distinct clinical type to the disease. In children, however, joint-symptoms are regularly less marked than in adults, and may be absent altogether (the " abarticular " form). The lesion is a simple serous synovitis. The synovial membrane is h)'per;i:;mic ; its cavity is filled with serum and flocculi of fibrin. There is no pus-formation. There are often similar lesions in the sheaths of adjacent tendons. There are pain, increased by motion, and tenderness of the affected joints. The extent ACUTE ARTICULAR RJIKUMAT/SM. 609 and character of the swelling depend upon the amount of synovial effusion and the involvement of the adjacent ten- don-sheaths. The skin over the joint is usually hot, red- dened, and not infrequently is oedematous. These symp- toms are less marked in children, who may only show some rigidity to passive motion of the joint, and a continued posi- tion of flexion which is especially marked in the knees, and appears to be due to inflammation of the sheaths of the hamstring tendons, the joints themselves escaping. Characteristic of rheumatic synovitis are the great rapidity of its development and subsidence, the involvement of many joints by jumps (fresh articulations being involved while those first attacked are recovering), and the rarity of its attacking one joint alone. Monarticular rheumatism is so uncommon that a diagnosis of rheumatism should always be made with extreme caution. The larger joints are especially liable to be attacked, but the small joints of the hands and the feet may be involved. Any joint may be attacked, but the temporo-maxillary articulation is so rarely involved as to throw doubt on the diagnosis, should this joint be affected. Symmetry of involvement is rare, the disease differing in this respect from acute rheumatic arthri- tis. Pain and swelling often persist after the acute process has subsided, and there may be some stiffness from adhe- sions within the joint-cavity. An acute attack may be fol- lowed by any of the forms of subacute or chronic rheuma- tism. Recurrences of acute rheumatism are exceedingly common, especially in the rheumatism of young people. Subacute rheumatism represents a milder form of rheu- matism. The constitutional and local symptoms are less intense, but the duration of the disease is longer than in the acute form, and the condition tends to become chronic. Complications of Rheumatism. — i. Cardiac Affections. — The endocardium and the pericardium may be involved in mild as well as in severe attacks of rheumatism, and may even be inflamed without any involvement of the joints, as in the abarticular rheumatism of children. The liability to heart-complications is most common in children ; this liabil- ity diminishes with increasing age. The heart-membranes 6lO M.lXr.lL OF niE PKACTICE of MEDICIXE. arc not usuall\- involved after the first week, if absolute rest and a restricted diet be enforced. {a) Pericarditis, which complicates from lO to 20 per cent, of the cases, may occur alone or with endocarditis. The inflammation ma\- be fibrinous, fibrino-serous. or purulent, and it is often associated with hyperpyrexia and delirium. The rheumatic pericarditis of children often runs an obscure course. The child grows pale and emaciated, and dies of exhaustion or of heart-failure without the development of either dropsy or dyspnoea. {Jii) Endocarditis is more commonh' a rheumatic lesion than pericarditis, and it appears in a large percentage of both mild and severe cases. Endocarditis may even be the solitary manifestation of the abarticular rheumatism of chil- dren. The mitral valve is the one most frequently affected. Valvular disease may not lead to serious consequences, or slow changes may ensue, resulting in vahailar thickening and retraction. In a few cases there occurs an added infec- tion of micrococci, resulting in malignant endocarditis. (r) Myocarditis is almost regularly secondary to endo- cardial or pericardial changes. 2. Pulinonary Affections. — {d) Pleurisy usually results by extension from a pericarditis, and is therefore left-sided and more intense in the portion of the pleura in most direct con- tact with the pericardium. The pleuris}- is usually fibrinous, rarely fibrino-serous. {b) RJieuviatic pnenmonia rarely occurs except in connec- tion with pericarditis, and is left-sided. The pneumonia ma)' present certain peculiarities : (i) Absence of the criti- cal fall of temperature ; (2) frequent absence of cough ; (3) rarity of rusty sputum ; (4) great rapidit}- with \\hich the physical signs clear up. 3. Hyperpyrexia is probably due to the action of the rheumatic poison upon the heart-centres, and is of compara- tively rare occurrence. It appears more commonly in hot weather ; it is more frequent in men than in women, and especially in those with weak nervous systems. It is un- known in childhood, the greatest liability being between the twentieth and thirtieth years. It is almost unknown after ACUTE ARTICULAR R IJI:UMA'TISM. 6l I the third attack of rheumatism. In one-half the cases peri- carditis is present. In an equal number of cases the joint- symptoms subside as the hyperpyrexia develops. The hyperpj'rexia may complicate mild or severe cases. The onset of high fever may be sudden, or it may be preceded by headache, delirium at night (not due to salicylic acid), restlessness, hyperesthesia of the skin, or excessive mictu- rition. The fever may rise gradually or suddenly to 106'^, 108°, or 110° F., or there may be merely a high range of temperature for a number of days, without any acute exacer- bation. Prostration, delirium, and coma usually appear, and may terminate fatally. 4. Ccj'ebral complications complicate the hyperpyrexia, and occur only in about 2 per cent, of the cases. Cerebral symptoms may suddenly develop, or they may be preceded by the same prodromal symptoms as in hyperpyrexia. These preliminary symptoms, if proven not to be due to salicylic-acid poisoning, should excite grave appre- hensions. According to Duckworth, cerebral rheumatism assumes one of three clinical types : [a) There is delirium, mild and wandering or so violent as to call for restraint, followed by semi-coma, coma, and death. {b) The patient passes suddenly into coma, which termi- nates fatally, at times within a few hours. {c) There are well-marked spasmodic symptoms, followed by fatal coma. In the great majority of the cases of cerebral rheumatism hyperpyrexia is present, and if the temperature be over 106° F., a fatal issue is almost certain unless prompt treatment be adopted. The pathology of cerebral rheumatism is obscure. The brain may be normal, anaemic, or congested. In rare instances there are found evidences of an acute meningitis. 5. The relation of chorea to rheumatism will be con- sidered under the former disease. 6. Cutaneous Complications. — There may be a fine miliary rash, or an eruption resembling that of scarlet fever. Pur- 012 MAXLAL OF llIE PRACTICE OF MEDICINE. pura is not uiicoiiinion, aiul the x^arious toinis of urticaria and erythema may occur. 7. R/icii)Na(ic Nodiili's. — Subcutaneous nodules, varying from a barel}' appreciable size up to that of a bean, may appear, attached to the tendon-shoaths, to the deep fascia coverini:^ the bony prominences, and to the cranium. Those attached to the tendon-sheaths are frcel\' mo\able. During the early stages of their development the\' may be a little tender, but when of longer duration they are absolutely painless. They are most numerous on the fingers, the hands, the wrists, and about the elbow-joints, but they may appear upon the patellar, the spines of the vertebrae, the skull, and the clavicles. They may appear during an attack of rheumatism or after its decline, and they are more common in the abarticular rheumatism of children. They ma\' last for weeks or months, and they are regarded as a positive indication of rheumatism. The}' consist of connective tissue undei'going rapid proliferation. 8. Pharyngitis and Tonsillitis. — Pharyngitis is not uncom- mon in rheumatic subjects, and is characterized by the amount of pain being out of proportion to the apparent degree of inflanmiation. Rheumatic pharyngitis may be practically considered as an erythematous affection of the fauces, of a nature similar to cutaneous erythema. Tonsillitis occurs in repeated attacks in rheumatic sub- jects, and max- complicate an acute rheumatic attack. Treatment. — Except in very subacute cases, the patient should be put to bed, no matter how mild the case, and not be allowed to get up until the acute symptoms liave entirely subsided. The diet should be of milk and farinaceous food, nitrogenous food being absolutely contraindicated. Lemon- ade or the alkaline mineral waters may be given freely. The patient should not be exposed to draughts, and should sleep between light blankets. Local treatment to the affected joints is often grateful. The joints may be encased in cotton and rendered immobile by padded splints. Hot applications are usually well borne, hot solutions of i per cent, of acetate of alumina or of lead and opium being highly efficacious. Counter-irritation by ACUTE AKT/Cl'I.AR A'/fEUA/A'/VSAl. 613 the thermo-cautcry or by small blisters about the joint sometimes relieves the pain. The joints may be bathed with chloroform liniment, or ichthyol ointment (3j :.?j) may be applied. Ice-bags are at times more grateful than hot applications, and are much used on the Continent of Europe. Constitutional Treatment. — Salicylic acid (gr. v-x), sodium salicylate (gr. x-xx), salol (gr. v-x), salophen (gr. v-x), and oil of wintergreen (TTl x-xx in capsule or in milk) may be given in the indicated doses every two hours until slight deafness and buzzing noises in the ears are experienced, after which the dosage is to be reduced gradually. This salicylic-acid treatment seems to have no effect in redu- cing the duration of the disease nor in preventing cardiac complications, but it exerts a specific effect upon the fever and the pain, the temperature falling to normal and the articular pains disappearing within from two to five days. It is said that relapses are more common under this than under the alkaline treatment, but the so-called " relapses " are probably recrudescences of the disease, as the symp- toms of rheumatism tend to recur should the treatment be discontinued too soon or should too small doses of the salicylic acid be given. Toxic syrnptoms — gastric disturb- ances, delirium, cardiac weakness, albuminuria, and a tend- ency toward hemorrhages — should not appear if the patient be conscientiously watched. The alkaline treatment seems to lessen the liability to cardiac complications. The treatment consists in giving alkalies in dose sufficient to keep the urine alkaline. For this purpose sodium bicarbonate in sj-ij doses should be given every three hours, in water rendered effervescent by the addition of the juice of half a lemon. The urine becomes alkaline usually within twenty-four hours, after which time only enough alkali is given to keep the alkalin- ity of the urine constant. The addition of quinine sulphate (gr. iij-v) to each dose of the alkali seems to increase its therapeutic value. The alkaline treatment may be given alone, but it is preferably combined with the salic}'l com- pounds. Trimethylamine and benzoic acid or sodium 6 14 M.IXC.IL OF THE FRACTICE OF MFDIC/XE. benzoate have been reconinicndcd for rheumatism, but their action is inferior to that of the saHcylates. For the reUef of pain opium may be necessary. Phen- acetine is of service, and antipyrine, in lO-grain doses every three or four hours, is useful in controUing the pains of afebrile rheumatism. Hx'perpyrcxia is to be treated by the energetic use of the wet pack or the cold bath, and no time should be lost in reducing the temperature. The treatment of the cardiac and pulmonary complica- tions is considered under their respective sections. During convalescence iron is indicated to relieve anaemia, and the alkaline treatment should be continued for some weeks after the cessation of acute symptoms. Over-use of the joints should be avoided. During convalescence nitrogenous food should be interdicted. PSEUDO-RHEUMATISM (SECONDARY RHEUMATISM). Under this heading are included a number of forms of articular disease secondar}' to a variety of infectious diseases, usually of septic origin. Among the most com- mon of these diseases are the articular affections complicat- ing mumps, dysentery, scarlet fever, typhoid fever, puer- peral fever, pyaemia, purpura rheumatica, .syphilis, and gonorrhoea. The characteristics of these pseudo-rheu- matic affections will be considered in connection with the diseases from which they originate. CHRONIC ARTICULAR RHEUMATISM. Etiology. — The chronic form may follow acute rheumatism, or the disease may be chronic from the start. Persons past the middle age of life, and whose occupation exposes them to wet and cold, are more liable to be attacked. The disease is greatly influenced by weather, and exacerbations may recur evcr\- autumn and last throughout the winter. Pathology. — The synovial membrane is congested, and, together with the capsule of the joint, is thickened. The thickening may also extend to tlie fibrous structures about CHRONIC ARriCULAK N JJRl -MA-nSAJ. 615 the joint. Slight erosions of the articular cartilages may occur, in protracted cases. There may be deformities from the contraction of fibrous bands formed about the diseased joints [rhciunatisvie fibrcnx), and in advanced cases ankylo- sis of the joint may occur. There may be atrophy of the muscles about the diseased joint, from disuse, from centric nervous causes, or from neuritis. Muscular contraction is not uncommon. Osteophytic deposits do not occur as in arthritis deformans. There are no cardiac complications as in the acute form. Symptoms. — Pain and stiffness characterize the affected joints, and acute exacerbations may occur, especially after over-exertion of the joints or during cold, damp weather. The affected joints are tender to the touch and are usually somewhat swollen. Synovial crackling may be appreciated on movement, and may readily be distinguished from the bony grating common to anthritis deformans. As a rule, many joints are involved, especially those exposed to fatigue in the patient's ordinary occupation. In working-women the small joints of the hand are usually favorite seats of the disease. Ulnar deflection of the fingers is common, but the deflection is not permanent except in the fibrous or ankylotic form. In rare cases the disease assumes a monarticular form, involving the hip, the knee, or the shoulder. The course of the disease is afebrile, and the general health does not directly suffer from the disease. The prognosis is good for life, but is bad for recovery from the rheumatism. Treatment. — The clothing should be warm, and exposure to cold, damp weather should be avoided. Salicylic acid is useless. A number of drugs have been recommended for this disease — potassium iodide, colchicum, arsenic, alkalies, guaiac, preferably combined with potassium citrate and tincture of cinchona — but the efficacy of internal treatment can seldom be demonstrated. Good results have been claimed for ichthyol (gr. v three times a day in pill form). The best results are obtained by improving the patient's nutrition (tonics, nutritious food, and cod-liver oil), by ap- plying counter-irritation to the joints (thermo-cautery, iodine, 6l6 MAXC'AL OF rilE rKACTICE OF MFDIC/XE. blisters), and by sending the patient for tlie winter months to a warm, equable chniate. Hot alkaHne waters are particu- larly useful, and sulphur-waters have also been recom- mended. The thermal springs may be advised, together with a change of climate. Alkaline baths have been recom- mended, but they are not to be advised in the case of those over sixty years of age with atheroma and myocardial degeneration. MUSCULAR RHEUMATISM. Etiology. — The exact nature of this affection is unknown. The condition, which commonly occurs after exposure to cold and after over-use of the muscles, is more frequent in those of a rheumatic or gouty habit. One attack renders the patient susceptible to recurrences. The patholog-y is unknown. The disease may be a mild form of inflammation of the muscles (mj^ositis), or the affec- tion may be entirely neuralgic. Symptoms. — There is pain, dull and aching or sharp and cramp-like, in the affected muscles, and the pain is regularly increased by motion. The pain is generally re- lieved by pressure, but there may be decided muscular ten- derness. The affected muscles may be contracted, so that the attitude of the patient frequently gives evidence as to the seat of the disease. Special names are given to muscu- lar rheumatism according to the location of the difficulty. Lumbago affects the muscles of the small of the back and their tendinous attachments. Torticollis, or " wry-neck," usually affects the sterno-cleido-mastoid muscle of one side, but both muscles may be affected, and the muscles of the back of the neck are often involved. Pleurodynia involves the intercostal muscles of one side, and occasionally the pectorals, the latissimus dorsi, and the serratus magnus. The duration of muscular rheumatism is usually brief, but the disease may at times run a subacute or a chronic course. Treatment. — Rest for the affected muscles is of the first importance. As the pain begins to wear away, the sub- sidence of the disease may be hastened by massage. In some cases massage will cut short a pronounced attack, and GOUT. 617 the effects of the manipulations may be increased by the use of stimulating hniments. Strapping of the side gives relief in pleurodynia. Phenacetine combined with salol or with salicylic acid frequently cuts short an attack, and should always be used as routine treatment. Steaming by covering the affected muscles with damp cloths and passing a hot iron over them is a domestic remedy of established value. A hot bath may be recommended. Rapid cure frequently follows " firing " with the thermo-cautery. The use of the constant current is also beneficial. Osier recommends acu- puncture for lumbago, sterilized bonnet-needles three or four inches long being thrust into the affected muscles and retained from five to ten minutes. In many cases instant relief follows this procedure. GOUT (PODAGRA). Etiolog-y. — Gout may be either inherited or acquired. Inherited gout is very common among the better classes in England, Germany, and France, but is rare among the Irish. An inherited tendency is seen in 75 per cent, of the cases. Gout may be acquired by habits ofease, indolence, and dis- sipation, by over-eating and over-indulgence in-alGohol, by deficient bodily exercise, and by any cause exhausting the great nerve-centres. It may be acquired through poisoning by lead, as Garrod found that 30 per cent, of his hospital cases of gout could be traced to this origin. Gout cannot always be traced to high living, as cases of "poor man's gout " are not uncommon, the disease being induced by improper hygiene, poor food, and indulgence in malt liquors. In America the acute forms of gout are uncommon, but the irregular manifestations of the 'disease are not infrequent. The disease occurs more often in men than in women. The inherited form usually appears earlier in life than the ac- quired form, which does not generally appear until the fifth decade. Three theories of gout have been advanced : I. TJie Uric-acid Theory (Garrod). — From renal insuffi- ciency the excretion of uric acid is diminished, and the symptoms of gout arise from its retention in the blood and 6lS MAXL'.IL OF THE PKACTICE OF MFDICIXE. tissues and from the efforts of nature to expel it. The de- posit of crystaUized urates in the joints gives rise to the classical inflammatory symptoms. Haig has thus modified the uric-acid theor\- : The deposit of urates, according to his modification, is not due to their excessive production nor to deficient elimination, but is produced by all conditions associated with diminished alkalescence of the blood. 2. The " Xcn'ous" or " Ahnui-Junnoral" Theory (Duck- worth). — Two conditions must be complied with: (i) The patient must possess the arthritic or diathetic habit from which gout and rheumatism arise, and (2) there must exist some functional disturbance of the nerve-centres to account for the sudden explosion of the .symptoms. This " gouty neurosis " may be inherited, acquired, intensified, or re- pressed. The causative effect of depressing physical and mental circumstances in inducing gout seems to lend cor- roboration to the nervous theory. 3. Ebstein believes that a local necrosis occurs in certain tissues from local nutritive disturbance, and that in the necrotic areas the urates are deposited secondarily. The nutritive-tissue disturbance may be inherited or acquired. Pathology. — The blood contains an excess of uric acid. This condition, however, also occurs in leukaemia, and is not therefore distinctive. The joints usually affected are the great toe, the small joints of the hands and the feet, and, least frequentl}', larger joints without an\' marked order of preference. During an acute attack the sx-novial membrane is congested, the ligaments are swollen, and there is an in- crease in the synovial fluid. The articular cartilages appear as if whitewashed, from an interstitial deposit of the sodium urate, with occasionally the addition of the calcium salt. In advanced cases the cartilage becomes roughened and eroded and infiltrated with urates, while deposits of urates are seen in the ligaments and in the neighboring fibrous structures. The synovial fluid is often transformed to a pasty mass of urates. Secondary inflammatorx' lesions consist of bony marginal outgrowths, and in ulceration b\- which the gouty masses may be discharged through the skin. The joint becomes GOUT. 619 distorted and immobile, and complete ankylosis may result. Gouty concretions or " tophi " are frequently seen under the skin, in the eyelids and the ears, and in other parts of the body. Associated lesions are of great importance. 1. The kidneys may show deposits of sodium urate as whitish lines in the apices of the pyramids. Chronic diffuse nephritis is so commonly present that the name " gout\' kidney " has frequently been applied to this form of nephritis. 2. The arteries are frequently the seat of chronic endar- teritis. Atheroma and calcareous deposits upon the aortic valves are not infrequent. 3. Hypertrophy and dilatation of the heart result from the nephritis, from the endarteritis, and from the atheroma of the aortic valves. 4. Emphysema with chronic bronchitis is almost con- stantly present in the chronic forms of gout. 5. Chronic gastro-enteritis or chronic colitis is frequent in long-standing cases. Symptoms. — Gout may be described as occurring in acute, chronic, and irregular forms. Acute Gout. — There may be premonitions of an attack. These premonitions consist of twinges of pain, cramps in the calves, irritability of temper, and dyspepsia. A pre- liminary asthmatic attack may also occur. The urine is usually over-acid and concentrated, and deposits urates. There may be a temporary albuminuria or glycosuria. The quantity of uric acid eliminated before and during the early period of the attack is regularly diminished. The attack itself generally appears suddenly, usually during the early morning hours, with a characteristic pain in the metatarso- phalangeal joint of the great toe, usually of the left side. The pain is grinding, throbbing, and excruciating, and is entirely disproportionate to the evident inflammation. The joint becomes swollen, dusky-red, shiny, and tender. The veins of the foot become turgid. As the attack wears off the foot usually becomes oedematous, and desquamation of the skin over the joint is observed. An initial chill is not 620 M.l.yC'.lf. OF THE PRACTICE OF MEDICLXE. iinconinioii. I^Y'\-er aniountiiiL^ to 102° or 103° V . is alnu>st reguIarK' obscrvcti. Other joints may become involved, especialK' the joint of the great toe of the other foot, but this extension of the disease is not common. A practical rule is that all cases of suddenly induced severe monarthritis should be suspected to be of gouty origin. In rarer cases the knee- joint is the one primarily involved. The attack terminates favorably within a week or ten days, unless the response to treatment be exceedingly prompt, and the patient is left with a weakened, tender joint for some little time. Usually, after an acute attack the general health is markedly improved. The terms " suppressed " and " metastatic " gout are ap- plied to sudden and severe internal s)-mptoms coincident with the rapid disappearance of the outward inflammatory siens. The following varieties mav be described : 1. Cardiac gout consists of sudden pain in the heart, .syn- cope, and heart failure which may be fatal. If the patient recover, dyspnoea and palpitation appear. 2. Cerebral Gout. — There may be mental confusion, delirium, or mania. Apoplectiform seizures with coma ma\' occur. Temporary insanity has been observed. In some of these cases, however, the cerebral symptoms have been ura^mic. 3. Gastro-intestinal Gout. — Pain in the stomach, nausea, and vomiting are not infrequent. Profuse diarrhoea may occur, with death in collapse. 4. ]\sual gout is characterized by t'requent painful mic- turition and haematuria. 5. Testicular gout is accompanied by painful swelling of the testis. Chronic Gout. — As the acute attacks become more fre- quent the local processes fail to leave the joints. The joints show various deformities, depending on the bony out- growths from the periphery of the articular cartilages, from visible deposit of urates, and from enlargement of and gouty deposits in the superjacent bursae. Synovial distention is less common in gout than in rheumatism. Crackling GOll'J'. 621 sounds are heard when the joints are moved. Pain and weakness are experienced in the affected joints, which first are those of the feet, then those of the hands. Tophi appear about the joints and in the ears, and may be dis- charged through the skin. The skin becomes soft and satin-hke. Symptoms of the associated lesions appear — high-tension pulse from the arterial changes, hypertrophy or dilatation of the left ventricle, abundant urine of low specific gravity, and uremic symptoms from the nephritis. Emphysema, bronchitis, and chronic intestinal catarrh com- plicate the course of the disease in almost all cases. Irregular or abarticular gout is extremely common, occurring as an inherited and as an acquired form. Various symptoms appear in different members of gouty families and among those whose habits are such as to predispose to gout. The symptoms are so varied and assorted that only a brief mention can be made of the most important : 1. Qitaneo?is Symptoms. — Eczema is frequent, especially the dry, scaly variety. Pruritus ani and hot itching feet at night are commonly the source of much distress. 2. G astro-intestinal Symptoms. — Dyspepsia is the rule. Flatulence, over-acidity, constipation, coated tongue, " bil- iousness," and the symptoms of functional disturbance of the liver are usually present. 3. Urinary Symptoms. — The urine is usually over-acid and deposits urates, uric acid, and lime oxalate. Temporary glycosuria and albuminuria are not uncommon, especially in patients of advanced years. The symptoms of chronic diffuse nephritis without exudation may appear. Renal calculi are not uncommon, and are usually of the uric-acid variety. Urethritis may develop without gonorrhcEal in- fection. 4. Cerebral symptoms are not uncommonly distressing. They comprise mental hebetude, loss of memory, irritability of temper, headaches of such severity as to suggest organic disease, vertigo, and sleeplessness. The eyesight is com- monly blurred, and the eyeballs may be hot and itching. 5. Cardio-vascular Symptoms. — Vaso-motor symptoms are common, and consist of " hot and cold flushes " and 622 J/.I.Vr.lL OF THE PKACJICE OF MEDICI XE. sudden s\vcatini:;;s. The pulse is one of hiL;h tension. Palpitation is a common symptom. The arterial changes may lead to the s\'mptoms of hypertrophied or dilated heart, atheroma of the aorta or of the coronary vessels, aneurysm, or sudden death. 6. Piihnoiiary syitiptonis include chronic bronchitis, em- physema, and asthmatic attacks. 7. Locomotor Orgtvis. — Shooting pains, stiffness, and sub- tendinal bursitis are common. Cramps in the calves of the legs, burning feelings in the feet at night, and tenderness in the heels on standing may appear. Gouty neuralgia is not infrequent, and involves the sciatic nerve with greatest frequency. 8. Eye-affcctioiis. — A number of conditions may occur, among which iritis and glaucoma are the most important. Conjunctivitis is not uncommon, and may be due to gouty tophi in the upper lid. Prognosis. — Gout is seldom the actual cause of death except in the rare visceral forms ; but the disease is ren- dered serious by reason of the nephritis and the arterial sclerosis which so frequentl)' complicate the disease, and it is upon these latter conditions that the prognosis depends. Treatment. — During an acute attack of gout the foot should be elevated and wrapped in cotton. Hot applica- tions are often of service, hot whiskey and water being a favorite application. Menthol may be used in alcoholic solution. The following prescription is used by Duckworth : I^. Atropinae, gr. iij ; Morphinse hydrochloratis, gr. xv ; Acidi oleici, . .5j. — M. Sig. Paint over painful joint with a camel's-hair brush. Colchicum has a specific effect on acute gout, and the wine or the tincture should be given in doses of from 15 to 20 minims every four hours, preferably combined with potas- sium citrate. A preliminary mercurial purge is usually given with advantage. The administration of colchicum should be watched carefully, and gastric distress and pur- GOUT. 623 gation should be avoided. In cases where colchicum fails or is not well borne, potassium citrate or acetate in 20- to 30- grain doses may be given every two liours, combined with diluent drinks. The preparations of salicylic acid are often employed, but their action is inferior to that of colchicum. Phenacetine or chloral hydrate may be given for the relief of the pain, but morphine is to be used with extreme cau- tion. The diet during the acute attack should consist largely of milk and light farinaceous foods, and alcohol should be withdrawn unless especially indicated as a stimu- lant. TJic treatment of clu'onic and irregular gout is largely by diet and hygiene. Starchy and saccharine food should be avoided ; beer and wines should be prohibited absolutely. Lean meats, eggs, fish, green vegetables, and milk should constitute the principal portions of the diet. Sweet fruits, berries, melons, and bananas are to be omitted from the dietary, but oranges and lemons may be allowed. The food should be simple, wholesome, and indulged in with modera- tion. If stimulants are needed, whiskey with water is the least injurious form. The patient should drink freely of pure water or of any of the alkaline mineral waters. Hygienic treatment consists of daily baths with friction of the skin and regular systematic exercise. Exercise is one of the most satisfactory means of treating irregular gout, but it should not be carried to the point of fatigue. The medicinal treatment is symptomatic. Lithia-water is of great service. 7\n artificial lithia-water can be made by dissolving a 3-grain tablet of effervescing lithium citrate in each glass of table-water that is taken throughout the day. Constipation is relieved by occasional mercurial pur- gatives and by the steady use of podophyllin and rhubarb. Small doses of colchicum (TTlv-x of the wine) with 10 grains of potassium iodide are of service during the more active manifestations of the disease. Quinine, guaiac, and the benzoates are also recommended. Iron and arsenic should be given for anaemic conditions. In obstinate cases much good is derived from a course of treatment at medici- nal springs, such as the White Sulphur Springs or those at 624 M.lXr.tL OF THE PRACTJCE OF MFD/CLVE. Saratoc^a. Carlsbad, Kissingen. or Homburg. The effects of the treatment are largel\' due to tlie iini)roved dietetic and h\'gienic conditions that attend a course of treatment at these places. ARTHRITIS DEFORMANS. Etiolog-y and Synonyms. — This disease may be primary in its origin, or it ma)' follow rheumatism, gout, or gonor- rhoeal arthritis; 85 per cent, of the cases occur in women, especially in those at the time of the menopause. The influence of heredit)' is often marked, especially among the female members of a gout\- family. Rarely the disease may occur in children. The true nature of the disease is obscure, but it seems probable that there is a nervous origin. This neuropathic theory is based upon the disease frequentl}' following depressing nervous or mental shocks, upon the extreme symmetry of the lesions, and upon the atrophic changes occurring in the nails, the skin, rmd the muscles. In many respects the lesions resemble the arthro- pathies of locomotor ataxia. Syfio?i}'iiis : Rheumatoid arthritis ; Rheumatic gout. Pathology. — The joint-cartilage becomes fibrillated, soft, and velvety, and is worn away in the centre, exposing thickened, polished, eburnated bone-surfaces. At the periph- ery of the cartilages a lipping or a heaping up is observed, from which bony outgrowths form — the osteophytes. Im- mobility and deformity result from the interlocking and mutual obstruction of these osteophytes, but bony ankylosis does not occur except in the spinal column. The synovial membrane and the fibrous capsule become greatly thickened. Synovial distention is rarely extreme. Ligaments which pass in or through the diseased joints may be absorbed. In some cases the articular ends of the bones may be increased in length and thickness, but in old people the bones may become atrophied and spongy. Atrophic changes occur about the affected joints ; the muscles undergo atrophy, the nails become brittle, the skin assumes a glossy appearance, and neuritis can frequently be demonstrated. . / A' 7 11 R / 7 7S DK FOKMA NS. 62 5 Symptoms. — Three clinical types of the disease may be described : 1. Heberdcn's Nodes. — The lesions involve the phalan- geal joints, and little nodules (Heberden's nodes) develop on the distal phalanges. These nodes are composed of osteophytic outgrowths, and may show small cystic swell- ings at their summits, due to hernia of the joint-capsule. The joints may be swollen and painful after indiscretions in diet or when they are accidentally struck, but usually the chief symptom is limitation of motion. The phalangeal joints are somewhat enlarged, and may yield a bony grating on passive motion. The affection is incurable, but does not tend to advance. 2. TJie Polyarticular Form. — This form may develop aciLtcly and may be mistaken for acute articular rheumatism. It may be distinguished from the latter disease, however, by the symmetrical involvement of the small peripheral joints, by bony outgrowths from the articular ends of the bones, and by the uselessness of salicylic acid. The acute form of onset is most frequent in young women who have recently borne children. In other cases the onset is subacute. The chronic form is the most frequent. Premonitory symptoms are at times observed — numbness and tingling of the skin over joints, rapid and high-tension pulse, and a persistent pain in the ball of the thumb. The small periph- eral joints are usually the first involved, and the lesions tend to advance steadily toward the trunk. The temporo- maxillary articulation is often involved. A characteristic feature is the extreme symmetry seen in the distribution of the lesion, for not only are corresponding joints simultane- ously involved, but the lesions progress in them with identi- cal rapidity. The joint-symptoms consist of pain, swelling, and limitation of motion. Pain is variable : it may be parox- ysmal or of a steady, gnawing character, increased by mo- tion and by warmth in bed, or there may be neuralgic pain or the pain of muscular cramp. The enlargement of the joints is due to thickening of the capsule, to bony out- growths, and in some cases to synovial distention. Bony 40 626 M.tXr.l/. OF THE PKACriCK OF MEDICIXE. crepitus can usually be excited b)' passi\-e motion. In time the joints become completel\' locked anil immobile. De- FiG. 52. — Deformity of arthritis deformans. formitics arc caused not onl\' b\' distortion by the osteo- phytes, but also by muscular atrojjhy and spasm. The DIABF/FKS MFJJJ'J'US. 62/ tendon-reflexes are usually increased, and ankle-clonus may- be present. 3. TJic Monarticular Form. — This form is most frequent in old people, and in men. The hip, the knee, the shoulder, and the spinal column are the parts usually affected. In many cases there is a history of previous joint-injury. In old people especially a slight injury is often sufficient to set up what may be regarded as a senile change. The lesions are essentially those previously described, but great atrophy of the ends of the affected bones is characteristic of the disease in old people. When affecting the hip-joint of the aged, the disease has been termed " morbus coxae senilis." Pain, limitation of motion, bony grating, and shortening are observed. The gluteal region is flattened from muscular atrophy. When affecting the spinal column, the disease has been termed " spondylitis deformans." Bony ankylosis is com- mon, so that immobility of the vertebral column iii the. in- volved section results. The prognosis is bad for recovery, although life is usually not shortened by the disease. Death occurs from intercur- rent disease, from chronic nephritis, or from tuberculosis. The disease may be arrested at any stage, or it may progress so that the patient is practically crippled. Treatment. — Arthritis deformans is practically an incur- able disease. Much good can be done, however, by build- ing up the general health and by the steady administra- tion of arsenic. A temporary improvement may follow prolonged treatment by hot mineral baths or by drinking the waters of thermal springs. Massage may be of service in preventing the muscular atrophy of disease. DIABETES MELLITUS. The term " diabetes " should be limited to those cases in which sugar accumulates in the blood and is excreted in the urine, accompanied by constitutional symptoms. The term " glycosuria " should be applied only to those cases in which sugar appears in the urine in small amounts without consti- 628 M.LXCAL OF THE PRACTICE OF MEDICIXE. tutional symptoms, or appears onl\' as a temporar\' condi- tion. Etiology. — The disease may be induced by long-continued indulgence in saccharine food, especially if the patient be of sedentar\- habits. In many cases tiie influence of heredity is marked. The disease ma)- follow lesions or injuries of the brain or of the spinal cord, and it has been produced artificially b\' puncture of the floor of the fourth ventriclejust behind the pneumogastric nucleus ( Bernard's diabetic cen- tre). Lesions causing atropli)' in extensive disease of the pancreas have been followed so frequently by diabetes that a special form of " pancreatic diabetes " has been described. Psychical disturbances, such as worry, care, and depressing emotions, have been followed by the disease, and in some cases diabetes has succeeded certain infectious diseases, such as syphilis, gout, and malaria. Disturbances of the liver have also been adduced as causative factors. The disease is wiot as common in America as on the Continent of Europe. Men are more frequently attacked than women, and the greatest liability occurs in adult life. Children under ten years of age are usually exempt. Hebrews seem to be predisposed to diabetes, and the disease is more com- mon among the higher classes. To explain the disease a number of theories have been advanced. Nervous lesions, diseases of the pancreas and the liver, insufficient alkalescence of the blood-plasma, and de- ficient oxidation-processes have each been the subject of separate hypotheses, but no one theory has been established definitely. Pathology. — A number of different lesions have been found, no one of which seems to be either constant or essential. The\^ may be thus classified : 1. The blood contains an excess of urea, fat, and sugar. The fat-particles may be visible in coagulated blood ; the sugar may be raised from the normal 0.15 per cent, to 0.40 per cent. ; glycogen may be found within the leuco- cytes. 2. Ncn'ous System. — There may be tumors or cysts in- volvincr the " diabetic centre " in the medulla or involvin^r DIABF.rES AiEij.rrus. 629 the cerebrum. Anaemia, oedema, or atrophy of the cortical convolutions may be found, or congestion and thickening of the meninges. Perivascular changes in the brain and the cord may occur. There may be found a tumor press- ing on the vagus. Peripheral neuritis is not uncommon. The sympathetic ganglia may be enlarged. 3. Cardio-vasctilar System. — The heart may be fatty or enlarged. Hypertrophy is not uncommon, and dilatation may be the cause of death. Endarteritis is frequently observed. Endocarditis may result from the irritation of the endocardium by the sugary blood. 4. The liver may be fatty or may be the seat of cirrhotic change. A peculiar form of pigmentary degeneration is described. For this form of " diabete bronze " see page 523. 5. The pane j'e as may be firm and atrophied, may be the seat of pigmentary cirrhosis, or may be the seat of cancer, of cysts, or of fat-necrosis. 6. The kidneys are usually fatty. Glycogen is often found in the epithelium of Henle's tubes. Chronic ne- phritis is common. 7. The lungs frequently show the lesions of broncho- pneumonia or of lobar pneumonia. Gangrene may occur. The lungs of diabetics are frequently the seat of tubercular inflammation. 8. The nincous inenibranes are usually the seat of chronic catarrhal inflammation. The symptoms of diabetes mellitus begin insidiously. The first symptom noticed may be an unnatural thirst, the passage of too much urine, or a loss of flesh. In some cases the disease is first appreciated by an accidental exam- ination of the urine. In rare instances it sets in rapidly. When the disease is developed the symptoms are changes in the urine, thirst, hunger, progressive emaciation, and the symptoms due to the complications. I. The uri)ie is usually pale, of a sweetish odor and taste, and is of a specific gravity ranging between 1025 and 1045, although a lower specific gravity may occur if the quantity of urine be enormously increased. The acidity is high. The urine irritates the genitals, causing intense pruritus,- 630 .y.lXl-.-lL OF THE PRACTICE OF MEDICIXE. whicli may be the first syniptoni for wliicli the patient apphes for rehef Urea and phosphates are passed in excess, and acetone may be detected. A special form of diabetes has been described, " phosphatic diabetes " (Ralfe), in which phosphates are greatly increased, although the sugar may not be present constantly. Transient albuminuria is observed in about one-third of the cases. The quantity of urine passed varies between two and fifteen quarts, from four to six quarts being the quantity in average cases. In rare instances polj'uria is not observed. The percentage of sugar varies up to from i to 2 per cent, in mild cases, and to from 5 to 10 per cent, in the severer forms. The total daily excretion of sugar varies up to from ten to twenty ounces, but it may exceed one to two pounds in the twenty-four hours. Sugar may temporarily disappear dur- ing the course of severe intercurrent diseases. The best methods of detecting and estimating the sugar are by Fehling's test and the fermentation-test. For details of these tests the reader is referred to works on urinary analysis. 2. Excessive hunger and tJiirst are observed in almost all cases. Thirst may be a distressing symptom. As a rule, the food is well digested, but from the excessive amount taken dilatation of the stomach may occur. 3. Emaciation is most marked in young subjects, in whom the disease seems to run a more malignant course. The tongue is usually dry and glazed, the gums swell and bleed, and aphthous stomatitis may occur. Saliva is scanty. The skin is dry and scaly, but in some cases drenching sweats may occur, the perspiration being charged with sugar and lactic acid. Intense general pruritus is often distressing, and this symptom is always highly suggestive of either diabetes or internal cancer. Constipation is the rule. 4. Complicating symptoms are exceedingly numerous. {a) Cutaneous Symptoms. — Boils and carbuncles are com- mon, and suppurative processes are liable to follow opera- tions. Purpura is frequent. Gangrene may occur, and is more frequently observed in the feet. The nails may yV./A'A7'A'.V MKL/.fllJS. 63 1 atrophy, and the hair may fall out. The occurrence of pruritus has been mentioned. (^) Genito-iin)iary Syviptoms. — Irritation and pruritus of the external genitals are common. In men balanitis occurs. Impotence may be an early symptom. Cystitis may occur. The symptoms of a chronic nephritis may be added to those of the diabetes. (c) Puhnonary complications are not uncommon. Lobar pneumonia, broncho-pneumonia, and gangrene of the lung may occur. Tubercular disease is common, and runs a rapid but somewhat insidious course. id) Cardio-vascular Symptoms. — Symptoms of arterial sclerosis are commonly present, and the heart is hypertro- phied. Dilatation may ensue, and may lead to a fatal issue. Sudden death from fatty heart is not uncommon. {e) Nervous symptoms are important. Diabetic coma occurs especially in young subjects, and is usually associated with rapid emaciation. Preceding the onset the urine may be diminished in quantity, although the excretion of sugar remains unchanged. Three clinical forms of diabetic coma are encountered. (i) After severe bodily or mental exertion the patient develops prostration with rapid and feeble heart-action, passes into coma, and dies within a few hours. (2) The patient suffers for a few days from weakness, constipation, dyspnoea, and abdominal pain. Then develop headache, restlessness, delirium, great dyspnoea amounting to " air-hunger," cyanosis, and rapid and feeble heart-action. The breath has a sweetish odor resembling that of rotten apples. Coma terminates the disease within a few days. (3) Neither dyspnoea nor prostration appears, but the patient complains of sudden severe headache, feels as if in- toxicated, becomes rapidly stupid and comatose, and dies in a few hours. The exact nature of diabetic coma is unknown. It has been ascribed to toxaemia from acetone or from oxybutyria acid. In other cases it has seemed to be due to uraemia or to fat-embolism of the branches of the pulmonary artery within the luns". 632 M.IXL'.IL OF TJJK PRACTICE OF MEDICIXE. Peripheral Neuritis. — Mild forms of neuritis give rise to neuralgic pains, numbness and tingling, and muscular weakness. Severe forms cause lightning pains in the legs, loss of tendon-reflex, paresis of the extensors of the feet, and a characteristic gait. To this grouping of symptoms the term " diabetic tabes" has been applied. In other cases paraplegia has been observed, and both hands and feet may be affected. (/") Mental symptoDis consist of melancholia, and in some cases general paresis has resulted. (yg^ Rye. — Cataract is common, especially in young sub- jects, and develops with great rapidity. Retinitis, hemor- rhages in the retina, optic atrophy, and sudden blindness have occurred. There may be parah^sis of the muscles of accommodation. Prognosis. — Complete recovery cannot be expected, al- though a large number of patients enjoy good health for a number of years, and the disease in them may be controlled b\' diet. A considerable number of the cases die of heart failure, diabetic coma, pulmonary affections, or nephritis. A smaller number die exhausted and emaciated from the diabetes alone. As a rule, the older the patient the slower the course of the disease. In cases under forty years of age the prognosis is exceedingly grave. The cause under- lying the diabetes must always be taken into account in rendering the prognosis. The treatment is by diet and by drugs. Diet. — Sugars and starches should be excluded, as far as possible, from the food. Saccharin or glycerin may be sub- stituted for sugar. All fruits and vegetables that abound in starch should be prohibited ; among these are potatoes, rice and cereals, flour- and starch-compounds, beans, peas, tur- nips, grapes, plums, apricots, pears, apples, melons, figs, berries, beets, onions, and asparagus. Beer, cider and champagne, and sweet wines should also be prohibited. Among other food-sub.stances to be avoided are liver, crabs, lobsters and oy.sters, thick gravies, and soups. Theoreti- cally, bread should be prohibited, and gluten bread be given GLYCOSURIA. 633 instead, but, as this is not readily taken by the patient, its use cannot in all cases be insisted upon. Among the articles that may be taken are butcher's meat, game, poultry, fish, clams, eggs, bacon, butter, cream, cheese, nuts, spinach, tomatoes, cabbage, cauliflower, lettuce, cucumbers and pickles, gluten, bran, and almond-meal bread, clear soups, lemons, tea, coffee, and cocoa. As a rule, the diet should be modified gradually, one pro- hibited article after another being cut off Care should be taken that the patient's strength is not too far reduced by the restricted diet. Drug Treatment. — The following forms of treatment have been recommended, and are given in the order of preference : Clemens' solution (a i percent, solution of arsenic bromide) may be given in 3- to 5 -drops doses after meals. Opium is a valuable drug, and in diabetes there exists a tolerance for its use. Codeia may be given in 3^-grain doses three times daily, and may be increased to from 6 to 8 grains in the day ; or morphine may be given (gr. \ doses t. i. d.), and increased until the daily dose is about 5 grains. The i-grain opium pill may also be used. Bicarbonate and salicylate of sodium may be given in i- to 2-dram doses in the day. Sulphide of calcium (gr. /^-ij four times a day), iodoform (gr. ^-ij four times a day), and antipyrine (gr. x-xx three times a day) are all occasionally of service. The alkaline waters of Carlsbad and Vichy may be beneficial. Jambul has also been employed. For the diabetic coma, venesec- tion and intravenous injections of a 3 per cent, solution of sodium bicarbonate have been recommended ; but recovery from the condition is exceedingly uncommon. GLYCOSURIA. Sugar may be found in the urine temporarily under the following conditions : 1. With various forms of poisoning, such as that by curare, morphine, amyl nitrite, alcohol, chloroform, chloral hydrate, and carbon dioxide. 2. With certain infectious diseases, especially diphtheria, cholera, typhoid fever, and epidemic cerebro-spinal meningitis. 634 .W.l.Vr.lL ()/■• TI/J-: PK.tCT/CK OF .]//■: D/C/.\7-:. 3. Gastro-intestinal disorders allowing^ of faulty digestion of sugar and starches, and with functional disturbances of the liver. 4. In gout)' patients with chronic diffuse nephritis. 5. l-'rom nervous causes, as neuralgia, concussion, cerebral hemorrhage, etc. 6. During pregnancy. DIABETES INSIPIDUS. Etiology. — Diabetes insipidus is most common in young adults, especially in men; it not infrequently attacks children. Congenital cases may occur. The influence of heredity is frequently well marked. The disease has fol- lowed injuries and diseases of the brain and the spinal cord, infectious diseases, sun-stroke, sudden mental excitement, and the rapid drinking of large quantities of fluid. Pathology. — The exact nature of the disease is un- known ; it is supposed, however, to be a vaso-motor dis- turbance of the renal vessels, or, in congenital or hereditary cases, to be due to unnatural permeability of the blood- vessels of the Malpighian tufts. There are no essential post-mortem lesions. Symptoms. — The disease begins, insidiously or sud- denly, with the excretion of an increased quantity of urine, of low specific gravity. From five to ten pints daily is an average quantity, but from thirty to fort)' pints may repre- sent the daily .secretion. The specific gravity of the urine varies from looi to 1004. Albuminuria and gl)'cosuria are rare, although muscle-sugar, or inosite, has at times been found. The excretion of solids, especially of urea and the phosphates, may be increased in some instances. Thirst is inordinate, depending upon the amount of urine passed, but the appetite is rarely excessive. A variety of hysterical and neurasthenic symptoms may appear, but grave constitu- tional symptoms are usually lacking. Prognosis. — Spontaneous cure results in a few instances. In the majority of cases the disease is intractable to treat- ment, although it does not tend to shorten life. The diagnosis should be made from hysterical polyuria, SCURVY. 635 the polyuria of nephritis, and diuresis from dru^s. Dia- betes is to be excluded by the absence of glycosuria. Treatment is not very satisfactory. The most reliable drug seems to be valerian in full doses. Ergot has been recommended, but large doses are usually required. Good results occasionally follow the use of antipyrine in 1 5 -grain doses every four hours. The bromides and arsenic have also been used with benefit. The constant galvanic current may be employed, one pole being applied to the back of the neck, the other pole on the lumbar region. Codeine is said to be of benefit, but the danger of the habit should preclude its use. In severe cases benefit may follow an exclusive diet of meat and hot water. SCURVY (SCORBUTUS). Etiology. — Devastating endemics and epidemics of scurv)^ have occurred from the earliest times among armies, among sailors on long cruises, and among the inhabitants of besieged cities, but the disease is now comparatively rare. Sporadic cases, however, are not infrequent, and the disease attacks young children more frequently than is usually supposed. Two theories as to scurvy are advanced : (i) That it is a dietetic disease. It is known to occur from bad and insuf- ficient food, from lack of variety in food, and from lack of fresh vegetables. Garrod ascribes the disease to lack of potassium salts ; while Ralfe believes that the disease is due to a diminished alkalescence of the blood, from diminu- tion' of vegetable salts, as citrates, oxalates, and lactates, in the food. The development of scurvy is regularly favored by poor hygiene, damp dwellings, lack of sunlight, depre- ciated general health, depressing mental states, and over- exertion. The disease is equally distributed between the two sexes. (2) The infectious theory is that scurvy is due to an unknown micro-organism, and that the dietetic and hygienic causes are only factors predisposing to infection. Patholog-y. — The kidneys, the heart, and the liver show parenchymatous degeneration. The spleen is enlarged and soft. Hemorrhages are found beneath the skin, beneath 636 A/AXCAL OF THE PRAC7/CF. OF MFPlCfXE. the serous and mucous membranes, and in internal orj^ans. Submucous hemorrhages may lead to ulcerations. Symptoms. — The onset of the disease is usually insid- ious, although acute cases have been described. The symp- toms are (i) general and (2) hemorrhagic. 1. Gciural Symptoms. — There are increasing weakness, pallor, and emaciation. Palpitation with feeble and irregular heart-action are common, and a haimic murmur usually de- velops. Mental depression and lassitude become extreme. The temperature is rarely elex'ated, and it may be sub- normal. QEdema of the ankles may be observed. The urine is usually of high color and of high specific gravity, and the phosphates may be increased. Albuminuria is not uncommon. The breath is foul. The bowels are constipated. 2. Hemorrhagic Sympto))is. — The gums become spongy, tender, and bleed readily. These changes, however, may not be observed in infants and in old people. The teeth tend to loosen and to drop out. Ecchymoses and purpuric spots ap- pear in the extremities and spread to the trunk; they may arise .spontaneously or after slight traumatism. Epistaxis is common, but hemorrhages from the lungs, the stomach, the intestines, and the kidnej^s are less frequently observed. Subperiosteal hemorrhages may occur, leading to pain, swelling, and immobility in the affected member, and ne- crosis of bone may follow, or separation of the epiph}'seal cartilage may result in young children. Paraplegia or convulsions may be due to cerebral or meningeal hemor- rhage. Scurvy in children requires separate mention. The fre- quent occurrence of infantile scorbutus in America has been brought to our notice by the able researches of Northrup of New York. The disease occurs in infants, usually between the ninth and fourteenth months, and is almost regularly due to an exclusive diet of proprietary food or of condensed milk. In rare instances it has followed the use of milk too largely diluted. There is no evidence that sterilized or Pasteurized milk can originate the disea.se. SCUR VY. 637 the fjums are Symptoms. — The child becomes anaemic, irritable, and cannot bear to be handled or touched. The .symptom.s of rickets may coexist. The changes almost constant, although they may not be carried to an extreme degree. The most constant symptom of infantile scorbutus is a painful fusiform swelling of the lower extremities, usually of the thigh. The swelling is regularly due to .subperiosteal hemorrhages. The skin over the swelling is usually tense and shiny, is not hot to the touch, and pitting on pressure does not occur. The tender- ness is exquisite and is increased by motion. As the swelling subsides thick- ening of the shaft of the bone may be appreciated. Fracture of the bones and separation of the epiphyses may occur. Pseudo-paralysis is an important symp- . -Fig. 53. — Vertical section tom ; it results from the pain caused of the thigh and leg m a case by a contraction of the muscles pulling "^ '"^^"''^^ scorbutus. The dark areas along the femur upon their tender periosteal attachment, and tibia represent subpen- There may be purpura, ecchymosis, and °^'""' hemorrhage (w. p. J >■ >■ •' Northrup, from a specimen hemorrhage from the various mucous preserved in the museum of membranes. Hematuria may be an theCoUegeofPhys.oansand ■' Surgeons). early symptom of infantile scorbutus. The prognosis is good if proper diet and hygiene can be enforced. Death, however, may result from weakness, from heart failure, or from internal hemorrhages. Treatment. — Sunlight, fresh air, a liberal diet of vege- tables, and orange-juice are sufficient for a cure. Orange- or lemon-juice is almost a specific, and in children milk and orange-juice practically constitute the treatment. The gums may be pencilled with a strong solution of nitrate of silver, or mouth-washes of myrrh or astringents may be used. Ansemia is to be controlled by iron, fresh air, and proper diet. The hemorrhagic symptoms are to be treated on the principles laid down under the consideration of purpura. 638 MA.yr.lL OF THE PRACTICE OF MEDIC/XE. RICKETS (RACHITIS). Etiology. — Rickets is a disease of the first and second years of life, and is rare before the sixth month, although cases of congenital rickets have been described. The dis- ease occurs especially in tenement-house children, from the combined effect of poor air, scanty sunlight, and defective food. The most common of the dietetic errors that may lead to the disease are premature weaning, the use of arti- ficial and proprietary foods, especially those composed mainly of farinaceous and starchy ingredients, irregular feeding, prolonged lactation, and nursing during pregnancy. Children of weak or vicious parentage seem to be predis- posed to the rachitic condition. The disease is more com- mon among negroes and in European cities than among American children. The connection between syphilis and rickets has not been proven satisfactorih-. Rickets is often delayed until the third or fourth year, and then may appear as a sequel to some infectious disease such as measles. The disease known as "acute rickets" is now supposed to be scorbutus. Pathology. — The lesions are seen in their fullest develop- ment in the long bones and in the ribs. The epiphyseal cartilages undergo rapid proliferation, and form thick, soft cushions, which by their projection may present evident bulging. The periosteum strips readily, and subperiosteal tissue is seen to be soft and vascular, resembling spleen- pulp. This subperiosteal thickening is best marked in the middle of the shaft of the bones, giving to them a spindle shape. There is regularly delay or arrest of ossification- proces.ses, and in the bones the organic ingredients may be reduced to two-thirds of their normal proportions. Rachitic bones are regularly soft, spongy, and vascular, especially near the epiphyses and beneath the periosteum. From the bone -softening various deformities arise — the box-like cranium, spinal curvature, deformed pelvis, knock-knee, bow-legs, and the like. In time there occur in the carti- lages and in the subperiosteal tissues reconstructive changes resembling the callus-growth upon fractures, and the bones RfCKK 'PS. 639 themselves become hard. In this way permanent deformi- ties result. The liver and the spleen are usually enlarged in rickets. Symptoms. — Certain prodromal symptoms may precede evident changes in the bones. Gastro-intestinal disorders are usually present, and a peculiar form of diarrhrta limited to the first part of the day, with scanty colorless stools, has been described. There may be attacks of screaming at night, and restlessness with an intermittent temperature and splenic enlargement. Profuse night-sweats about the neck and the back of the head are highly suggestive of incipient rickets. There is often such extreme soreness of the body that the child cries when handled. This diffused soreness is a most suggestive symptom. The child becomes flabby and anaemic, and usually emaciates. There may be " pseudo- paresis," from a combination of muscular weakness and dis- inclination to move on account of the general soreness and tenderness. Nervous symptoms often are present. Attacks of spasm of the larynx are not uncommon. Convulsions, either general or partial, may appear at intervals ; the convulsions may be fatal. Tetany and carpopedal spasms may be observed. The child is irritable and nervous. Symptoms due to changes in the bones are seen first in the ankles, wrists, ribs, and cranium. The epiphyseal ends of the bones are swollen ; the bones are liable to curvature, and " green-stick " fractures may be caused by slight injuries. Curvature of the spine (rachitic scoliosis and kyphosis) and pelvic deformities may ultimately result. The thorax shows noticeable changes. The swellings at the junction of the ribs with their cartilages produce visible nodules, to which the name "rachitic rosary" has been applied. The lateral portions of the thorax are frequently drawn inward at the portions corresponding with the insertion of the diaphragm. " Pigeon-breast " may occur. The changes in the thorax may be so marked as to interfere with proper chest-expan- sion, so that pulmonary affections trifling to the non-ra- chitic may become serious diseases in these children. The clavicles may be distorted or fractured. 640 M-IXiAI. OF THE rKACTICE OF MEDICIA'E. Characteristic chancres become apparent in the cranium. Tlie fontanelles remain unclosed until the second or third year of life, and the occiput may be so thin and yielding that it can bo pressed in like parchment. To this latter condition the name " craniotabcs " has been applied. The head becomes large and square. The occiput is flattened, the biparietal diameter is increased, the frontal bones are broad and prominent. The square, box-like cranium may resemble h\-drocephalus, but in rickets the child is men- tall\' bright. The maxillary bones are small and narrowed, and the vaulting of the roof of the mouth is increased. Dentition is late, and the teeth ma\' be ill formed, small, or irregularly crowded. From the diminished growth of the bones the child may be stunted and dwarfed. The prognosis is good for the disease itself, but many rachitic children fall victims to gastro-intestinal or pulmon- ary disorders. The prognosis should also regard the ulti- mate effect of the thoracic spinal and pelvic deformities. Treatment. — The most important treatment is improve- ment of the general condition by proper diet, good air, sun- shine, and salt-water baths. Carbohydrates should be re- duced to a minimum, the diet consisting of nitrogenous foods and fats, such as red meats, milk, cream, eggs, and fruit. Cod-liver oil is of service in nearly every case. Anae- mia is to be treated by syrup of the iodide of iron, and di- gestive disturbances should receive prompt attention. The child should lie on a hair mattress or pillow, and should not be allowed to walk so long as the bones are soft. Theoreti- cally, preparations of lime, such as calcium lactophosphate, are indicated, but as a matter of experience they do very little good. The drug par excclloicc is phosphorus, which should be given in doses of gr. yi^- three times a day in cod- liver oil. The deformities ultimately require special g}minas- tic exercises for their correction, or orthopajdic treatment. PURPURIC DISEASES. Under this heading are included a number of diseases having one symptom in common — the extravasation of PURPURIC DISEASES. 64 1 blood under the skin. Small hemorrhagic spots are known as " petechiae ;" larger hemorrhages are called " echymoses." Various degrees of intensity are met with in each variety of purpuric disease. The mildest form consists of subcuta- neous hemorrhages alone ; the severer forms include as well hemorrhages from free mucous surfaces and visceral hemor- rhages. Thus purpura may be a trifling, a serious, or even a fatal disease. The following classification may be adopted, although it should be remembered that transitional forms are frequently encountered: i. Symptomatic purpura; 2. Pur- pura rheumatica; 3. Purpura heemorrhagica. Symptomatic Purpura. 1. Toxic cases folloiviiig certain drugs, such as potassium iodide, chloral hydrate, quinine, copaiba, and more rarely ergot, mercury, and belladonna. 2. Severe infectious diseases, such as acute yellow atro- phy of the liver, snake-bites, typhoid fever, pneumonia, and the exanthemata. 3. Severe cow\\x\.\xq.6, jaundice. 4. Profound ancsniia, leukcemia, pseudo-leukmmia, scui"vy, and exhausted and cachectic conditions. 5. Nezv-born children zvitJi congenital syphilitic change in the a^'terial zvalls. 6. Nezv-born children zvitJiout arterial change. This form occurs in i per cent, of children, with a mortality of 75 per cent. 7. Embolic cases with malignant endocarditis and with multiple sarcoma. 8. Neurotic cases, from vaso-motor relaxation or enfeeble- ment of the arterial walls, after fright, deep emotion, hysteria, hypnotism, severe neuralgias, and inflammations of the spinal cord. Symptoms. — Secondary purpura may occur with sub- cutaneous hemorrhages alone, or with free and visceral hemorrhages as well. Arthritic pains may occur as in purpura rheumatica. 4] 642 M.lXr.lL OF rUE PNACnCE OF MEDICINE. Purpura Riieumatica (Peliosis Rheumatica, or Schonlein's Disease). This affection is most common between the ages of twenty and thirty, and is more frequent in males than in females. An antecedent history of rheumatic fever is fre- quently obtained, but the exact relationship of the disease to rheumatism has not been determined satisfactorily. Symptoms. — The disease usually begins with a sore throat, malaise, moderate fever, and pain in the joints. The gums are not affected as in scurvx-. The articular pain and swelling are due to small hemorrhages in and about the joints. More rarely arthritis with serous or hemorrhagic effusion occurs. Purpura precedes or accompanies the articular pains, and there are frequently associated urticarial wheals which may be hemorrhagic, or any of the manifesta- tions of erythema. Hemorrhagic pemphigus may also occur. The urine may contain albumin. The duration of the disease is between ten days and three weeks. Relapses are common, especially if the patient walk too soon. The prognosis is perfectly good. Purpura H.emorrhagica (Morbus Maculosus, or Werlhoff's Dlsease). Under this heading are included cases of purpura having a disposition to bleed from the mucous membranes and into internal viscera. Severe cases of secondary purpura may be thus included. In some cases purpura haemor- rhagica runs a course more like that of an infectious disease. An acute and a subacute form may be described. Acute Purpura H.emorrhac.ica (Fulminating Purpura). — The acute form is more common in young adults, but is a rare condition. I. In some cases the patient is seized with a chill, fever rising to 103° or 104° F., and intense prostration. Purpuric spots rapidly appear, and bleeding occurs from any of the mucous membranes. The patient pa.sses into stupor alter- nating with restlessness and mild delirum, and dies, either from the hemorrhages or in coma, in from one to seven PUR/'lJ/aC DISEASES. 643 days. The prognosis is bad, 75 per cent, of all cases ter- minating fatally. 2. In other cases the visceral hemorrhages are the excit- ing cause of death. Cerebral and meningeal hemorrhages are usually multiple and show no favorite seats of selection. Hemorrhage into the suprarenal capsules may cause death in collapse within a few hours. 3. When the disease attacks pregnant women, miscar- riage and severe post-partum hemorrhage result, and the disease runs a rapid, and usually a fatal, course. Symptoms. — Subacute Purpura H.emorrhagica. — Prodromal symptoms may precede the actual onset ; these symptoms comprise malaise, chilly feelings, and a slight evening rise in temperature. Constitutional Symptoms. — An initial chill may occur, but usually chilly feelings are scattered throughout the course of the disease. The temperature varies from 100° to 104° F., and is higher in severe cases and in children. Prostration is a marked and constant symptom, and usually persists during convalescence. In severe cases the " typhoid con- dition " may be developed, and in this condition the patient may die. The spleen and the liver are usually enlarged during the attack, and a light form of jaundice is not un- common. The blood rapidly shows the changes of anaemia. Hemorrhagic Symptoms. — Purpura develops, the hemor- rhagic areas varying from pin-head size to that of the palm of the hand. Extensive ecchymoses may be followed by gangrene of the skin. Free hemorrhages occur from any of the mucous membranes, the most frequent sources of bleeding being respectively the nose, the kidney, the intes- tines, and the uterus. These hemorrhages may be moder- ate, or they may be so profuse as to induce a fatal anaemia. Internal hemorrhages into the brain and its membranes, the lungs, or the adrenals may occur, but they are not as com- mon as in the acute form. Pain and swelling of the joints, especially of the hands, the feet, and the knees, may be ob- served. The articular symptoms are identical with those seen in peliosis rheumatica. In rare cases ankylosis or arthritis may develop. The gums may be normal, or they 644 .^/.l.yC.lA OJ-- THE PRACTICE OE MEDICLVE. may be swollen and may bleed, but the teeth are not loos- ened as in scurvy. The pathology of the disease is unknown. Letzerich has described a bacillus which grows in the liver and enters the blood-vessels, causing in the smaller vessels hyaline thrombi which so weaken the internal wall as to allow of hemorrhage; but his experiments have not been sufficiently verified. The duration of the disease varies from several days to several weeks, but b\' relapses the disease may be protracted for months or e\'en for years. The prognosis is usually good, but death may result from anaemia, from fatt}- degeneration of the heart, from exhaustion, or from visceral hemorrhages. HoioclCs Disease. — A severe form of subacute purpura haemorrhagica has been described by Henoch and bears his name. This form occurs especially in children between the ninth and twelfth years, although it has occurred between the ages of three and forty-six. Males are affected five times as frequently as females. There is a prodromal period with malaise, slight fever, and pain in the joints. The onset is characterized by purpura, pain and swelling of the joints, and severe gastro-intestinal s}^mptoms. These latter symp- toms consist of abdominal tenderness with a colicky pain of great severit\\ The abdomen is rigid and retracted. Rectal tenesmus occurs, with bloody stools. Vomiting is severe, and the vomited matters may contain blood. These gastro-intestinal symptoms seem to be due to hemorrhages in the submucosa or to hemorrhagic infarcts of the small blood-vessels of the intestinal wall. Intestinal ulceration, perforation, and peritonitis ma\' result. The spleen is enlarged. The temperature is slightly raised. Haematuria occurs in one-fifth of the cases. These symptoms continue for a few days and then subside, but relapses are the rule^ and as many as twenty subsequent attacks have been de- scribed. The nature of the disease is unknown. The prognosis is fairly good, being better in children (5 per cent, mortality) than in adults, of whom 25 per cent, die. IlyKMOPIIIfJA. 645 Treatment of Purpuric Diseases. In the secondary purpuras the treatment should be directed toward the excitini:^ causes. In the other forms the treatment is supporting and symptomatic. Arsenic in full doses is at times of service. Iron is indicated for anaemic conditions, but it should be withheld during the acute attacks, as it seems to increase the liability to hemorrhage. In all cases fresh air, good food, and a tonic supporting treatment are indicated. The salicylates are at times of service in peliosis rheumatica, but in sorne cases they seem useless. For the hemorrhages various drugs may be used, but no one hemostatic can be relied upon. Among the drugs used are aromatic sulphuric acid, turpentine, acetate of lead, and gallic acid. Epistaxis may require plugging of the nares. Menorrhagia may be controlled by firm tamponage. In acute purpura free stimulation is necessary, and in case of profuse hemorrhage rectal or hypodermic injections of sterilized saline solutions should be employed. In subacute purpura much benefit may be derived from a change of climate, inland places where the air is dry and bracing being preferable. HEMOPHILIA. Etiolog-y, — By " haemophilia " is meant a constitutional inherited tendency to uncontrollable bleeding. The disease appears in males in the proportion of 13 : i. Females rarely suffer, although the female members of a bleeding family transmit the tendency to their male offspring. Paternal transmission is exceedingly rare. In rare instances the tendency is acquired. Pathology. — The exact nature of the disease is unknown. An unusual thinness of the arterial walls has been observed, but this condition is inconstant. The joints may be found to be the seat of hemorrhages, and inflammation of the syno- vial capsule has been described in a few instances. The symptoms generally appear in early childhood, al- though excessive bleeding does not usually accompany the 646 MAXL'AI. OF THE PRACTICE OF MEDICIXE. cutting: of tlie umbilical cord. The symptoms consist of licmorrhages and inflammation of the joints. The hemor- rhages may be spontaneous or nia)- follow traumatism. Cuts, or abrasions bleed profuseK', and continuous capillary oozing may continue for da)-s after the extraction of teeth. Epistaxis is couunonly profuse. These hemorrhages weaken the patient and may at any time prove fatal. Subcutaneous hemorrhages evince themselves as purpuric spots, ecchy- moses, and hrematomata. Large ecchymoses may be suc- ceeded by gangrene. In the female menstruation may be profuse, but parturition is rarely complicated by hemor- rhage. The joint-symptoms usually occur after exposure to cold, to which hajmophilic patients are exceedingly sus- ceptible. Pain and swelling occur, especially in the larger joints, and the condition may closely resemble rheumatism. Prognosis. — Haemophilia is a contant menace to life. Half the cases die before the seventh year, and only one- eighth reach majority. The younger the patient the more serious the prognosis. The prognosis is better in girls than in boys. Although a serious condition, haemophilia is not inconsistent, in some instances, with a prolonged and busy life. Treatment. — Sons born to female members of bleeding families should be protected from external injuries, and the system should be fortified by fresh air and general hygiene. Surgical operations, however slight, should be resorted to only when absolutely indicated, and every appliance should be at hand to check hemorrhage. The hemorrhages, when they occur, should be treated by compression and by the application of the well-known haemostatic remedies. For the joint-affections rest and soothing applications are in- dicated. VIL DISEASES OF THE BLOOD AND THE LYMPHATIC GLANDS, ANEMIA. Anemia is a generic name applied to deficiencies in the quality or quantity of the blood or of its important constitu- ents. The quantity of the blood may be diminished (oligae- mia), or the number of the red corpuscles may alone be diminished (oligocythasmia). In other cases such important constituents as albumin or haemoglobin may suffer diminu- tion (oligochromaemia). The following classification of anaemia is generally adopted: i. Secondary anaemia; 2. Chlorosis; 3. Pernicious anaemia. Secondary Anemia. Etiology. — The causes of secondary anaemia have been conveniently classified by Osier as follows : .1. AncBmia from lievion'liage. 2. Loiig-contimicd drain on tJie albiiniinons materials of the blood, as in chronic suppuration, Bright's disease, prolonged lactation, or rapid-growing tumors, as cancer. 3. AncEniia from inaniiioji and defective nutrition, as from insufficient or improper food, digestive disturbances causing malassimilation, improper modes of life, and intestinal parasites. 4. Toxic ancemia results from the use of certain drugs, as lead, mercury, arsenic, salicylic acid, or from organic poison- ing, as in syphilis, malaria, infectious diseases, tuberculosis, and pyrexia. Pathology. — In secondary anaemia the number of the red corpuscles and the percentage of haemoglobin are pro- portionately diminished. In severe forms some of the cells may be unnaturally small (microcytes) or of irregular sizes 647 648 M.lXr.lL OF THE PKACTJCE OF MEDICINE. (poikilocytcs). Nucleated red cells arc always found, al- though their number may be small in the mildest grades of anivmia. In an;emia after hemorrhage a primary in- crease in the number of the white corpuscles is usually noticed. The restoration of the watery, saline, and albu- minous materials rapidly occurs by absorption, but the regeneration of the red cells is a slower process. Restora- tion of the normal percentage of haemoglobin is the last process of regeneration. General Symptomatology of Anaemia. — i. Pallor oi\}i^Q skin and the mucous membranes. It must be remembered that not all ana.»mic patients are pale, and that not all pale patients are anaemic. Ana.'mic pallor is best appreciated by the colorless appearance of the ears. In suspected cases of anaemia more reliance should be placed upon the results obtained by counting the red blood-cells and estimating the percentage of haemoglobin than upon the appearance of the patient. 2. Cardiac Symptoms. — The pulse is rapid and usually of low tension. Occasionally a high-tension pulse is en- countered. The heart-action is irritable. Palpitation and syncopal attacks are common. In acute anaemia death from syncope may occur. The heart, being supplied with blood ' of poor quality, tends to become fatty and loses its muscular tone. Mild grades of dilatation are common. A systolic haemic murmur ma\' be heard over the pulmonary area and is transmitted upward. This murmur comes and goes, and is often appreciated only while the patient lies down. The origin of the anaemic murmur is obscure. There may be heard at the apex a systolic murmur transmitted to the axilla. This murmur arises from relati\'e mitral insufficienc}'- occasioned by poor muscular contraction, or from slight dilatation of the left ventricle. A continuous venous hum (the bruit de diablc) may be heard over the jugular vein on the right side of the neck. In extreme anaemia there is a tendency to thrombus-formation, especially in the femoral vein. Unless thrombus occur in the cerebral sinuses, the condition is not serious. 3. Dyspeptic syuiptoins are rarely absent. The tongue is AN/KMFA. 649 flabby and coated. The bowels are constipated ; the appe- tite is irregular and capricious, 4. Piilinonary Symptoms. — Dyspncea on exertion is in proportion to the extent of the anaemia and the rapidity of its development. In acute anaemia from hemorrhage there may be " air-hunger." A slight cough without expec- toration not infrequently occurs. 5. Cerebral Symptoms. — There is regularly mental apathy and loss of the power of concentrating the mind. Spots be- fore the eyes, buzzing noises in the ears, and vertigo indicate cerebral anaemia, whether of general or local origin. Head- aches, usually more marked in the top of the head and increased by standing, are frequent, but other forms of headache due to digestive disturbances are commonly en- countered. 6. There are body-weakness and lack of endurance. The inability to exercise is often aggravated by the dyspnoea thus induced. Slight oedema of the ankles or the legs is not uncommon. An irregular low temperature may be noted in severe cases. Emaciation does not belong to simple anaemia. If present, some primal cause, as tuberculosis or cancer, should be suspected. 7. Menstruation is often affected. There may be menor- rhagia, but, as a rule, the menses become scanty and light- colored or may even cease. Amenorrhoea is of no signifi- cance and demands no special treatment, as it is nature's method of preventing further drains upon the already im- poverished blood. 8. Nervous and liysterical symptoms are usually present. The patient becomes irritable and restless, sleepless by night, drowsy by day, and may complain of various nervous symptoms, such as hot and cold flashes, irregular pains, and curious sensations in the skin. The diagnosis of anaemia is rendered positive by the results of blood-examination. For methods of counting the corpuscles and of calculating the percentage of haemo- globin the reader is referred to books on clinical diagnosis. The diaenosis should never rest with the detection of 650 MAXr.lL c'/ JJJK rK.ICT/CE OF MEDICINE. anaemia, but must extend to the discovery of the cause, to which the blood-condition is secondar\-. Treatment. — The primal cause, if possible, should be re- moved by correcting improper modes of life and controlling digestive errors and constipation. The \alue of fre.-;h air and sunlight cannot be over-estimated, but it is equally im- portant not to over-fatigue annemic patients by keeping them walking or exercising all day, as is sometimes done. The specific drug for anaemia is iron. The special prep- aration used should not be such as to cause constipation or headache. The preparations recommended are Blaud's pill (gr. V, t. i. d.), tartrate of iron and potassium in lo-grain doses in water and glycerin (Price's English glycerin should be used), citrate of iron and quinine, the pyrophosphate of iron, and the liquor ferro-mangans of Gude or of Dietrich. During the administration of iron the bowels must be moved daily, preferably by salines given in the morning. Should iron not be well borne, arsenic or small doses of bichloride of mercurx' or of binoxide of manganese may be given. In severe cases rest in bed at the beginning of the treat- ment is to be recommended. Chlorosis. Etiolog-y and Symptoms. — This condition is common to women between the ages of fourteen and twenty-four. More rarely the affection is encountered in males at the age of puberty. Blondes are more frequently attacked than bru- nettes. The disease is especially frequent in over-worked factory-girls who live amid poor hygienic surroundings and who work hard upon insufficient or improper food ; but cases among the upper classes are not unconmion. Young female immigrants are often attacked soon after their arrival in America. There seems to be some connection between chlorosis and puberty, as in many cases there is the history of precocious development and the early appearance of the menses ; in other cases the menses may be retarded. Sir Andrew Clark attributed chlorosis to a blood-poisoning from the absorption of toxic products from a constipated bowel. In some cases it would seem that chlorosis had a ANyJiMIA. 65 1 primary nervous orig'in. Mothers chlorotic in their youth are apt to beget clilorotic daughters. In a few instances chlorosis seems to be due to a congenital lack of develop- ment of the arterial system (Virchow). Synonyms : Chloro- ansemia ; Green sickness. Pathology. — The essential blood-change consists in the reduction of haemoglobin. In average cases the haemoglobin falls to 40 per cent, in severe cases to 20 per cent. The number of the red cells may be normal, although, as a rule, they are considerably reduced, but never to the same pro- portional extent as the haemoglobin. In a series of 63 cases reported by Osier the average reduction in the num- ber of red cells was 74 per cent. ; the average quantity of the haemoglobin was 42.3 per cent. Poikilocytes, micro- cytes, and a small number of nucleated red blood-cells may be seen. Symptoms. — Anaemic symptoms are constant, especially those of nervous and dyspeptic origin. Amenorrhoea is most commonly observed. The color of the skin is not that of anaemia, but is a pale greenish-yellow that is quite characteristic. There has been described a gastric type of chlorosis with nausea, vomiting, and epigastric pain as prominent symptoms. There may even be vomiting of blood, so that the case may resemble one of gastric ulcer, The diagnosis in these cases from gastric ulcer is often one of great difficulty, and is rendered more uncertain by the fact that gastric ulcer not uncommonly occurs in chlorotic women. The appetite is apt to be capricious and is even perverted. Constipation is usually constant and obstinate. Emaciation does not occur. CEdema of the ankles may be noticed, and there may be an irregular fever. The cardiac symp- toms of anaemia are usually well marked. The prognosis is good for recovery, but relapses are common, and by them the course of the disease may be prolonged. Relapses may occur even during the third decade of life. Treatment is usually followed by brilliant results if the patient faithfully carries out the directions. Iron is a 652 MAXLAL OF THE PRACTICE OF iVEDICIXE. specific, and under its use the haenio<;"lobin increases from 5 to 10 per cent, eacli week. The patient rapidly improves under its use, and often feels capable of discontinuincj the treatment, but it is important to continue treatment until the hjemoglobin is above 90 per cent., as otherwise the ]:)atent is apt to relapse. The cure in average cases is obtained by about three months" treatment. Fresh air, good nourishing food, improved hygiene, and the daily use of laxatives, if needed, are important adjuvants to the medicinal treatment. In severe cases a short rest in bed at the beginning of the treatment is often of incalcula- ble service. In the chlorosis of young immigrants per- oxide of manganese or permanganate of potassium in 2- grain doses three times a day may be advantageously com- bined with the iron. Pernicious Anemia. Synonyms. — Essential anaemia ; Idiopathic anaemia. Under the heading "pernicious anaemia" are included cases of anaemia running a progressive course and not due to any evident cause. Severe secondary anaemia, resem- bling the pernicious form in its clinical features, may follow atrophy of the stomach and certam intestinal parasites, especially the bothriocephalus latus and the ankylostoma duodenale, but it is doubtful whether these secondary cases are to be considered as examples of the true pernicious ana:;mia. Etiology. — The disease is one of adult life; more rarely it attacks children. Both sexes are equally affected. In some cases there is a history of pregnancy or of parturition ; in other cases no assignable cause for the an;emia can be found. Pathology. — The essential lesions are found in the blood, the liver, and the bone-marrow. The blood is diminished in quantity and is ])ale and watery. The number of the red blood-corpuscles is greatly reduced, in some instances to as low as one-tenth or less of their normal number (500,000 to the cubic millimeter is not an uncommon reduction ; in one instance the number was ANyKMJA. 653 reduced from the normal 5,000,000 to 143,000). The per- centage of haemoglobin may be reduced in proportion to the reduction in the number of the red cells, or it may even be relatively increased. It is pathognomonic of pernicious anaemia that each red corpuscle remaining in the blood carries Its normal, or even more than its normal, load of haemoglobin. Large and small red corpuscles are seen in the freshly drawn blood (" megalocytes " and " micro- cytes "), and the corpuscles may be deformed, flask-shaped, and distorted (" poikilocytes "). Nucleated red cells are constantly present, and, if present in large numbers, are dis- tinctive only of pernicious anaemia and of the last stages of leukaemia. In dried and stained specimens of blood two varieties of nucleated cells are seen — one normal in size, with a sharply defined nucleus (" normoblast "), and others of large size, with large, poorly-stained nuclei (" giganto- blasts "). The leucocytes are generally diminished in number. The liver may be enlarged and fatty. The peripheral zones of the acini are pigmented by iron — a condition, in all probability, characteristic of pernicious anaemia. The boiie-viarrozv shows an increase of lymphoid and nu- cleated red cells, and resembles the red marrow of the child. There is found fatty degeneration of the heart, the kidneys, and the intima of the smaller blood-vessels. The spleen may be normal or slightly enlarged, and may be pigmented by iron. The lymphatic glands may resemble spleen-pulp in consistency and color. Hemorrhages are usually found under the skin and the mucous and serous membranes. Two theories of pernicious anaemia have been advanced : 1. Hunter maintains that, by reason of faulty gastro- intestinal digestion, toxic products gain access to the liver and cause extensive blood-destniction, with the deposit of pigment in the liver and the passage of urobilin by the kidneys. Hunter's views, although not absolutely proven, are those generally adopted. 2. The second theory is that there is an increased ten- 654 M.lXi'AL OF THE J' K AC TICK OF MEDICIXE. derness or vulnerability of the blood-corpuscles, from faulty processes in blood-manufacture. The symptoms are those of progressive anaemia. The color of the patient is a peculiar waxy white or pale lemon. The fat is usually well preserved, and the patient presents a bloated appearance. Syncopal attacks are frequent, and fatal s\-ncope, from fatty degeneration of the heart, may occur. In some cases capillary pulsation and visible pulsation of the arteries may be as well marked as in aortic regurgitation. Haimic murmurs and slight dilatation of the left ventricle are almost constant. An irregular temperature develops from time to time — usually iOO° or ioi° F., more rarely from 102° to 104° F. At other times the temperature may be subnormal. The urine is suggestive of the disease ; it is of low specific gravity and of high color, and it contains an excess of urobilin. The pigmentation of the urine, however, is not constant. Gastro-intestinal symptoms of anaemia are common ; diarrhoea, however, may not be infrequent. Dropsical swelling of the ankles attends the later stages of the disease, and the dropsy may become general. The tendency to hemorrhage is seen in purpuric spots and in submucous ecchymoses. Retinal hemorrhage is not uncom- mon. Free hemorrhages from mucous surfaces, with the exception of epistaxis, are rather infrequent. Prognosis. — The course of the disease is progressive, with periods of temporary improvement, but cases of apparent recovery are not uncommon since the inaugura- tion of the arsenic treatment. Death is usually preceded by a prolonged state of prostration, stupor, and mild delirium with irregular fever. Diagnosis. — According to Osier, the following are the essential points : (i) The severe grade of reduction in the number of the red cells ; (2) their relative richness in hiemoglobin ; (3) the presence of many megalocytes and gigantoblasts ; (4) the absence of any cause for secondary anaemia; (5) occasional febrile disturbances; (6) the yellow tint of the skin ; (7) hemorrhages, particularly retinal ; (8) a progressive course and the inefficiency of treatment. LK UCOC YTOSIS. 655 Treatment. — Iron in pernicious anaemia seems to be worthless. The main reliance must be placed on arsenic in full doses, given to the point of tolerance. Osier's plan is to give Fowler's solution in 3-minim doses after meals, increased to 5 minims at the end of the first week, to 10 minims at the end of the second week, and so on until the patient is taking 20 or 25 minims after each meal. Toxic symptoms are rare. Should they occur, the drug is to be discontinued until the poisoning symptoms cease, and is then to be resumed at the dose at which the patient left off In some cases the addition of phosphorus seems to be beneficial. Iron may be given if arsenic disagrees, but not much is to be expected from it. Rest in bed from time to time is important in conserving the patient's strength. Prolonged residence in a warm inland climate has been recommended, but the climatic treatment is often disap- pointing. The diet should be light and nutritious. Mas- sage is sometimes found to be beneficial. Delafield describes a clinical set of cases midway between simple and pernicious anaemia, occurring in those past middle life. The etiology of these cases is obscure. The blood shows the changes only of secondary anaemia. The symptoms are those of a fairly marked anaemia, but im- provement under treatment reaches only to a certain degree, and the patients relapse as soon as treatment is discon- tinued. Absolute recovery does not occur. In this class of cases arsenic seems to be of no use. Iron is the drug on which reliance is to be placed, but dietetic and hygienic treatment seems to be of almost equal service. LBUCOCYTOSIS. By the term " leucocytosis " is meant a temporary increase in the number of the white blood-corpuscles ; this is a con- dition entirely distinct from the disease leukaemia. Nor- mally the ratio of white to red corpuscles is i : 500, but in leucocytosis the proportion may be i : 150 or even i : 50. Physiological leucocytosis occurs during pregnancy and after hearty eating. Inflaviniatory leucocytosis occurs in acute infectious dis- 656 MAXLAL OF THE PRACTICE OF MEDICINE. eases attended with local inflammaton- reaction. It appears most commonly with pneumonia, diphtheria, and suppura- tive processes, and it is said to be a sign of good prognostic value.- C^r/riV/'/irleucocytosis occurs in the cachexias of malignant tumors. Relative leucocytosis occurs in anaemia, where, from diminution in the number of the red corpuscles, the white cells appear in an increased ratio, although they are not actuall\- increased in number. LEUKEMIA (LEUCOCYTH^MIA). Etiology. — The cause of the disease is obscure. There occur acute cases which suggest bacterial infection, but upon this point definite knowledge is lacking. In about one-third of the cases there is the history of malarial poison- ing. Syphilis seems to possess some obscure relation to the disease. Leukaemia may occur at any age, but it is most common in middle life. Males are affected twice as frequently as females. In women the disease often appears at the time of the climacteric or after pregnancy. Pathology. — The essential lesions are found in the blood, the spleen, the lymphatic glands, and the bone-marrow. The blood-changes are constant. According to the relative intensity of the changes in the other structures mentioned, splenic (or lienteric), lymphatic, and myelogenous forms have been described. As true myelogenous leukemia is so very rare, the disease is usually described under two principal forms, (i) splenic-myelogenous or lieno-myelogenous, and (2) lymphatic leukaemia. Blooei-cha?iges consist in the increased number of white cells, their proportion to the red corpuscles rising to i : 20 or I : 5, or the cells even being in equal proportions. The increased proportion is greater in the splenic-myelogenous form than in lymphatic leukaemia. The blood is pale and watery and may be whitish or brownish-red in color. The red cells are diminished, but not to an excessive degree; haemoglobin is reduced to a somewhat greater proportion. LEUKyEMIA. 657 Nucleated red cells may be seen. Charcot's octahedral crystals separate when blood-slides are kept for some time. A more detailed account of the changes of the white cells is deemed advisable. • In the normal blood, Ehrlich describes the following varieties of white cells : 1. Lyinphocytes,^\Vi'3\\, equal in size to a red corpuscle. The nucleus is large, round, stains deeply, and is surrounded by a narrow rim of non-granular protoplasm. 2. Large ino7tomidear leucocytes, several times larger than the red cells. The nucleus is oval or elliptical and is surrounded by a wide margin of non- granular protoplasm. 3. A transition form resembling the preceding, but the nucleus is inden- tated. 4. Polymiclear leucocytes, smaller than the large mononuclear forms, with long, twisted nuclei which stain deeply. The protoplasm is granular and does not stain easily. To these cells, owing to peculiarities of staining, the name " neutrophiles " is given. 5. Cells like the preceding, but the protoplasm contains coarse granules which stain deeply with eosin, hence the name " eosinophiles." In normal blood these varieties of white cells bear a fixed proportion to each other — the lymphocytes, from 15 to 30 per cent., the polynuclear leuco- cytes, from 65 to 80 per cent., the mononuclear and transitional forms, 6 per cent., the eosinophiles, from 2 to 4 per cent. According to Osier, the charac- ter of the cells in splenic-myelogenous leukaemia differs materially from that in the lymphatic form. In splenic-myelogenous leukcemia the lymphocytes are rarely, if at all, in- creased ; the eosinophiles are present in normal or increased proportion, so that there is a great total increase. The polynuclear neutrophiles are usually relatively diminished. In this form there appears a new variety of cell, de- rived from the marrow of the bones, and known as the myelocyte. These cells are large and contain a single nucleus, but the protoplasm is finely granular and does not stain well with acid coloring matters, resembling in this regard the neutrophiles. In lymphatic leukcemia the ratio of white to red corpuscles rarely exceeds 1 : 10. The increased number of colorless corpuscles is due to the lympho- cytes, which may form 93 per cent, of the total number of white cells. Eosin- ophiles and red nucleated cells are rare, and myelocytes do not occur. In mixed forms of leukaemia the blood-condition may deviate from either of these classical types. The accurate study of stained blood-specimens is highly important for diag- nostic purposes in obscure cases. The spleen is usually much increased in size, weighing from two to eighteen and a half pounds. The enlargement is due to a true hypertrophy of all its constituents. In acute cases the spleen is soft and inay even rupture. In pro- 42 658 MAXi'AL OF THE PKACJ/CE OF MEDICIXE. tracted cases the organ becomes firmer and the capsule is often thickened and adherent to surrounding structures. On section hemorrhages ma)' be fountl in its substance, and there may be seen grayish-white areas which consist of aggregations of Ij'mphoid cells. The lesions in the Iwnc-iiinrnnv are usualK' associated with the splenic enlargement. A pure form of medullary or myelogenous leukaemia is exceedingly rare. The marrow, which is yellowish or even purulent in appearance, contains many lymphoid and nucleated red blood-cells. The h'liip/iatic g/aiids may be involved alone (lymphatic leukaemia) or in connection with the splenic and medullary lesions. The histological change consists of hyperplasia of the glandular tissue. The glands are enlarged and soft, but are freely movable and do not mat together. In many cases the glands remain perfectly normal. The liver is usually increased in size, from a diffuse infiltration of Ij'mphoid cells. New growths composed of lymphoid cells may be found in various parts of the body, especially in the tonsils, intestinal glands, liver, kidney, retina, lungs, and pleura. The hem- orrhagic tendency of the disease is shown by hemorrhages in various parts of the body, especially under the skin, under the serous and mucous membranes, and in the retina. Symptoms. — i. There are regularly present anaemic symptoms resembling those of pernicious anaemia, so that a detailed description is not necessary. Nervous symptoms, however, are not usually marked. CEdema of the feet and general dropsy are commonly present. 2. Hemorrhagic symptoms may be slight or may lead to a fatal issue. Hemorrhages may occur from any of the mucous surfaces or into the retina, while death may result from cerebral hemorrhages. The most frequent hemorrhages arise from the nose, stomach, intestines, lungs, and kidney. 3. There may be an irregular fever as in pernicious anaemia. Rare cases of acute leukaemia are encountered, in which a continuous temperature of 103° or 104° F. is observed. These acute cases may be mistaken for typhoid fever unless blood-examination be made. 4. Splenic tumor is readily appreciated by palpation. leuk./[<:mia. I'l.A IK 22. -/ Blood stained with Ehrlich's "triple stain " of acid fuchsin, methyl-green, and orange-G; drawn with the camera lucida from normal hlood (Osier, in American Text-Book of the Theory and Practice of Medicine) : a, red corpuscles ; 6, lymphocytes ; r, large mono- nuclear leucocytes; d, transitional forms; e, neutrophilic leucocytes with polymorphous nuclei fpolynuclear neutrophiles) ;/", eosinophilic leucocytes. LEUIOJ'.MIA. 659 The spleen may extend to or beyond the umbilicus. The free edge is sharp and notched. In acute cases there may be pain and tenderness over the spleen, so that, in connection with its enlargement, abscess of the organ may be suggested. Rupture of the spleen in acute ca.ses has occurred. In pro- tracted cases no symptoms are caused by the splenic tumor except those due to its increased size and weight. 5. Changes in the marrow rarely give rise to clinical symptoms. Exceptionally there is pain in the bones. If the sternum be affected, it may be tender on pressure. 6. Lymphatic enlargements do not occur in all cases. More rarely the lymph-glands are affected alone, with the changes in the blood ; to this form the term " lymphatic leukaemia " has been given. These cases usually run a rapid course with fever or hemorrhages. The glands enlarge, but seldom present the same large bunches as in Hodgkin's dis- ease. Pain is rare, the glands usually giving rise to no symptoms except those caused by pressure. The super- ficial glands are usually first involved, next in frequency the retroperitoneal and mesenteric glands. Enlargement of the abdominal glands may often be appreciated by pal- pation. 7. Leukaemic new growths may be discovered in the tonsils, retina, or liver. Leukaemic deposits in the liver may give the symptoms of peritonitis. 8. In males persistent priapism may occur ; it may be the first symptom of the disease. 9. The urine may be albuminous; uric acid is usually increased. The diagnosis is to be made upon the results of blood- examination. Mild degrees of leukaemia may be differen- tiated from excessive leucocytosis by the fact that in the latter the polynuclear neutrophils are alone increased. The diagnosis from Hodgkin's disease can readily be made by the blood-examination. Prognosis. — The course of the disease is progressive,, although through appropriate treatment there may occur periods of temporary improvement. Acute cases terminate fatally within a few months ; the less rapid forms terminate 6CxD M.l.VL'AL OF THE PRACTICE OF MEDJCLXE. at the expiration of one or two years. Death may be due to anxmia, exhaustion, fatt\' degeneration of the heart, or hemorrhage. The treatment is practically that of pernicious anaemia. Iron may be given, but any great amount of improvement from its use is not to be expected. Quinine should be given to malarial cases, and potassium iodide and mercury should be ordered if the patient be syphilitic. Arsenic is the drug usually employed, and its use is frequently fol- lowed by brilliant although temporary results ; to be of service, however, the drug must be pushed with due precau- tion vmtil large doses are reached. During treatment by arsenic the number of the white cells may be much reduced. Splenic remedies have been tried, but they are not serviceable. Faradism, injections of ergotine and of qui- nine, and the use of piperin and of oil of eucalyptus have been recommended. Extirpation of the spleen has been performed, with a mortality of 95 per cent. Surgical opera- tions are extremely dangerous in leukaemia, owing to the liability of uncontrollable hemorrhage. PSEUDO-LEUKEMIA. Etiology and Sjmonynis. — The cause of pseudo-leu- kaemia is obscure, but of late the view is gaining ground that the condition is an infectious process, and that pseudo- leuktxmia really should be assigned to the group of infec- tious tumors. The disease is more frequent in males than in females, in the proportion of 3 : i. It occurs at any age, but two-thirds of the cases are observed in those under fort}' years. In some cases the development of the disease has been preceded by inflammatory conditions of any group of lymphatic glands. Synonyms : Hodgkin's disease ; Lymphatic anaemia; Adenia; General lymphadenoma ; Pseudo-lcucoc)-thajmia ; Malignant lympho-sarcoma. Pathology. — The lymphatic glands undergo enlargement. Histologically the process consists of an increase of the lymphoid cells, with or without increase of the reticulum. At first the glands are soft and elastic ; they may become firm and hard. Isolated and freely movable at first, the PSE UDO-L/C UA'AiM/A. 66l glands tend finally to become fused together to form large lobulated tumors surrounded by a fibrous capsule. The new growth of lymphatic tissue may even extend beyond the capsule to involve neighboring structures. Suppuration of the superficial glands is not uncommon. The glands are usually affected in the following order of frequency ; the cervical, axillary, inguinal, mediastinal, retroperitoneal, and mesenteric groups. The spleen is enlarged in three-fourths of the cases, but the increase is rarely so marked as in leukaemia ; in one- half the cases grayish-white tumors are found in its sub- stance ; they consist of lymphoid cells and a connective- tissue reticulum. The lymphoid cells of the bone-marrow may be increased in number, often to such an extent that the marrow resembles pus in its appearance. Secondary growths of lympJiatic tissue may occur in any part of the body, especially in the tonsils, in the lymphoid tissue at the base of the tongue, in the liver, spleen, kidneys, lungs, pleura (causing fibrino-serous effusion), spinal cord (causing paraplegia), and in the skin. The ovaries, testicles, and dura mater may also be the seat of new lymphatic growths. The blood shows the regular changes of anaemia. Poikilocytes and nucleated red cells are not present to any considerable extent. Lciicocytosis does not normally occur in pseudo-leukaemia, but cases occur, occupying a middle ground between Hodgkin's disease and lymphatic leu- kaemia, in which the white cells are increased in number and in which the lesions of a pure lymphatic leukaemia may ultimately develop. Some of these cases occur in children under two years of age. Symptoms are due (i) to anaemia, (2) to the enlargement of the lymphatic glands, and (3) to the secondary lymphatic growths. I. The ancemia gives rise to the regular symptoms of that condition. The pallor, hemorrhages, oedema, dyspnoea, and the cardiac and cerebral symptoms are like those seen in pernicious anaemia, and need not be again described. Pigmentation of the urine, however, does not occur in 66: M.iXr.lL OF TJIK PRACTICE OJ- M EJ^JCIAE. Hodgkin's disease. The anaemic symptoms may precede or follow those due to the glandular enlargements. The temperature is usually irregularly elevated even during the earlier stages of the disease. The fever may be continuous or recurrent. Remarkable ague-like paroxysms may occur, separated by periods of normal temperature. The duration of the febrile paroxysms ma}^ be weeks or months. nJular swellings in Hodgkin's disease. 2. The glaiuhilar szuellings are frequently the first symp- toms noticed. The glands on one side may be involved alone, but later the swellings become symmetrical. At first it may be impossible to exclude syphilitic or tubercular dis- ease of the glands; but later, when large bunched tumors form, the diagnosis is usually easy. Marked variations in PSEUDO-LEUK'/KMIA. 663 the size of the glands may be observed from time to time. In the latter stages the skin may be involved and ulcerated. Enlarged retroperitoneal glands may reach such a size that large abdominal tumors are formed. Besides the disfigure- ment caused by the glandular tumors, important symptoms may arise from their pressure on neighboring structures. The cervical glands may press upon the trachea and may necessitate tracheotomy. Enlargement of the mediastinal glands may cause pressure upon the trachea, oesophagus, bronchi, vena cava, and aorta. Alarming cardiac disturbance may arise from compression of the vagus. The enlarge- ment of the abdominal glands may cause abdominal pain ; they may press upon the portal vein (causing acites and portal obstruction) or upon the common bile-duct (causing persistent obstructive jaundice). Pressure upon the adrenals or upon the splanchnic nerves may be followed by bronzing of the skin. The axillary glands may press upon the brachial or axillary veins (causing swelling of the arm) or upon the brachial plexus (causing numbness, tingling, pain along the course of the nerves, or paralysis). The enlarged glands in the pelvic and iliac regions may cause sciatic pain and swelling of the leg. Lymphatic growths in the liver and the spleen are regularly followed by an increase in size of these organs. 3. New lymphatic growths in other parts are followed by the regular symptoms of small tumors in the affected struc- tures. The diagnosis from leukaemia is to be made by the blood-examination, there being in Hodgkin's disease no in- crease in the number of the white cells. The occasional merging of pseudo-leukaemia into lymphatic leukaemia should not, however, be forgotten. The diagnosis from tubercular adenitis is usually rendered easy by the presence of other foci of tubercular disease in the latter condition. Tubercular adenitis usually involves the submaxillary glands, whereas in Hodgkin's disease the glands along the borders of the sterno-mastoid muscle are the glands first to be involved. Suppuration is common to tubercular glands, uncommon to those of Hodgkin's disease. 664 M.iXr.lL OF THE Ph\lC77CJ: (.>/■ MKDICIXE. Prognosis. — With rare exceptions Hodgkin's disease ultimately ends fatally. The course of the disease is fre- .quently marked, however, b\^ more or less prolonged periods of improvement. Acute cases may run a course of several months ; the more protracted cases may extend over two or three years. Death results from debility and anaemia, from hemorrhage, from the mechanical pressure of the lymphatic tumors, or from intercurrent disease. Treatment is mainly that of pernicious anaemia. Arsenic is to be given until the point of tolerance is reached. Phos- phorus has also been recommended, but it is of doubtful utility. The internal use of Lugol's solution of iodine in from 5- to lo-drop doses after meals has been recommended. In early cases, in which only a few glands are enlarged, these glands may^ be removed by surgical operation. Re- moval of the glands may also be resorted to in case of severe pressure-symptoms. ADDISON'S DISEASE. Etiology. — Addison's disease is more frequent in men than in women, and usually occurs in middle life, although no age is exempt. About the causation of the disease there is much doubt. Two theories exist: (i) That the disease is due to loss of function of the suprarenal capsules. (2) That the disease is due to irritation of the abdominal sympathetic plexus, usually owing to disease of the nerves, the ganglia, or the adrenals. In other cases a functional nerve-disturbance must be supposed to exist. Pathology. — In 88 per cent, of all cases the adrenals are found diseased. In the vast majority of cases the lesion in the adrenals is tubercular, the capsules being converted into masses of fibrous tissue and cheesy matter. In other cases the adrenals are found atrophied, absent, or the seat of malignant tumors. Against the theory that Addison's disease is due to loss of function of the suprarenal capsules through disease are the following facts: (i) In 12 per cent, of all cases of Addison's disease the adrenals are found to be normal. (2) Every variety of adrenal lesion has occurred without giving rise to the symptoms of Addison's ADJJ/SOjWS JJfSJ'lAS/'.. 66$ disease. Owing to improved technique in nerve-staining, there are found an increasing number of cases of Addison's disease in which lesions are found in the sympathetic nerve- structures in the abdomen. Of the 30 cases most recently examined, 27 showed sympathetic nerve-lesions. The ordinary lesions found in the ganglia and nerve-fibres consist of degeneration, congestion, hemorrhages, ^nd in- filtration by leucocytes or new connective tissue. The blood shows the changes common to anaemia. The heart may be fatty ; it is seldom enlarged. The liver shows no essential lesion. The spleen may be somewhat increased in size. Tubercular changes are often found in various parts of the body if tubercular disease of the adrenals be present. Symptoms. — Four cardinal groups of symptoms appear: (i) prostration, (2) heart weakness, (3) gastro-intestinal symp- toms, and (4) bronzing of the skin. 1. Prostration is shown by the early appearance of intense languor both of body and of mind. The patient becomes weak, dull, apathetic, listless, and peevish. The symptoms of prostration are constant and progressive. 2. Heart iveakness is attended by frequent syncopal at- tacks, any one of which may be fatal. The pulse is feeble and rapid. The poor condition of the circulation induces the symptoms of cerebral anaemia, which usually are well marked. 3. Gastro-intestinal symptoms diXQ: almost constant. Nausea and vomiting may, with the prostration, appear as initial symptoms. The vomiting, which is not usually influenced by diet, cannot be accounted for by any lesion found in the stomach, but seems to be of nervous origin. The vomiting occurs in violent paroxysms and becomes more distressing as the disease progresses. Diarrhoea is twice as frequently observed as constipation. 4. The bronzing of the skin is usually observed after the constitutional symptoms have lasted for some little time. In other cases it is the first symptom observed. The pig- mentation of the skin usually begins in the exposed portions of the body, as the face and the hands, or in areas exposed to friction of the clothing, or in places which are normally 666 M.lXr.lL OF THE PRACTICE OF MEDICIXE. pigmented, as about the nipples. The color varies from a yellow to a brown or even a black. The pigmentation may at first occur in scattered areas, but finally tends to become diffused, so that the patient may resemble a mulatto. Simi- lar discoloration may be found in the mucous membrane of the lips, gums, and tongue. Internal pigmentation does not usually occur. Among the remaining symptoms to be enumerated, the most important are pain and tenderness in the lumbar or epigas- tric regions ; these symptoms occur in one-third of the cases. In the last stages of the disease the patients become ex- tremely feeble and may develop stupor, delirium, coma, or general convulsions. Death occurs from asthenia or from syncope. In a few acute cases the disease runs a course with fever, vomiting, diarrhoea, and intense exhaus- tion, and before the pigmentation appears the diagnosis may be impossible. Prognosis. — Recovery is practically unknown. Acute cases may terminate within a few months. The average duration is about one year, but cases are on record in which the symptoms continued as long as ten years. Treatment is sj-niptomatic, as for the disease itself no curative treatment is known. The patient should be guarded from causes leading to syncope, and anremic conditions should be controlled by iron and arsenic. The vomiting may be alleviated by bismuth, creosote, hydrocyanic acid, or codeia. Purgatives should be given with caution, as they may induce an exhausting diarrhcea. TUBERCULOSIS OF THE LYMPH-GLANDS (SCROFULA). Etiology. — Scrofula is tubercle, and the etiology of scrofula is therefore that of other tubercular infections. Tubercular infection of lymphatic glands is favored by previous adenitis, so that children with catarrhal inflamma- tions of the mucous mcinbranes that excite adenitis of the * neighboring lymphatic glands seem to be especially sub- ject to subsequent lymphatic tuberculosis. The pathology of scrofula is that of tubercular foci. TUBERCULOSIS OF THE LYMPH-GLANDS. 667 which are usually localized in certain groups of glands and show a tendency to spontaneous healing. In many cases suppuration of the infected glands occurs, espe- cially with tubercular glands in the neck. In these in- stances the pus is usually sterile, and it is not known whether the suppuration is excited by the tubercle bacilli and their products or by a mixed infection of pus-or- ganisms. An unhealed focus of tubercular adenitis may at any time discharge bacilli into the blood-vessels or the lymph-vessels ; it is said that three-quarters of the cases of acute miliary tuberculosis originate in this way. Symptoms. — i. Gene^ml tuberculous lymphadenitis is a rare condition, and usually occurs in the negro race. The lymph-glands throughout the body are the seat of a diffuse tubercular infiltration. Acute cases resemble clinically Hodgkin's disease, but there is apt to be more fever. 2. Local Tuberculous Lymphadenitis. — {a) Cervical. — This form is frequently seen, especially in tenement-house and asylum children and in the negro race. The submaxillary glands are usually the first to be involved, and subsequently the cervical chains of glands become infected. The glands may remain isolated and mobile, but they tend to become fused so as to form large knobby tumors. Suppuration is common. For the details of this affection the reader is referred to works on surgery. {b^ Bronchial. — The bronchial glands are extremely sub- ject to infection, and they may be involved with or without local lesions in the lung. Acute miliary tuberculosis is apt to result. (For details see Miliary Tuberculosis and Bron- cho-pneumonia.) (c) Mesenteric {Tabes Mesenterica). — In this form the mesenteric and retroperitoneal glands are enlarged and tubercular. They may suppurate, or they may become encapsulated and infiltrated by lime-salts. Mesenteric tuberculosis may be primary or may complicate tubercular disease of the intestines. The treatment of tubercular adenitis is that of tuber- culosis in general. Cervical tubercular glands may be removed. Vm. DISEASES OF THE NERVOUS SYSTEM. J, DISEASES OF THE MEMBRANES OF THE BRAIN. ia) Diseases of the Dura Mater. ACUTE EXTERNAL PACHYMENINGITIS. Etiolog-y. — Pach\-nieningitis is regularly secondary to injuries and diseases of the cranial bones and to suppura- tive disease of the middle ear and of the mastoid cells. Pathology. — The dura is thickened by a purulent infil- trate ; the products of inflammation collect between the dura and the skull, forming a circumscribed abscess. The lesion is usually localized over one cortex. The inflamma- tion may extend to the pia mater or to the venous sinuses. The symptoms are usually obscure. Pain is usually referred to the seat of the lesion. Septic symptoms develop, and compression-symptoms may result in hemiplegia if the motor area be pressed upon. The prognosis is good if the treatment be scientific and if the pia and the venous sinuses be not invoked. The treatment consists in trephining and draining the abscess-cavit\\ ACUTE INTERNAL PACHYMENINGITIS. Etiology. — Pach\-meningitis interna is secondary to in- flammation of the external surface of the dura, or compli- cates erysipelas, Bright's disease, pyaemia, pneumonia, puer- peral fever, and the exanthemata. Pathology. — The inner surface of the dura is covered with fibrin and pus or with pus alone ; the thickness of the dura is not usually involved. The inflammation is apt to fifiS C'lIRONIC INTERNAL PACHYMENINGIT/S. 669 extend to the pia and to the venous sinuses. The purulent exudation is usually circumscribed over the cortex. The symptoms resemble those of a localized purulent meningitis. In the complicating cases the symptoms may be so obscured by those of the primary disease that the diagnosis is rendered obscure. The prognosis is not good, owing to the liability to meningitis and thrombosis of the cerebral sinuses. The treatment is that of meningitis. CHRONIC INTERNAL PACHYMENINGITIS. Etiology and Synonyms. — The disease is usually found in males over fifty years of age ; it occurs in connection with insanity and degenerative diseases of the brain. Al- most all the subjects are markedly alcoholic, and the disease is one almost exclusively of tramps and almshouse inmates. Synonyms : Hemorrhagic pachymeningitis; Haematoma of the dura mater. Pathology. — The disease is characterized by the growth of a new membrane upon the dura, usually involving a small area over one cortex. In the earlier stages this membrane resembles a brownish-red staining of the dura, and consists of large, thin-walled blood-vessels supported by a delicate connective-tissue framework. From these blood-vessels hemorrhages occur, constituting the principal feature of the disease. In the later stages the dura is thickened over the affected area by dense fibrillated connective tissue, and upon its inner surface the original membrane is found as already described. The dura may be from half an inch to an inch thick, and thus the brain becomes slowh' compressed ; the compression of the brain is further increased by hemor- rhage between the dura and the pia, which may occur at any time. The symptoms are due to slow and to sudden brain- compression. Slow Coinpressio7i. — Headache is prominent, constant, and usually localized. There are loss of memory and increasing stupidity. The gait is shambling, slow, and unsteady, but paralysis and ataxia are not observed. The speech becomes 6/0 MAXr.lL OF THE PRACTICE OF MEDICIXE. slow, faltering, and scanning. One or both pupils may be contracted. In the earlier stages of the disease these symp- toms are not marked. Snddoi conipnssiini is caused by meningeal hemorrhages. The patient will become unconscious, with or without pre- ceding convulsions, and will develop hemiplegia (see Menin- geal Hemorrhage). The hemorrhage may occur sponta- neously or after exertion, or after a blow or an injury to the head. In the latter instance the disease possesses great medico-legal interest. The hemorrhage may occur early in the disease and may be the initial symptom. Prognosis. — The disease is slow in its progress, extend- ing over years. Rare cases of recovery have been reported. Death usually occurs from degeneration of the brain with insanity, or from hemorrhage. Treatment. — As the diagnosis from syphilitic meningitis cannot in all cases be made, potassium iodide should be given in full doses. This treatment, however, is of no ser- vice in non-syphilitic pachymeningitis. The treatment of the disease is chiefly prophylactic. Quiet, easy employ- ment, and the avoidance of severe bodily exertion should be enforced, to lessen the chance of meningeal hemorrhage. SYPHILITIC PACHYMENINGITIS. This disease will be considered under the heading of Syphilitic Disease of the Brain-membranes. {6) Diseases of the Pia Mater. The pia mater may be the seat of a tubercular, a non- tubercular, and a syphilitic inflammation. Its inflammations are called " meningitis " or " leptomeningitis." TUBERCULAR MENINGITIS. Etiology. — In young children tubercular meningitis is regularly only part of an acute general tuberculosis. For the etiology see the latter disease. In adults tubercular meningitis is usually a local inflam- mation secondary to some pre-existing tubercular dis- ease. In some adults with acute general tuberculosis TUBERCULAR MENINGfT/S. 6/1 the lesions of tubercular meningitis may be found at the autopsy, but clinical symptoms during life are not usually observed in these cases. Tubercular meningitis is most common in children be- tween two and seven years of age. In adults the disease is rare after the twenty-fifth year. The attack may seem to be induced by some exciting cause, as a blow, a fall, or exposure to a hot sun. Pathology. — Upon removing the skull-cap the brain appears too large and the convolutions are flattened. The tubercles appear as small grayish points, occasionally with cheesy centres. The tubercles are most abundantly found along the course of the blood-vessels and in the sulci. They may be confined to the base (hence the name " basilar men- ingitis ") or they may be more uniformly distributed. The pia about the tubercles is thickened by serum and by cel- lular infiltration. Properly speaking, there should be no purulent exudate, but a fibrino-purulent exudate is not uncommon from a " mixed infection." The cortex is oedematous and is infiltrated with cells. In children the ventricles are regularly distended with clear or turbid serum, and the walls of the ventricles are studded with tubercles (" acute hydrocephalus "). This distention may be so great that the septum between the lateral ventricles will rupture, and great compression of the brain from within outward will ensue. In adults the distention of the ventricles is less fre- quent. In all cases tubercular inflammations are seen in other parts of the body. The symptoms may be classically divided into four groups : Prodromal Symptoms. — The child is irritable, restless, and disinclined to play. Causeless vomiting is a symptom which in children is suggestive of incipient meningeal inflammation. Symptoms of Brain-irritation. — The child may be taken with convulsions or a chill. Fever develops and runs an irregular course. The temperature may vary between iOO° and 103° F. with irregular remissions; more rarely a fever of 104° to 105° F. is encountered. The temperature gives no euide to the diagnosis, nor does it indicate the actual 6/2 J/.-LVr.l/. OF THE J'K.tCT/CE OF .yF.D/C/\F.. scv'crity of the disease. Headache becomes severe, and the special senses are so h\per;vsthetic that the child becomes intolerant of liy^ht or noise, and tlic hyperaesthesia of the skin may render any handling; of the patient extremely pain- ful. There is rigiditj' and retraction of the back of the neck ; the muscles generally are rigid and resist passive motion, and the general attitude is one of general flexion which is quite characteristic. Convulsive movements or automatic motions are common. Mild or violent delirium develops, alternating with periods of stupor in which the child may moan or give vent to the shrill " hydrocephalic cry." The pupils are usually contracted. The pulse varies between 1 10 and 1 20. Vomiting attacks occur without nausea, and are not influenced b)' the taking of food. The bowels are usually obstinately constipated. The abdomen is retracted and " boat-shaped." Symptoms of braiii-comprcssion next appear, and are due not only to the thickening of the pia, but also to the disten- tion of the ventricles. The child becomes dull and apathetic. The special senses are blunted. Stupor succeeds the delirium and merges into coma. The automatic motions of the hands and feet may continue, or there may be evident paralysis of certain groups of muscles, of which paralyses squint is the most easih' recognized. The pulse may now become slowed to 90, 80, or even ^o in the minute. This characteristic slowness of the pulse, however, may not be marked in }'oung children. Irregularity of the pulse is frequently observed. The coma becomes profound, the sphincters relax, paralysis becomes more evident; the pulse during the last stages of the disease becomes rapid and feeble, and the breathing becomes irregular and may assume the Cheyne-Stokes variety. Death occurs from depression of all the vital functions. Not all cases, however, run this classical course. The symptoms of irritation and of compression may be vari- ously admixed, according to the intensity of the inflam- mation in various portions of the pia mater. Some young children are seized at the onset with convulsions, which may be repeated; the child becomes stupid and drow.sy, moans as ACUTE NO N- TUBERCULAR MKNINGfTIS. 673 if in pain, and develops irregular fever ; the rhythm of the respirations becomes disturbed, and coma precedes a fatal issue. In adults, owing to the less frequent movement of the ventricles, the compression-symptoms are less marked. The prognosis is uniformly bad. The duration of the disease is from one to four weeks. The treatment is that of acute non-tubercular meningitis. ACUTE NON-TUBERCULAR MENINGITIS. Etiology. — Meningitis is regularly due to germ-infection of the pia mater. The inflammation of the pia mater occurs as the characteristic lesion of epidemic cerebro-spinal menin- gitis. Cases of secondary pus-infection occur more commonly, the germs infecting the meninges (i) by direct extension or (2) through the arteries. 1. By direct extension, following inflammation or injury of the bones of the skull, of the dura mater, or of the orbital cavity. The most frequent cause is necrosis of the petrous portion of the temporal bone from middle-ear disease. The germs may travel along the nerve-roots during the course of facial erysipelas, or a phlebitis arising from suppuration of the orbit or cheek may infect the cavernous sinus and thus spread to the pia. 2. Tlirough the Arteries. — Infectious emboli may occur in the course of pyaemia, abscess of the lung, and malignant en- docarditis. Bacterial infection also occurs during the course of certain infectious diseases, especially pneumonia, ery- sipelas, typhoid fever, rheumatism, and the exanthemata. Infection is favored b)' Bright's disease and gout. The con- gestion following sunstroke predisposes to meningitis. Pathology. — Two anatomical forms are found, w^hich during life give rise to the same clinical symptoms : 1. Cellular Meningitis. — The pia is congested, dry, and lus- treless. The substance of the pia is the seat of a cellular infiltration. There is no purulent exudate. This form is analogous to the cellular form of peritonitis in peritoneal septicaemia. 2. Exudative Meningitis. — There is an exudation of fibrin, 43 6;4 .y.i.vL'.iL OF riiK practice of medicine. serum, and pus into the thickness of the pia, more rarcl\- appearing upon its free surface. In children and in young adults the lining of the ventricles becomes inflamed and the \'entricles become distended with turbid serum. The pia mater covering the spinal cord may be involved by direct extension. The locality of the meningitis varies. In pneumonia and in malignant endocarditis the process is usually bilateral and limited to the cortex ; with middle-ear disease the lesion is over the temporo-sphenoidal lobe on one side ; in other cases the base alone may be involved. In children, should the patient recover from the meningitis, the ventricles ma)- remain distended for some time. The symptoms depend largeh- upon the character of the original disease. 1. If the meningitis follow middle-ear disease, the symp- toms of meningitis are well developed and resemble those of the tubercular or the epidemic form, so that a further description is unnecessary. The diagnosis from tubercular meningitis is to be made by attention to the following points : Tubercular RIeningitis. Simple Meningitis. History of tuberculosis. History of ear disease, etc. No apparent cause. Cause evident. Longer prodromal period. Short prodromal period. Longer course. Short course. Presence of tuberculosis in No tuberculosis. the lungs, etc. Heredity in 20 per cent. No heredity. 2. If the meningitis complicate severe infectious disease, the symptoms may be obscured by those of the original disease. Retraction of the head and paralyses may consti- tute the only suggestive symptoms. Facial paralysis and squint are usually the most evident. The pulse may or may not become slower, but it usually becomes irregular. Irregularities of the rhythm of respiration are usually observed. It may be impossible to differentiate between pnuemonia in children with cerebral symptoms and pneu- monia complicated by meningitis. The duration is about a week, but the disease may con- tinue for from two to four weeks. CI IRONIC MICNINGITIS. 6y$ The prognosis is bad, yet a number of patients recover. Treatment. — Tlie patient should be kept free from noise and hght. The continual use of the ice-cap throughout the disease is frequently of service, and should always be employed. Leeches should be applied behind the ear in robust cases, but depletion in the latter stages of the disease is not to be advised. Blisters to the occiput add to the dis- comfort of the patient and do no good. Calomel and mag- nesium sulphate should be given at the outset, in such doses as will act on the bowels and reduce the meningeal congestion. Ergot is advised during the earlier stages, to reduce congestion. Potassium iodide in 5- to lO-grain doses is employed as a routine treatment, but its use is theoretical. The restlessness and headache are to be controlled by opium, phenacetine, chloral, bromide of sodium, and sul- phonal. For the tubercular form the head may be shaved and covered with iodoform ointment; for this treatment good results have been claimed. Should menmgitis follow middle-ear disease or suppurative disease of the dura, local- ized trephining and drainage should be practised. To avoid meningitis prophylactic treatment should be directed toward the careful cleansing of the ear in suppura- tive otitis media, the opening and draining of abscesses of the mastoid cells, and the antiseptic treatment of suppura- tive processes about the cheeks and the orbit. SYPHILITIC MENINGITIS. (See Syphilis of the Brain.) CHRONIC MENINGITIS. Etiology and Synonym. — The disease is one of middle life, and is most commonly seen in those who have led a life of privation and exposure. It is common in tramps and in the inhabitants of almshouses. Chronic alcoholism and cerebral endarteritis seem to lead to the disease. Chronic meningitis may complicate fractures or inflammation of the cranial bones, chronic pachymeningitis, chronic Bright's disease, chronic degenerations of the brain, and slow-srow- ing cerebral tumors. Synonym : Chronic leptomeningitis. 6/6 j/.Lvr.iL OF THE practice of medicine. Pathology. — The pia mater is thickened, opaque, oedem- atous, and infiltrated with cells. There may be adhesions between the pia and the dura. The brain-cortex may be softened or sclerotic. The ventricles may be distended with clear serum, and the ependyma lining them may be thick- ened and rough. The meningitis may be localized at the base or the cortex of the bram. The symptoms are those of slow compression ; they re- semble those of chronic pachymeningitis except that hemor- rhages do not occur. Prognosis. — The disease is chronic in its course, extend- ing over }'ears, but recovery cannot be expected. Treatment. — Syphilitic meningitis should be excluded b)' a conscientious trial of mercury and of potassium iodide in full doses. Otherwise the treatment is symptomatic. MENINGEAL HEMORRHAGE. Hemorrhage may occur between the dura mater and the bones of the skull, and between the dura and the pia mater. Hemorrhage between the Dura Mater and the Boxes of the Skull. — Etiology. — These hemorrhages are regularly due to violence, either by concussion separating the dura from the cranial bones and laceratmg the middle meningeal artery, or by fracture of the cranial vault. The sym.ptoms are those of shock, laceration and com- pression of the brain, followed by the symptoms of menin- gitis. Although these cases are of surgical rather than of medical interest, they are important to the physician, owing to the unpleasant results that follow an erroneous diagnosis. A man whose breath is alcoholic may be found unconscious in the street with a scalp-wound. The case is regarded as one of alcoholism, but the coma deepens, the temperature rises, and the patient dies. At the autopsy there is found a fracture of the skull with laceration of the middle cerebral artery and meningeal hemorrhage. Treatment. — In suspected cases incision should be made, exposing the site of probable fracture. When the diagnosis is made, trephining and removal of the clots should at once be resorted to. meningeal jiemor kj/agk. 677 Hemorrhage between the Dura Mater and the Pia Mater. — Etiology. — This form of meningeal hemorrhage may occur from — (i) Traumatism ; (2) thrombosis of the venous sinuses ; (3) in new-born children as the result of severe labor or the pressure of forceps ; (4) chronic hemor- rhagic pachymeningitis ; (5) rupture of an aneurysm of one of the cerebral arteries; (6j after convulsions in children; (7) hemorrhagic diseases. The disease may occur at all ages, thus differing from cerebral hemorrhage. Pathology, — The hemorrhage may be at the base of the brain, at the convexity, or may be more equally distributed. Small hemorrhages may ultimately be absorbed, leaving haematin staining. It must be remembered that in cerebral hemorrhage the blood may rupture through the cortex or may leak out by the fourth ventricle and appear between the membranes. The symptoms vary according to the size, location, and cause of the hemorrhage. 1. Lai^ge Clot over One Cortex. — There is sudden coma, with stertorous breathing, slow pulse, and abolition of all reflexes. There may be hemiplegia or monoplegia, according to the size and position of the hemorrhage. Convulsive movements of muscles ultimately to be paralyzed may occur. The temperature falls to 96° or 97° F"., but subsequently rises to 103° or 105° F. or even higher. The patient may die in coma within twenty-four hours, or may die in several days with the symptoms of meningitis. Recovery occurs only if the clot be small. Small hemorrhages over a con- vexity may give rise to the symptoms of acute meningitis without the occurrence of sudden coma. 2. Clots over both heniisplieres give rise to sudden coma and general convulsions, so that the diagnosis from uraemia may be one of great difficulty. 3. Hejiiorrhagc at the base of the brain compresses the medulla and leads to death in a few hours. A high ante- mortem temperature is usually observed in these cases. 4. Meningeal Hemorrhage of the New-born. — The child maybe stillborn, or it may be born in asphyxia, from which it may die, or from which it may recover, only to die in 6/8 A/AXCAL OF THE PA'ACT/CK OF MEDICIXE, coma with convulsions witliin a few days. In those who hve, symptoms of parahsis with or without athetosis, mental defects, and epileptic seizures max* develop (see Cerebral Atroph\- of Children). The prognosis of meningeal hemorrhage is bad unless the clot is small and is situated over the convexity. Re- covery ma)' be complicated by permanent paralysis (with or without convulsive movements) of groups of muscles upon the side opposite to the lesion. Death from meningeal hemorrhage usually occurs earlier than from cerebral hemorrhage. 2. DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. CONGESTION. Congestion may be active or passive. Active hypcncmia may be due to exposure to the sun, to the ingestion of such drugs as alcohol, amyl nitrite, and nitroglycerin, to excessive brain-work, to reflex causes, or to fever. Passive /lyperceiiiia results from (i) mechanical obstruc- tion to the venous return of blood, as with tumors of the neck or strangulation ; (2) from general venous congestion due to heart or lung disease. The symptoms are neither characteristic nor constant. The active congestion causes headache, a sense of fulness and throbbing in the head, and hyperaisthesia of the special senses. The face is flushed ; the superficial arteries pulsate visibly. Passive hyperaemia gives rise to dull headache, to mental slowness, to disturbances of sleep, and to a feeling of fulness in the head. Attacks of delirium or unconscious- ness may attend the severer forms of congestion. Treatment. — The patient should be kept quiet, and the bowels should be freely moved. Venesection may be in- dicated in acute congestion of an intense type, and an ice- cap should be applied to the head. In passive hyperaemia the treatment should be directed toward the cause of the condition. CEREBRAL IfEMOR J< I/.ICE. 6ycj ANEMIA. Anaemia may result from general or local causes. Local- ized anaemia may be due to vaso-motor constriction, en- darteritis, or cerebral compression. Symptoms. — Acute anaemia, such as results from pro- fuse hemorrhage, gives rise to confusion of ideas, marked dyspnoea amounting to " air-hunger," spots before the eyes, ringing noises in the ears, a tendency to yawn, nausea, and dilated pupils. Convulsions and syncope may occur. Sud- den death in syncope may result from an intense anaemia suddenly induced. Chronic anaemia is characterized by vertical headache, disturbances of sleep, lack of mental power and concen- tration. There are spots before the eyes and buzzing in the ears. There may be repeated syncopal attacks. The symptoms are regularly relieved by lying down. The treatment is that of anaemia. OEDEMA. CEdema may be due (i) to atrophy of the cerebral cortex, there being an increase of the cerebro-spinal fluid and oedema of the overlying pia : to such a condition the term "wet brain" has been applied; (2) to long-continued passive congestion ; (3) localized oedema occurs about tumors and abscesses ; (4) oedema may occur during the advanced stages of Bright's disease. The symptoms are obscure, and, in general, are due to the disease to which the oedema is secondary. CEREBRAL HEMORRHAGE (APOPLEXY). Etiology. — Cerebral hemorrhage usually occurs after the age of forty, the age of the greatest liability being between the seventieth and eightieth years. More rarely the disease occurs in children and in young adults. The condition is more common in males than in females. An "apoplectic habit " has been described — a short, thick-set body, wath flushed face, prominent color, and short neck, but, as a matter of fact, hemorrhage is, if anything, more common 68o A/.i.vr.ii. OF THE practice of mediclxe. to those of spare habit. In ahnost all cases there occurs degeneration of the cerebral arteries, rendering them liable to rupture. Fatty degeneration, atheroma, or the weaken- ing of an artery from an embolus may be found, but the most frequent cause of hemorrhage is an endarteritis which allows of the production of miliary aneur\-sms, from whose rupture the hemorrhage takes place. These miliary an- eurysms occur with greatest frequency upon the middle cere- bral artery ; thc\' vary in size up to that of a pin's head. The predisposing causes for the endarteritis are gout, syphilis, alcoholism, and a life of over-work and privation. There may be an inherited tendency toward arterial degeneration. The exciting cause for rupture is an increased arterial ten- sion. As high tension so frequently occurs with chronic nephritis and hypertrophy of the left ventricle, the associa- tion of these conditions with cerebral hemorrhage is ex- ceedingly common. A sudden increase of blood-tension may occur from strain, fright, anger, a cold bath, or over- eating or drinking. In other cases the hemorrhage may occur during rest or sleep. Cerebral hemorrhage in young adults may be associated with congenital lack of development of the aorta and large vessels. Hemorrhage may occur during the course of hemorrhagic disease, as leukaemia, pernicious anaemia, and purpura haemorrhagica, but these hemorrhages are usually multiple and have no especial seat of selection. Pathology. — Cerebral hemorrhage usually occurs from the middle cerebral artery, and involves the internal cap- sule, optic thalamus, corpus striatum, and the neighboring brain-tissue. Next in frequency are hemorrhages into the cortex, pons, and cerebellum. The right side is more fre- quently involved than the left. Should the hemorrhage occur near the cortex, the blood ma\- rupture through and appear beneath the dura. Rupture into a ventricle may also occur. The clot at first is red, soft, and admixed with lacerated brain-tissue. Gradually the clot becomes firmer, the haemoglobin becomes converted into reddish-brown haematoidin, the disintegrated brain-tissue undergoes fatty degeneration and absorption, and a connective-tissue capsule CKREBA'AL IIKArORNI/AGE. 68 1 may form about the hemorrhagic mass. Ultimately there may be left a pigmented puckered cicatrix, or a mass of softened pigmented tissue with or without a connective- tissue wall, or a cyst with brownish fluid contents. The torn brain never unites. From the point of laceration sec- ondary degeneration occurs, upward to the cortex if the sensory tract be involved, downward in the motor tract as far as the anterior motor cells of the spinal cord if the lesion involve motor fibres (see Secondary Lateral Scle- rosis). The symptoms depend upon the size, rapidity, and posi- tion of the hemorrhage. The symptoms are the prodromal, those of the attack, and those of the chronic stage. Prodromal syviptonis, which are due to the cerebral endar- teritis, consist of headache, dizziness, ringing in the ears, and irritability of temper. More characteristic are temporary loss of speech, incomplete temporary paralysis of an arm or a leg, or temporary and partial blindness. Symptoms of the Attack. — The patient, without warning, becomes dizzy and falls unconscious. In other cases coma may be developed gradually, or may be preceded by forget- fulness and mental aberration. The face is flushed ; the arteries of the neck pulsate visibly ; respirations are slow and stertorous, and may be irregular; the eyes and the head are turned toward the side of the lesion (" conjugate deviation ") ; the pupils vary, but are usually dilated and in- active ; the pulse is full, slow, and of high tension ; the tem- perature at the time of onset falls to subnormal, but within twenty-four hours it begins to rise. The more severe the hemorrhage, the greater is the initial fall and the higher the subsequent rise. Evidences of paralysis may be discovered : the mouth may be drawn from the paralyzed side ; the paralyzed cheek may blow out during respiration more than the other cheek, and the naso-labial fold may be obliterated. Hemiplegia may be discovered by finding that the affected arm and leg drop more " dead " than do those of the un- paralyzed side, and lack their normal " tone." The urine may contain a trace of albumin or of sugar, even if there be no nephritis. 682 MAXCAL OF THE PRACTICE OF MEDICINE. Small hemorrhages slowly developing may cause no actual coma, but bewilderment and mental confusion are commonly observed in these cases. Hemorrhages in the cortex or into a ventricle may cause convulsions at the onset, but these cases are uncommon. In this condition of coma the patient ma\' die, from involvement of the vital functions or from hypostatic pneumonia and pulmonary oedema. Symptoms of the Chronic Stage. — When the attack does not prove fatal, consciousness becomes gradually restored and the reflexes return, and it becomes possible to gauge the extent of the damage done by the hemorrhage. The symptoms of motor paralysis depend upon the extent to which the motor tract is lacerated. If the hemorrhage be in its usual location, there remains a hemiplegia of the op- posite side. The muscles, however, are not uniformly par- alyzed. Those muscles used automatically and in pairs, as the muscles of respiration, escape paralj'sis ; the arm is more paralyzed than the thigh, the hand and foot more than the arm and leg. If recovery ensue, the larger and more auto- matic muscles improve more rapidly and completely, the leg before the arm, the arm before the hand. An " initial rigidity " of the paralyzed muscles is due to irritation about the lesion. An " early rigidity " may develop on the second or third day and may last for one or two weeks ; this rigidity is due to inflammation about the lesion. In early rigidity the position of the limbs is one of rest. " Late rigidity " appears after several weeks and is usually permanent. It is due to descending degeneration of the motor tract (see Sec- ondary Lateral Sclerosis). The position of the affected limb is generally one of flexure. Slow convulsive twitch-, ings may occur in the paralyzed muscles; this "post-hcmi- plegic chorea " is due to destructive lesions of the optic thala- mus. During late rigidity the reflexes of the affected limbs are greatly exaggerated. Atrophy of the paralyzed muscles does not occur. Facial paralysis occurs with hemiplegia in lesions of the internal capsule, but the eyes can be closed. The tongue deviates when protruded toward the paralyzed side. Aphasia of some kind may accompany right hemi- plegia or may occur alone. Hcmiana;sthesia develops after CERI'inRAL HF.ArORKJ/A GE. 683 lesions of the posterior portion of the internal capsule, but is seldom absolute or permanent. Mental symptoms attend Fig. 55. — The motor tract (Starr): S, fissure of Sylvius : NL, lenticular nucleus; OT, optic thalamus ; NC. caudate nucleus ; C, crus ; P, pons ; M, medulla ; O, olivary body. The tracts for face, arms, and legs gather from the lower, middle, and upper thirds of the motor area, pass into the capsule, and through the crus and pons, where the face-fibres cross to the opposite VII. N. nucleus, while the others pass on to the lower medulla, where they partially decussate to enter the lateral column of the cord, the non-decussating fibres pass- ing into the ant. median columns. Lesion in cortex causes monoplegia ; in capsule, hemi- plegia; in pons, alternating paralysis. recovery in the majority of cases, and consist of irritability of temper, imperfect memory, bewilderment, delirium, or even dementia. These mental symptoms may clear away or may remain. Crossed facial paralysis occurs with destruc- tive lesions of the lower portion of the pons (see Fig. 55)- Small hemorrhages in the cortex cause monoplegia accord- ing to their situation. Hemianopsia occurs if the lesion in- volve the optic tracts or the cuneus. Prognosis. — Small hemorrhages in the cortex may be recovered from without extensive or permanent paralysis. 684 M.i.YL.u. (.>/■ JJU: j'K.tcnc/-: o/-' medici.xe. If the speech-centre be involved, some degree of aphasia may remain. Large central hemorrhages rupturing into the ventricles are rapidly fatal. Hemorrhages into the basic ganglia and the internal capsule may be fatal. In case of recovery from the coma, permanent hemiplegia with con- tracture is the result. Coma persisting for more than forty- eight hours, congestion and oedema of the lungs, low initial temperature and high secondary rise with delirium and stupor, albuminuria, and the rapid formation of atrophic bed-sores are indications of a speedy termination. Treatment. — The patient should be kept quiet, with the head high. Ice may be applied to the head, and hot bottles to the feet. In robust patients with liigh arterial tension venesection should be resorted to ; but this is contra- indicated if the blood-tension is low and the pulse is weak. If the tongue falls back and mucus collects in the throat, the patient should be rolled to one or the other side. Many patients, according to Bowles, are allowed to suffocate from lack of this precautionary procedure. The mouth should be cleansed with antiseptic solutions to diminish the danger of septic broncho-pneumonia. A laxative should be given at the onset — i or 2 drops of croton oil or \ grain of elaterium. For throbbing pulse and high tension aconite may be given if venesection cannot be performed. The paralyzed limbs should be massaged to maintain their nutrition. Faradism is indicated after the lapse of one or two weeks, but when paralysis has lasted for several months and late rigidity with contracture has occurred, further use of electricity is hopeless. EMBOLISM OF THE CEREBRAL ARTERIES. Etiology and Synonym. — The usual origin of the em- bolus is from the valves of the left heart ; less frequently the embolus arises from aneurysm or atheroma of the aorta or the great vessels of the neck, or from the lungs. The embolus may be part of a thrombus that has formed in the auricular appendi.x, most commonly associated with the puerperal state. Septic emboli occurring during the course of ulcerative endocarditis and abscess of the lung give rise EMBOLISM OF -riJK CERKBRAL .lA'TEA'/ES. 685 to cerebral abscesses, and will be considered under that heading. Embolism is most frequent in young adults, and both sexes are affected in about equal proportions, although, according to the statistics of some authors, the condition seems more prevalent among women. Synonym : Cerebral softening. Pathology. — The middle cerebral artery or one of its branches is occluded in 90 per cent, of all cases, the left artery being more frequently involved than the right. Less frequently are involved the basilar, posterior cerebral, ver- tebral, anterior cerebral, and the internal carotid. As col- lateral circulation is never sufficient to maintain the nutrition of the brain-tissue whose blood-supply is suddenl}' cut off by the occlusion of its nutritive artery, softening and de- generation ultimately result. The nerve-elements are infil- trated with serum and undergo fatty degeneration. If the affected area be the seat of a reflux of venous blood, it will be stained red — " red softening ;" later, when the hemo- globin becomes altered, "yellow softening" results. If there be no reflux of blood, " white softening" results. No matter what the color of the softened spot may be, the actual disease process is the same in all cases. The soften- ing process proceeds rapidly and is usually complete in one or two days. The area of softening may remain unchanged for considerable time, or may be absorbed, leaving a cicatrix which may be pigmented. In other cases the softened area is replaced by a cyst with connective-tissue walls. The symptoms depend upon the artery occluded. I. Embolisin of the Middle Cerebral Artery. — {a) The oiiset differs from that of hemorrhage in the following particulars : (i) There are no premonitory symptoms ; (2) the onset is more sudden ; (3) coma is less complete and is shorter in du- ration ; (4) in many cases unconsciousness is not lost, but the patient becomes dizzy and bewildered ; (5) convulsive move- ments of muscles ultimately to be paralyzed occur in one- quarter of the cases ; (6) there are no signs of cerebral com- pression ; vomiting, hard pulsating arteries, slow pulse, flushed face, and stertor consequently do not appear; (7) 686 .y.L\L'.lL OF THE PRACTICE OE MEDICEVE. the initial temperature-changes are sliglit, but in a few days fever may develop {b) Pcrmaucut Syiiif^foiiis. — If the trunk of the middle cerebral artery be blocked, hemiplegia and paralysis of the face and tongue occur on the side opposite to the lesion. There may be aphasia if the left cerebral artery is occluded. Attempts at collateral circulation are attended by a decided improvement in the patient's condition in from twelve to thirty-six hours. The improvement may continue or may be but temporary. The sudden onset of hemiplegia, the tem- porary improvement, and the relapse arc characteristic of embolism. The subsequent course resembles that following hemorrhage. The mind in embolism, however, is less fre- quently affected. If the embolus lodges in a small cortical artery, the softening will be of a small area, so that mono- plegia or aphasia alone may develop. In these cases the stage of onset may not be well marked. The following symptoms follow occlusion of the other arteries : 2. Vertcbi'al Artery. — Symptoms of acute bulbar paralysis occur, leading to speedy death. 3. Basilar Artery. — There is bilateral paralysis with spasm and rigidit)'. S\-mptoms of acute bulbar paralysis occur, and death follows with a high ante-mortem temperature. 4. Inter ua/ Carotid Artery. — Owing to perfect anastomosis, no symptoms may result. In other cases a transient or permanent hemiplegia may develop. 5. Anterior Cerebral Artery. — No symptoms may result, or there may be mental weakness. Diagnosis from cerebral hemorrhage : Hemorrhage. Adults between 40 and 80. Hypertrophied heart. Endarteritis. Right middle cerebral usually. Aphasia less often. Monoplegia rare. Prodromal symptoms. Coma profound. Convulsions rare. Cerebral compression. Embolism. Young adults. Endocarditis usual. Not essential. Left middle cerebral. Aphasia more often. Monoplegia common. No ]irodromal symptoms. Coma slight, transient, or absent. Convulsions in 25 per cent. No cerebral compression. ANEURYSM OF 'JlIE CEREBRAL AR'JER/ES. 68/ The prognosis as regards the attack is, as a rule, some- what better than in hemorrhage. From the resulting paralysis recovery is not usualy, to be expected. The treatment resembles that of hemorrhage, except that venesection should not be resorted to. Active purgation is not necessary, as in hemorrhage. The heart's action is often so weak and irregular as to require the use of stim- ulants and digitalis. THROMBOSIS OP THE CEREBRAL ARTERIES. Etiology. — Thrombi may form in an artery from disease of its wall, from embolism, or from pressure on the vessel, as from a tumor. Thrombosis may also occur after ligation of the internal carotid artery. The patholog-y resembles that of embolism, except that the softening occurs more gradually ; otherwise the results of the two conditions are identical. The middle cerebral and basilar arteries are those most commonly affected. The symptoms resemble those of embolism, but they appear more gradually. There may be premonitory symp- toms — vertigo, transient aphasia or hemiplegia, and drowsi- ness. Hemiplegia slowly develops, taking several hours for its completion, and the patient gradually becomes comatose. The prognosis and treatment are those of embolism, ANEURYSM OP THE CEREBRAL ARTERIES. Etiology. — The condition occurs in middle age and is more frequent in men. The etiology is that of endarteritis and aneurysm in general. In many cases aneurysm follows embolism, the embolus disappears, and dilatation follows the secondary inflammatory changes in the coats of the artery. Pathology. — The aneurysm occurs most frequently on the central, basilar, and internal carotid, less frequently upon any of the branches of the circle of Willis. The aneurysm is usually small, rarely exceeding the size of a cherry, and is usually sacculated. The symptoms are those of tumor at the base of the 688 M.lXr.lL OF THE PRACriCE OF MEDICINE. brain, and hemorrhage. The pressure-symptoms are those of a small basal tumor, the involvement of the cranial nerves being especiall\- frccjuent. Of suspicious significance is the occurrence of crossed hemiplegia and third-nerve paral\'sis. The accompanying illustration (Fig. 56) shows that only pressure on one crus could cause such a distribution of paralysis, and the most likely thing to press on the crus is an aneurysm at the base of the brain. OP. th ^x Fig. 56. — Diagram of a section through the crus. etc., in front of the corpora quadrigemina (modified from Wernicke) : P C, posterior commissure; Aq, aqueduct of Sylvius; P L, posterior longitudinal fibres; III., third nerve; LB, Luy's body; OPT, optic tract; A, aneurysm causing compression-paralysis of third nerve on same side, and opposite hemiplegia. The symptoms of rupture lead quickly to a fatal issue, and the sudden occurrence of a large meningeal hemor- rhage at the base of the brain is the first information of the disease in the majority of cases. The prog-nosis is exceedingly bad. Treatment. — If the diagnosis of aneurysm be made, the patient is to be put to bed, the circulation is to be rendered tranquil, and iodide of potassium is to be given as for aortic aneurysm. The vertebral or the internal carotid artery may be ligated as an extreme measure, but the results of such surgical Jireatment are not good. TIIROMBOSfS OF THE VENOUS SINUSES. 689 THROMBOSIS OF THE VENOUS SINUSES. Btiolog-y. — Primary or marantic thrombosis occurs as a terminal event in cachectic conditions, and is not infrequent in the aged. Infants during the first six months of Hfc may be affected, usually after exhausting diarrhoial diseases. Secondary thrombosis complicates embolism and cerebral tumors producing pressure upon a sinus. In these cases the clot is not septic. Septic thrombus occurs with disease or injury of the cranial bones or of the middle ear, with meningitis, and with suppurative disease or erysipelas of the scalp, face, or orbit. Pathology, — The effect of a clot within a venous sinus or a vein is to cause intense congestion and oedema of the brain-territory the circulation of which thus becomes ob- structed. Softening of the brain-tissue may ultimately result. Septic thrombi soften, break down, and may give rise to embolic abscesses or to purulent meningitis. Symptoms. — General cerebral symptoms, which are usually present, consist of apathy, stupor, delirium, con- vulsions, muscular rigidity, vomiting, optic neuritis, and coma. Localizing symptoms do not usually occur. The cerebral symptoms are most marked when the superior longitudinal sinus is involved, but they are never character- istic. Of diagnostic importance are oedema and distention of the veins outside the skull, in the parts from which the veins pass through the bones to join the internal sinuses, as in the following instances : Thrombosis of the superior longitudinal sinus causes congestion and oedema of the sides of the head and forehead, prominence of the anterior fonta- nelle in children, and epistaxis. Thrombosis of the caver- nous si7ins causes oedema and congestion of the eyelid and a prominence of the eyeball. Thrombosis of the lateral sinus causes oedema and congestion over the mastoid. Septic thrombi give rise to septic symptoms — chills, in- termittent or remittent pyrexia, and the "typhoid state." The course of the disease may be complicated by menin- gitis or abscesses of the brain. 4-i 690 M.lXi'AL OF THE PRACTICE OF MEDICINE. The duration of the disease is from a few days to several weeks. The prognosis is bad, except that in case of small, non- septic thrombi recover}' may be possible. Treatment. — The shoulders and the head should be raised in bed to facilitate the venous outflow of blood. The lateral sinus has been explored and septic clots removed, with recovery. Otherwise the treatment is symptomatic. CEREBRAL ENDARTERITIS. Etiolog-y. — Cerebral endarteritis usually occurs in males, and is a disease of middle and advanced life. The condi- tion may be due to senile degeneration of the arteries, chronic alcoholism, gout, syphilis, or chronic nephritis. The pathology is that of endarteritis (see Arterio-cap- illary Fibrosis). The walls of the cerebral arteries are thickened and rigid, and may be the seat of atheroma or of fatty degeneration. Increased connective tissue in the intima may lead to occlusion ("obliterating endarteritis "). Such degenerated arteries cause an irregularly diminished supply of blood to the brain, are subject to spasm, and may lead to softening of the brain, to miliary aneurysms and hemor- rhage, or to larger aneurysms of any of the cerebral arteries. Symptoms. — Three groups of clinical S}-mptoms may be described : • I. Symptoms of Brain-ancpviia. — The patient suffers from headache, dizziness, spots before the eyes, and buzzing noises in the ears, and becomes unable to concentrate the mind for any length of time. These symptoms are com- mon to brain-ansemia from any cause. 2, Suddenly-induced Aiuzmia from Spasm. — Spasm may occur without known cause at any time, or may follow mental excitement or over-eating or drinking. The spasm is most common in the middle cerebral artery. In mild cases the patient will suddenly develop a partial paralysis of the arm or leg, or will become aphasic. Hemianopia may occur. The onset is usually accompanied by a " wave of faintness " and mental bewilderment, but actual loss of consciousness does not often occur. Spasm may precede CEREJSRAL ENDAR'JKKITIS. 69 1 the muscular weakness. These attacks are usually tem- porary, lasting but an hour or so and then wearing off; they are liable to be repeated. In other cases the spasm leads to softening and the symptoms become permanent. In .severe cases the patient loses consciousness, although the coma is not as complete as in hemorrhage and is of shorter dura- tion. Hemiplegia with or without aphasia develops, and may be preceded by convulsive movements of the muscles. The temperature rarely undergoes initial changes, and there are no symptoms of compression (slow pulse, stertor, flushed face, and throbbing arteries), as in hemorrhage. The pulse is usually of high tension, owing to the presence of general endarteritis and nephritis. Under favorable circum- stances the spasm passes off and recovery takes place in a few hours or days. Illustrative Case. — Male, sixty-five years ; chronic nephri- tis, general endarteritis. 2 p. m., fell unconscious : right hemiplegia, aphasia ; pulse 70, of high tension ; no stertor ; temperature normal. 12 p. m., conscious; begins to move and to talk. 4 A. m., walked and talked ; is rational. 6 a. m., perfectly recovered. 3. Symptoms of Brain-softening. — If the spasm be too long continued, or should a thrombus form in the vessel, the brain-tissue, thus deprived of its blood-supply, will die and soften as in embolism or thrombosis. A similar effect is produced by obliterating endarteritis. In these cases the patient does not recover. If the softened area be extensive, the patient will die in a few days in coma with hemiplegia, death usually being due to pulmonary oedema. In some cases coma is not marked at first, so that paralysis without loss of consciousness is regarded as indicative of acute soft- ening from arterial obstruction, however produced. If a smaller area be involved, the patient will live, but with per- manent paralysis or aphasia. In these cases mental de- rangement is common. The diagnosis is made by the presence of extensive arterial degeneration, by the history of previous attacks fol- lowed by recovery, by the absence of symptoms of cerebral compression, by the absence of causes for embolism, and by 692 MA.yr.lL OF THE rJx\lCTICE OF MEDICINE. the rapid recovery under appropriate treatment. When softening occurs the diagnosis from thrombosis cannot be made. Prognosis. — As the lesion is continuous and progressive, there is habihty to recurring attacks which tend to become more and more severe. The prognosis is rendered worse by the nephritis, by the atheroma of the aorta and the coronary arteries, and by the chronic alcohohsm if such a habit exists. The danger of hemorrhage must also be con- sidered. The immediate prognosis during an attack de- pends upon the duration of the spasm and upon the chances of a thrombus forming in the vessel ; a positive assurance of recovery, therefore, should never be made. Treatment. — Between attacks the treatment should be directed toward the arterial degeneration (see Arterio-capil- lary Fibrosis). For the anaemic symptoms the arteries may be relaxed with small doses of potassium iodide, nitro- glycerin, or chloral hydrate. Digitalis is contraindicated. At the time of spasm the arterial dilators above mentioned should be pushed to physiological limits. The bowels should be moved, and the functions of the skin and kidney should be stimulated, to eliminate from the system such noxious products as might cause arterial spasm. Whcji actual softening occurs treatment becomes inopera- tive. 3. DISEASES OF THE BRAIN-SUBSTANCE, CEREBRAL LOCALIZATION. Cortical Areas. — i. Tlie motor area is located in the cortex of the anterior and posterior central convolutions bordering upon the fissure of Rolando. The area of each hemisphere controls muscular movements of the opposite side of the body. The different groups of muscles are supplied by definite portions of the motor area, as is shown by the accompanying diagram (Fig. 57). Irritation of the motor area gives rise to localized spasm or convulsions (" Jacksonian epilepsy "). Destructive lesions cause paral- ysis. Slowly spreading lesions, as the growth of a tumor, CEREBRA L L O CA /. IZA TION. 693 cause spreading irritation followed by destructive symptoms (convulsions followed by paralysis), and involve fresh groups of muscles, so that the size and position of the lesion may be determined accurately. Cortical paralysis is monoplegic and is associated with increased reflexes, but the paralyzed muscles do not atrophy and the electrical reactions are unchanged. Destructive lesions in the motor tract from the cortex to the anterior nerve-cells in the spinal cord are regularly followed by descending degeneration (see Secondary Lateral Sclerosis). 2. The sensory area is in the cortex posterior to the motor area, but accuracy in localization cannot be obtained. The tactile sensibility of muscles seems to be in the motor area. Fig. 57. — The functional areas of the brain, left hemisphere (Starr). 3. The visual area is in the occipital lobe, including the cuneus on the median surface and the occipital convolutions on the convexity (see Fig. 58). Each area receives impres- sions from the same side of each retina, so that distinctive lesions cause failure of visual perception in the same side of each retina, the blind field of vision being therefore on the opposite side to the lesion (" homonymous hemianopsia ;" see Fig. 59). Irritation of the visual area causes visual halluci- nations. Destruction of the visual area of the left side is followed by word-blindness. 4. The auditory area is in the first and second temporal 694 MAXr.lL OF THE PRACTICE OF MEDIChWE. convolutions. Deafness from unilateral lesions is seldom noticeable. Lesions of the auditory centre on the left side are followed by auditory amnesia, or word-deafness. 5. The smell- and tastc-ccntrcs are found at the tip of the temporal lobe, where it rests upon the .sphenoid bone. Uni- lateral lesions do not produce noticeable symptoms. 6. The speech-centres are found in the left hemisphere in right-handed people, in the right hemisphere in those who Fig. 58. — Inner surface of right hemisphere: A, ascending frontal, B, ascending parietal convolution ; to the inferior longitudinal sinus, c to the straight sinus, teria or Fried- reich's ataxia in children. Anomalous cases are occasionally encountered, which resemble transverse myelitis, locomotor ataxia, or general paresis. The prognosis for recovery is bad. Treatment is practically unavailing. A course of mer- cury bichloride with potassium iodide may be tried in alter- nation with small doses (gr. -^ ) of nitrate of silver. In all cases a quiet life is to be advised. GENERAL PARESIS. Etiology and Synonyms. — The disease is common be- tween the ages of thirty and fifty-five, and is more frequent in men than in women. Heredity appears in 15 per cent, of the cases. The exciting cause may be prolonged mental strain, excesses, syphilis, alcoholism, and lead-poisoning. The disease is not uncommon among active, ambitious GENERAL PARESIS. 7O9 business-men. S)nio)iyms : Paretic dementia ; General paral- ysis of the insane; Chronic meningo-encephalitis ; Chronic periencephalitis. Pathology. — The membranes are thickened, opaque, and adherent in places to the brain-substance ; the cortex is firm and more or less atrophied ; there is an increase in the cerebro-spinal fluid. Microscopic examination shows an increase of connective tissue, with a degeneration and dis- appearance of nerve-fibres and ganglionic cells. In the cord similar sclerotic areas are found in the posterior and lateral columns. The ventricles are usually dilated. There may be small areas of softening in the brain-substance, associated with arterial sclerosis. The symptoms begin insidiously with a change in the moral nature. The patient becomes inattentive and forget- ful, and may violate the ordinary rules of decency and deportment. There is increasing mental weakness, with irritability of temper. A peculiar egotism usually but not invariably develops, with delusions of grandeur, so that the patient becomes absurdly boastful, and believes himself to be possessed of millions of money, or to have made the most wonderful inventions, or to be king, emperor, or even God himself Vaso-motor phenomena and general neuras- thenia add their symptoms. In the earlier stages motor symptoms may be noticed : the tongue trembles when it is protruded ; the gait is unsteady and shuffling. The pupils are frequently unequal. They may react to distance, but not to light (" Argyll-Robertson pupil "). There may be epileptiform seizures or Jacksonian epilepsy, frequently fol- lowed by transient paralyses. The speech becomes thick, owing to the difficulty of pronouncing the lingual and labial consonants. Scanning or a slow, hesitating, monoto- nous speech is common, words and syllables are frequently omitted, and the patient stumbles over words. Writing becomes uncertain and irregular, and letters or words may be omitted ; finally the writing becomes totally illegible. The gait becomes increasingly impaired, and may be spastic or ataxic. The knee-jerk is usually increased. ?klaniacal outbursts may follow the delusions of grandeur, or there 710 M.IXLAL OF THE PRACTICE OF MEDIC EVE. ma)' be periods of melancholia or of depression. In the last stages the patient becomes demented, the bladder and rectum become unretentive, the health fails, and the patient becomes bedridden. Death results from exhaustion or from intercurrent disease. The course of the disease is progressive, with periods of temporary improvement. The average duration is from three to four years. The prognosis is unfavorable. Treatment. — In syphilitic cases a thorough course of iodide and mercurials should be employed, but not much is to be expected from the treatment. Nursing and a quiet life in an asylum really constitute the only treatment of the disease. CHRONIC HYDROCEPHALUS. An increase in the amount of fluid in the ventricles occurs in a congenital and an acquired form. Congenital Hydrocephalus. — No known cause has been discovered for this condition. It has occurred in several members of the same family. The lateral ventricles are principally affected, and are distended with fluid, so that the cerebral cortex over them is thin and stretched and may be converted to a thin shell less than a quarter of an inch in thickness. The sutures and fontanelles are widely distended, so that the skull becomes enormously enlarged, in some cases exceeding thirty to thirty-two inches in diameter for a child of two or three years. The bones of the cranium are thinned, the orbital plates are so depressed as to cause exophthalmos. The fluid is limpid, contains traces of albumin and salts, and sometimes contains urea. Symptoms. — The head may be so large at birth as to interfere with natural labor. In other cases the head does not increase in size until several weeks after birth. The child is restless and irritable. There is difficulty in getting the child to walk, or the legs may be feeble and in a con- dition of exaggerated reflexes. A few children are bright, but in the great majority some grade of imbecility is present. Strabismus and optic atrophy may develop ; nys- SYPHILIS OF IIIK BKAIN. /If tagmus is commonly present. Vomiting, coma, and con- vulsions ultimately appear, and the child rarely lives for more than three or four years. Acquired Chronic Hydrocephalu.s. — This condition may result from compression or obliteration of the straight sinus or of the passage from the third to the fourth ventricle by a tumor ; other cases follow meningitis. In a few in- stances the condition arises without known cause (" serous apoplexy "). The symptoms are obscure, and a diagnosis during life is but seldom made. Headache, optic neuritis proceeding to atrophy, and attacks of stupor are commonly observed. The head in the acquired form does not enlarge. There are no localizing symptoms. Treatment of Hydrocephalus. — Gradual compression of the skull should be made by straps of adhesive plaster crossed in various ways. When pressure-symptoms are present, puncture of the ventricles by a fine aspirating needle and the withdrawal of small quantities of fluid from time to time are justifiable procedures. The subarachnoid sac between the third and fourth lumbar vertebrae may be punctured without risk of injury to the cord, and the fluid slowly removed without much danger of collapse. Med- icines are useless, although inunctions of mercury and the administration of potassium iodide have been recommended. SYPHILIS OP THE BRAIN. Congenital syphilis of the brain may develop during earl}^ childhood, but it is rare. The acquired form is usually a late tertiary manifestation of the disease, although it may develop in from six months to thirty years after the primary sore. The earlier occurrence of symptoms is by some authors attributed to the appearance upon the mem- branes of an actual syphilitic eruption analogous to the cutaneous exanthems of the secondary period. I. Syphilis of the Bones of the Cranium. — The lesion con- sists in the formation of spots of dry caries, nodes, and necrosis. Cerebral symptoms arise only if the membranes be secondarily inflamed. If the lesions involve the foramina 712 M.IXLA/. OF THE PRACTICK OF MEDIC IXE. tliroLigh which the cranial nerves pass, there will be developed neuralgic pains or motor spasms, followed by ancEsthesia or paralysis. 2. Syphilitic Meningitis. — The meinbrancs show the lesions of an acute or chronic inflammation, and are invaded b\- gummata. The symptoms arc those of the meningitis and those of the multiple tumors pressing on the cortex, and according to the predominance of either group of symptoms the case will resemble acute or chronic menin- gitis or cortical tumors. The suggestive points of s)'philitic meningitis are — (i) Headache, existing several weeks before the onset of other symptoms, severe in character, and worse at night, preventing sleep ; (2) the admixture of symptoms of inflammation of the meninges and of cortical tumors; (3) the rapid improvement under treatment. 3. Gummata of the Brain. — The symptoms of brain- tumor are frequently preceded by intense nocturnal head- ache, by temporary incomplete paraK'sis of an arm or a leg, or by temporary squint. These partial passing palsies are quite suggestive of cerebral syphilis. The general and localizing symptoms of cerebral gummata have been dis- cussed under the heading of Tumors of the Brain. 4. Syphilitic Endarteritis. — The syphilitic changes in the walls of the cerebral arteries were described by Huebner in 1874, and the lesion is known as " Huebner's arteries." The lesion consists in a thickening of the intima by con- nective tissue, in some cases leading even to an obliteration of the lumen. Areas of softening may occur in the brain- tissue, from the obliteration of the lumen of the vessel by this new growth or by thrombus-formation. The middle cerebral artery is the one most usually and most exten- sively affected. The symptoms resemble those of cere- bral endarteritis. Syphilitic stupor and paralysis require special description. Syphilitic Stupor. — The patient complains of severe noc- turnal headache, and after a time passes into a peculiar somnolent condition ; he may lie for days apparently asleep, or may sit for hours at a time in a torpid, dazed state of mind, answering questions in a peculiar, slow, automatic SYPHILIS OF HIE BRAIN. 713 way, as though talking in his sleep. From time to time the patient may wander about in an aimless fashion. The evidences of severe headache are usually marked, even during the periods of stupor. Prolonged stupor is of seri- ous import, but is not incompatible with complete recovery. The majority of cases, unless relieved by treatment, sud- dently pass into a condition of profound coma, which is usually fatal. Syphilitic paralysis comes on suddenly, without loss of consciousness and without exciting cause. The paralysis, which is not complete, and is of a transitory, fugitive charac- ter, may be of irregular distribution or may be hemiplegic in type. Oculo-motor paralysis is not uncommon. These fugitive palsies are due to functional brain-disturbance from the diminished blood-supply through the narrower arteries. Should thrombus occur, softening will ensue, so that the paralysis becomes permanent. 5. Syphilitic disease of the brain may present nearly the clinical picture of general paresis. The exact pathology of these cases, however, is not known, and it cannot be asserted as yet that this form of syphilitic brain disease is an independent affection. The prognosis is, upon the whole, favorable, although it should be guarded. More or less recovery is to be expected unless the symptoms indicate an absolute destruction of brain-tissue. Treatment consist in the vigorous employment of anti- syphilitic drugs. Mercury should at once be ordered by inunction, and pushed until the " gums are touched." Sali- vation, however, should always be avoided. Potassium iodide in 30-grain doses three times a day, largely diluted in water or milk, should be pushed rapidly until 300 grains daily are taken, unless the patient show such dangerous symptoms of iodism as hemorrhages. In cases of sudden coma timely venesection may be the means of savine life. 714 ^^/.l.vr.lL OF THE PRACTICE OF MEDICEXE. 4. DISEASES OF THE SPINAL CORD, [ii) Affections of tuk Meninges. DISEASES OP THE DURA MATER. PACHVMENiNciiTis EXTERNA occui's ill ail acutc aiid in a chronic form. The acute cases regularly are secondary to intlainniation of the vertebral bones or to the extension of neighboring abscesses. The inflammation is fibrino-purulcnt and gives the symptoms of a compression-myelitis. Chronic external pachymeningitis is usually due to tubercular disease of the vertebrae. The external layer of the dura is rough, thickened, and covered with cheesy material. The symptoms are due to irritation and compression of the anterior and posterior nerve-roots (hj'perassthesia and motor spasms, anaesthesia, paralysis, atrophy of muscles, and loss of reflexes) and to slow compression of the spinal cord (loss of motion and sensation below the lesion). Treatment is that of the original disease and that of myelitis. Pachymeningitis Interna H.emorrhagica (Hcnematoma of the Dura Mater). — This disease is usually associated with a similar affection of the dura mater of the brain, and the two lesions are identical, so that a further description of the disease process is not necessary. The cervical region is the one usually affected. The symptom? arc those of chronic spinal meningitis — pain in the back, motor and sensory irri- tation and impairment. Hemorrhages occur from time to time, causing sudden exacerbations of the spinal .symptoms and compression-.symptoms (see Meningeal Hemorrhage). Treatment is unavailing. P.A.CHVMENINGIT1S INTERNA HvPERTROPHICA. The dura becomes thickened by fibrous tissue, which irritates and de- stroys the nerve-roots and causes slow compression of the cord. The thickening of the dura generally extends above the cord like a ring, and is usually limited to the cervical resfion. DISEASES OF 77/E J' J. I MATER. 715 Symptoms. — i. Stage of Irritation. — The symptoms are due to irritation of the anterior and posterior nerve-roots. Neuralgic pains develop in the course of the affected nerves, and are referred to the neck, arms, and the upper portion of the thorax. There are areas of hyperaesthesia with tingling sensations. Motor symptoms consist of spasm and rigidity of the neck and of the muscles of the upper extremities. 2. Stage of Destruction. — Hyperaesthesia and neuralgia give way to anaesthesia. Paralysis with atrophy and loss of reflex succeeds the muscular spasms. Deformities result from the atrophy and paralysis. If the lower cervical en- largement be compressed, the ulnar and median nerves are chiefly affected, so that over-e.xtension of tl\e hand results. If the lesion be higher up, the musculo-spiral nerve is affected, so that the hand will drop. Secondary degenera- tion of the pyramidal tract results from the pressure-myelitis, and spastic paraplegia develops (see Secondary Lateral Sclerosis). The prog-nosis is bad for recovery, although death usually results from intercurrent disease. In some cases the dis- ease may be arrested, and the patient live for years with permanent contractures and deformities. Treatment consists of counter-irritation to the affected portion of the spine, and the empirical use of potassium iodide. DISEASES OF THE PIA MATER. Acute Leptomeningitis. Etiology. — Acute inflammation of the pia covering the cord may be due to extension of a similar inflammation of the pia of the brain, being thus part of the lesion of a simple or an epidemic meningitis ; or it may be due to traumatism of the vertebrae, or to operation, such as the opening of a spina bifida. The disease may complicate certain acute infectious diseases, especially pneumonia, small-pox, scarlet fever, and typhoid fever. A tubercular inflammation of the spinal meninges may also occur. In a few cases the excit- ing cause seems to be exposure to wet and cold. The in- fecting germ may be that of epidemic cerebro-spinal men- 7l6 .VJ.Vr.-1L OF THE PK.ICIVCE OF MEDICI.XE. ingitis {(J. 7'.), the cocci of pus, the pncumococcus, or Eberth's bacillus. Patholog'y. — The lesions may be diffused throughout the length of the cord or may be localized in the cervical region. The pia is congested, thickened, and infiltrated with fibrin, serum, and pus. The exudation is usually more abundant in the posterior portions of the pia, owing to gravitation when the patient lies upon his back. The peripheral por- tions of the cord are usually infiltrated by inflammatory products. The nerve-roots may also be involved. In the majority of cases similar lesions are found in the cerebral pia mater. The symptoms are due in the first stage to intense irrita- tion of the spinal nerves. Pain in the back and shooting pains along the nerves, with areas of hyperassthesia, are the prominent sensory s\-mptoms. Irritation of the motor ncrx'cs gives rise to spasm and rigidity of the affected muscles. The spine is stiff and rigid ; the head is thrown back; there may be opisthotonos. Owing to the retraction of the head and neck, the larynx may be so firmly pressed against the spinal column as to cause obstructive dyspnoea with stridor. The reflexes are generally exaggerated. There may be reten- tion of urine from reflex spasm of the bladder. During the earlier stages there is no paralysis, though the muscles may be kept quiet, so as not to increase the neuralgic pains. Fever is regularly present, but runs an atypical course, rarely ex- ceeding 104° F. Finally the second stage develops, in which hyperaesthesia is succeeded by anaesthesia, the pains cease, and complete paralysis supervenes. There may now^ be developed bed-sores and paralysis of the sphincters. Reflex irritability becomes lost. The diagnosis ma\^ be difficult. Symptoms of spinal meningitis may be present in cases in which the meninges are afterward demonstrated to be normal, while well-marked cases of leptomeningitis, especially of the cerebro-spinal form, may be unattended by characteristic symptoms. The diagnosis from tetanus is made by the absence of trismus and of the risus sardonicus and by the intensity of the pains. Myelitis is to be excluded b\' the marked and continued DISEASES OF THE EI A MATER. JIJ hyperaesthesia, by the late appearance of paralysis, and by the bladder not being involved. The prognosis is not good, although the acute condition may subside and symptoms of chronic meningitis develop. Dyspnoea the result of spasm or paralysis of the re- spiratory muscles is a most unfavorable symptom. The treatment is practically that of acute myelitis. Chronic Leptomeningitis. Etiology. — Chronic spinal meningitis may follow an acute attack or may be chronic from the start. In the latter case the disease may be due to syphilis or alcoholism, or the lesion may complicate chronic diseases of the cord that ex- tend so as to involve the membranes, or extra-medullary lesions, such as tumors or disease of the vertebral bones. Pathology. — When the condition follows an acute attack, the lesions usually involve an extensive area of the mem- branes; in other cases, chronic from the start, the distribu- tion is more limited. The pia is thickened and adherent to the cord and the dura. The nerve-roots may be compressed, and may even become atrophied. The cord usually shows increase of connective tissue in the cortical zones. The symptoms resemble in kind those of the acute form, and are due to the involvement of the nerve-roots, but mus- cular spasms are much less prominent. There is pain in the back, radiating along the course of the nerves, with areas of hyperaesthesia. Stiffness of the back and generally increased reflexes are present in the earlier stages. The rectum and the bladder are but seldom involved. Motor weakness gradually merges into paralysis, with atrophy of the muscles and loss of reflexes. These symptoms result from atrophy of the anterior nerve-roots through compres- sion by the thickened pia. The symptoms of meningitis are frequently accompanied by those due to a primary disease in or outside of the spinal cord. Prognosis. — The disease is chronic in its course, extend- ing over years. Recovery cannot be expected. Treatment is that of the chronic stage of myelitis. 71 8 maxcal of the practice of mediclxe. Hemorrhage into the Spinal Membranes. Etiology and Synonyms. — This rare condition may re- sult from (i) blows and concussions, (2) chronic pach\'menin- gitis hiL-morrhagica, (3) rupture of an aortic aneurysm into the spinal column after erosion of the vertebral bones, (4) hemorrhagic diseases, as purpura ha:morrhagica, and scurvy, (5) after convulsions or tetanus, (6) or as a lesion of caisson- disease. Blood effused into the cranium, as in hemorrhages at the base, may make its way down between the membranes of the cord. This latter diffusion of blood occurs most commonly with rupture of an aneurysm of the vertebral or basilar artery. Synonyms : Extra-medullary hemorrhage; Ha^matorrhachis ; Spinal apoplex)'. Pathology. — The blood may be found between the dura and the bones (extra-meningeal hemorrhage), and is extrav- asated from the large plexus of veins h'ing outside the dura. In other cases the blood is found between the membranes (intra-meningeal hemorrhage). Hemorrhage is most com- mon in the cervical region, but it ma\' occur anywhere. In extensive extravasations the spinal cord may be com- pressed, but the amount of blood is rarely sufficient for this. Symptoms. — The characteristic features of hemorrhage within the spinal membranes are the sudden appearance of symptoms of an intense meningeal irritation without initial fever. Pain develops suddenly in the back and radiates along the course of the nerves. There are muscular rigidity and spasm. Motor and sensory impairment may ultimately appear, but seldom to a great extent. If the hemorrhage be in the cervical region, the pain is felt in the arms, the neck is rigid and immobile, and dysphagia, interference with respiration, and dilatation of the pupils may appear. Larger hemorrhages in the upper cervical region may be immediately fatal. Occurring in the dorsal region, the pain encircles the abdomen. Hemorrhage in the lumbar region causes pain in the legs ; there may be spasmodic retention of urine. If the hemorrhage compress the cord, compres- sion-myelitis will result, with paraplegia and anaesthesia, and the rectum and bladder will be involved. IIEMORRHAGR INTO THE CORD. 719 The prognosis is bad, but not hopeless. Perfect recovery may follow slight extravasations. Treatment. — The patient should lie on the face while ice-bags are applied to the spine. Ergot may be given at the onset in full doses. After the hemorrhage has ceased the treatment is that of myelitis. [b) Diseases of the Blood-vessels. ANEMIA. The etiology and symptomatology of spinal anaemia are but little known. In profound anzemia there may be no symptoms referable to the cord. It is known that ligature of the abdominal aorta in animals is followed by paraplegia, and in man this paralytic condition has followed sudden blockage of an aneurysm of the abdominal aorta by a thrombus or by a detached portion of the clot. A transient paraplegia has also followed sudden and profuse hemorrhage or exhausting diarrhoea. The weakness of the legs in those suffering from aortic regurgitation is supposed to be due to spinal anaemia. HYPEREMIA. Acute hypercsmia results from sexual excesses, physical over-exertion, sudden cessation of the menses, and from over-dosing by strychnine. The symptoms are indefinite. There may be numbness, with neuralgic pains, muscular twitching, and weakness, these being usually confined to the lower extremities. Treatment consists in the application of an ice-bag or of cups to the spine. The patient should lie on the side or the face. Sodium bromide may be given to control the symp- toms. Ergot, although recommended by some, does not seem to be of as much service as is generally supposed. CJironic JiypcrcBinia may complicate various lesions of the cord and membranes, but the symptomatology is obscure. HEMORRHAGE INTO THE CORD. Etiolog-y and Synonyms. — Hemorrhage into the cord has been found with tetanus, str\xhnine-poisoning, and 720 MA.yr.lL OF THE PKACT/C/-: OF MEDICIXE. conditions leadins^ to sudden asphyxia. Hemorrhage commonly comphcates inflammations and tumors of the cord. Primarx- hemorrhage, which may be due to blows or falls, to convulsions, or to hemorrhagic conditions, is most common in young males. S)')iofi)>)ns : Ha.'mato- myelia ; Intramedullary hemorrhage; Spinal apoplex}-. Pathology. — The clot is rarely larger than an almond, and is usually situated in the central gray matter. The nerve-structures are lacerated at the seat of hemorrhage, re- sulting in a total transverse destructive lesion of the cord. The symptoms resemble those of acute transverse mye- litis, but there is no initial fever, the paraplegia is suddenly induced, and the stage of irritation is not marked. The case may resemble one of spinal meningeal hemorrhage, but in the latter condition pains and spasm are more marked than anaesthesia and paraplegia, and there is more liability of recovery. The ultimate course of spinal hemorrhage is that of a chronic transverse myelitis, and in many cases it is impos- sible to say whether the case is one of primary hemorrhage with myelitis or of myelitis with secondary hemorrhage. The prognosis is not good. Many cases die during the acute symptoms, while others live for years with permanent paraplegia. In these cases the prognosis is that of chronic myelitis. The treatment is that of myelitis. Embolism and thrombosis are rare conditions. Em- bolism may be suspected, should a patient with valvular disease suddenly develop paraplegia and paranaesthesia with- out other apparent cause. CAISSON-DISEASE; DIVER'S PARALYSIS. Etiology. — Persons who work in caissons and diving- bells under an increased atmospheric pressure may develop this disease when they suddenly emerge into the normal atmosphere. The pressure mu.st be more than three atmo- spheres, and the longer they work in the caisson and the more suddenly they return to the surface, the greater is the CAISSON-DISEASE; DIVER' S PARALYSIS. 72 1 liability to the disease. Those unused to the work are most frequently attacked. The pathology is somewhat obscure. Under raised atmospheric pressure the blood is driven from the surface to the internal organs. When the pressure is reduced to the normal, vascular disturbances are supposed to result in the cord, with spots of congestion and small hemorrhages which may ultimately result in myelitis. Another theory is that an excess of nitrogen is absorbed by the blood when under high pressure, and that when the pressure is too sud- denly reduced bubbles of this gas are liberated and lacerate the nerve-structures of the cord. The symptoms may appear at once or may be deferred half an hour or more after leaving the caisson. In most cases there are agonizing neuralgic pains in the limbs, the legs are tender to the touch, and there is some loss of motor power. There are apt to be epigastric pain, nausea, vomiting, headache, and dizziness. In severe cases paralysis and anaesthesia rapidly develop in the legs, although neur- algic pains may still continue. There may be temporary loss of consciousness. Prognosis. — The patient may convalesce in a few days, or recovery may result only after weeks or months of suf- fering and paralysis. Severe cases may pass into coma, and die in a few hours or days after the onset. Atrophic bed-sores and cystitis may complicate the course of the protracted cases. In some instances the patient is left with permanent paraplegia and the symptoms of transverse myelitis. Treatment. — A sufficient time must be spent in passing through the lock, in which the pressure is reduced. At least five minutes should be spent for each atmosphere. Workmen should be carefully selected and gradually accus- tomed to the work, and the hours of labor in the caisson should at first be short. When the symptoms occur, it is recommended that the patient should at once be put back under a slight atmospheric pressure. The use of ergot in large doses seems to be of service during the acute stages of the disease. Morphine may be required for the neural- 46 722 MAXL'AL OF THE PKACTICE OF MEDICINE. gic pains. The paralytic symptoms are to be treated on the same principles as those governing the treatment of myelitis. {c) DlSE.\SES OF THE SuBSTANCE OF THE CoRD. ACUTE ANTERIOR POLIOMYELITIS (ATROPHIC SPINAL PARALYSIS). Acute anterior poliomj-elitis occurs bdth in children and in adults. An infantile and an adult form are to be described. Anterior Poliomyelitis in Children. Etiology and Synonym. — The disease occurs in children between two and five \-ears of age, and is equally frequent in boys and girls, in weakly and in robust subjects. The majority of cases appear during the warm summer months. There may be a history of exposure to the hot sun, of a fall or an injury, or the condition may follow some acute infectious disease, especially measles. In some instances it would seem that the disease itself was of an infectious origin, and epidemics of the disease have even been re- corded. Synonym : Infantile paralysis. Pathology. — The lesion consists in the degeneration of the anterior motor cells, preferably of the lumbar and cer- vical enlargements. The ganglionic cells become swollen and degenerated, and may either return again to a normal condition or may become atrophied. During the earlier stages the gray matter about the motor cells becomes congested and infiltrated by leucocytes ; later the inflammation becomes chronic and results in an in- creased production of connective tissue. As the anterior motor cells preside over the nutrition of the anterior nerves and the muscles to which they are distributed, granular degeneration and atrophy of nerve and of muscle follow the destructive lesion of the motor cells. The lesion is usually bilateral, and affects groups of cells functionally associated (Remak describes an " upper-arm type," in which the supinator longus is paralyzed, with the biceps and the ACUTE ANll'.RIOR POLIOMYELITIS. 723 brachialis anticus). Through the anterior motor cells pass fibres from the central regions of the cord, controlling vas- cularity and general nutrition, so that destructive lesions of the anterior cells are regularly followed by imperfect growth, cyanosis, and a lowered temperature of the affected members. In cases of long standing the affected cornua become small and atrophied, and slight sclerotic changes are found in the pyramidal tract. Fig. 63. — Diagrammatic representation of the symptoms that result from acute destruc- tion of the anterior cornua of the spinal cord (Bramwell). On the left side the destruction of the nerve-cells is complete : the anterior nerve-roots, motor nerve-fibres, and the muscles which they supply are all degenerated ; there is a total " block " to the passage of voluntary motor and reflex motor impulses. On the right side two-thirds of the motor cells are de- stroyed ; two-thirds of the muscular area connected with the right anterior cornu are degen- erated and atrophied ; one-third (M) remains healthy, and can be made to contract by voluntary or reflex motor impulses. The symptoms may be divided into three stages : I. TJie Stage of Onset. — The onset begins abruptly, with fever of from 100° to 103° F., usually accompanied by con- vulsions, twitching of the muscles, delirium, or even coma. There may be, in older children, some complaint of aching in the joints. The symptoms may be well marked, or there may be only moderate fever which may pass unnoticed. The symptoms of this stage last for a few hours or for several days. ;24 .UAXCAL OF THE PRACTICE OF MEDICIXE. 2. The Stage of paralysis is distinctix'e in that the greatest degree of paral}'sis is reached at the onset, and any change afterward is for the better. When the paralysis has remained stationary for twenty-four hours the danger of further ex- tension is extremely small. The distribution of the paral- ysis depends upon the situation and extent of the lesion. The type is paraplegic, and the legs are more frequently affected than the arms, in the proportion of 4 : i. One or both legs may be paralyzed, or the muscles of the upper extremities may be affected as well, or may be paralyzed alone, or one arm and one leg may be involved. The paralyzed muscles are those functionally associated. The extensors are more frequently involved than the flexors. All the muscles of a limb are but rarely affected. After a stationary period of from two to six weeks some of the paralyzed muscles acquire their former power, while others remain paralyzed. The affected muscles are flabby, undergo wasting, and there is absence of all reflex action. Fibrillary twitchings may occur in the paralyzed parts, and the skin is bluish and cold to the touch. The affected muscles show the reaction of degeneration,' there being at first an ^Reaction of D<;generation (R. D.). — Since contractions only occur on clos- ing or opening the galvanic current, and as there are but two poles, the anode or positive and the cathode or negative, there are of necessity but four possible forms of contraction : 1. When the cathode is on the muscle and the anode upon a neutral and distant point — {a) the contraction which occurs on closing the current (the cathodal closure contraction, or C. C. C.) ; {b) the contraction which occurs on opening the current (cathodal opening contraction, or C. O. C). 2. When the anode is on the muscle and the cathode upon a distant neutral point — {a) the contraction which occurs on closing the current (anodal closure contraction, or A. C. C); (^) the contraction which occurs on opening the current (anodal opening contraction, or A. O. C). These four forms of contraction occur in a definite order of intensity, which order dififers in health and in disease. In health the order is — C. C. C- A. C. C.-A. O. C.-C. O. C. The A. O. C. and the C. O. C. are usually evident only with currents of such intensity as to cause pain. In degeneration of the anterior nerve or of the motor cells of tlie anterior comua the order is changed to the "reaction of degeneration," in the follow- ing order of intensity : A. C. C.-C. C. C.-C. O. C.-A. O. C. The character of the contraction is also changed, being slow, prolonged, and even tetanic. ACUTE ANTF.R/OR I'OLIOMYEIJTIS. 725 increase and then a decrease in the galvanic irritability, and in two weeks or sooner there is a total loss of farad ic ex- citability. Negative symptoms are important: (i) There is no secondary involvement ; (2) the bladder and the rectum are unimpaired; (3) trophic changes in the skin do not occur; {4) there is no change in the mental condition nor in the general health; (5) the cranial nerves are not involved. 3. Symptoms of pei'manait deformity are due (i) to the condition of the paralyzed limb — the growth is retarded, the limb appears atrophied, withered, cold, and bluish ; (2) to increased mobility of the joints, owing to the relaxed con- dition of the paralyzed muscles ; (3) to muscular contracture of the unparalyzed muscles, the type of which deformity is club-foot. The prognosis for life is good, but perfect recovery from paralysis is not to be expected, although a certain amount of improvement almost always occurs. The following rules may be given in the way of estimating the extent of perma- nent paralysis: Muscles which in two weeks respond to faradism will surely recover, while muscles not thus respond- ing will remain paralyzed for a greater or less time. Mus- cles which in three months show a return of irritability to faradism will recover partially. Muscles which do not re- spond to faradism in six months will never recover. It is important never to give too gloomy a prognosis as long as the faintest contraction is produced by the faradic current. Treatment. — During the stage of onset the spine should be cupped and fever be controlled by the ordinary measures. A brisk laxative should be given at the onset. During the earlier part of the stage of paral5'sis ergot and sodium bro- mide with small doses of potassium iodide should be given until some amount of improvement appears. During this time the paralyzed members should be wrapped in cotton. In two or three weeks, when the acute stage has passed, strychnine should be administered, as in the following prescription : •J 26 .U.LVr.lA OF THE PRACTICE OF MEDICLXE. R. Strychnin.x sulphat., g*"- "gV 5 Feni pyropliosphat., gr. j ; Acid, phosphoric, dil, TIX iv ; Sx'rup. zingiberis, ad .^j. — M. Sig. Such a dose three times a day to a child from three to five )'ears of age. Tlie affected parts should be carefuU)- and persistently rubbed morning and evening, and the muscles should at the same time be gently kneaded. The faradic current should be applied daily to such muscles as respond, while to the paralyzed muscles the slowly interrupted galvanic current should be applied. For the permanent deformities much good can be done by various apparatus or by surgical measures. Anterior Poliomyelitis in Adults. Males are more usually affected than females. The etiol- og}'- and pathology are the same as in children, but the fol- lowing clinical differences are observed: (i) The onset is less acute ; (2) the cranial nerves may be involved in some cases ; (3) rheumatoid pains may be present, and are referred to the affected muscles and joints ; (4) muscular tenderness may be extreme ; (5) fewer muscles are affected than in children, and recovery is usually more complete ; (6) owing to the development of the limbs of an adult, the withering and retarded growth of the affected member are not so noticeable. Although the adult cases of anterior poliomyelitis are described as the counterpart of the same disease in children, there is strong probability that the disease is really a multi- ple neuritis. Further observations are necessary to deter- mine this point. SUBACUTE AND CHRONIC POLIOMYELITIS. Synonyra. — Duchenne's paralysis. It is undecided whether this disease is a chronic polio- myelitis or a multiple neuritis. The pathology is therefore obscure. PROGKKSSIVIi MUSCULAR A'1'N()J'//Y. 727 Etiology. — The disease is rare, and is almost exclusively confined to adults. Symptoms. — The onset is gradual, and is characterized by motor weakness which increases in extent and ultimately leads to paralysis. The paralyzed muscles rapidly atrophy, show absence of reflexes, and the R. D. can be obtained. There is no sensory involvement, nor is the bladder or the rectum implicated. The symptoms usually begin in the legs and extend to the trunk and the upper extremities (ascending type) ; or the disease may be first noticed in the arms, and may spread to the legs (descending type). The early stages of the descending type, in which the arms are first affected, may closely resemble lead-paralysis. Prognosis. — In the majority of cases a certain degree of improvement is noticed in a few weeks or months, but recovery is incomplete except in rare cases. In some instances death results from an extension of the disease to the medulla, with the symptoms of bulbar paralysis. The duration of the disease is usually from one to four years. Treatment is that of the acute poliomyelitis after the febrile stage has passed. PROGRESSIVE MUSCULAR ATROPHY. Etiology and Synonyms. — The disease is most frequent in males between twenty-five and forty-five years of age. An hereditary influence is often observed, and there are cases in which the disease has been handed dov/n for five genera- tions. It is possible that some of these hereditary cases, however, are really examples of idiopathic muscular atrophy. Excessive physical exertion, mental worry, expos- ure to wet and cold, syphilis, and chronic lead-poisoning have been ascribed as exciting causes ; the affection has been known to follow measles, typhoid fever, and acute rheuma- tism. Synonyvis : Wasting palsy; Chronic anterior polio- myelitis. Pathology. — The lesions are found in the muscles, nerves, and cord. The muscles are wasted and pale, and the fibres are shrunken. Certain fibres are seen to have entirely disap- peared, leaving empty and collapsed sheaths. The wasting 728 J/.I.Vr.lL OF THE PKACTICE OF MEDICINE. of the muscle is not en masse, but fibre after fibre is picked out in the process of atrophy. There may be an increase in the interstitial tissue. The atrophy of the fibres is simple, and granular degeneration is not apparent as in infantile paralysis. The anterior nerve-roots emerging from the affected part of the cord undergo simple atrophy, and fibre after fibre disappears. In the cord the lesion is practically confined to the anterior cornua. The motor ganglionic cells Fig. 64. — Diagrammatic representation of the symptoms that result from slow destruction of the multipolar nerve-cells of the anterior cornu (Bramwell). On the left side the disease is in an early stage. One nerve-cell {a') is completely destroyed. Its muscular fibre (1') is completely atrophied Voluntary motor and reflex motor impulses are " blocked " at the seat of the lesion {a'). One nerve-cell (//) and its muscular fibre (a') are very much atro- phied, but feeble motor and reflex impulses can still pass through the cell to the muscle. Two nerve-cells (cV) are healthy. Their muscular fibres are of normal bulk, and can be made to contract either by voluntary or reflex impulses. On the right side the disease is much more advanced. The muscular area is three-fourths degenerated. There is a total " block " at a and a. This condition represents a late stage of progressive muscular atro- phy. The atrophy of the muscular fibres is represented as simple. waste, lose their processes, and one after another undergoes simple atrophy (Fig. 64). Sclerotic changes are usually found in the direct and crossed pyramidal tract, and when these changes are sufficiently marked to give rise to symp- toms, the name of " amyotrophic lateral sclerosis " is given to the resulting complex lesion This form of disease will be separately considered. In many cases the disease extends upward to involve the motor nuclear cells in the medulla. The symptoms begin gradually and insidiously. It is PROGRKSSfVP: MUSCULAR ATROR/fY. 729 noticed that the muscles tire easily, are not so firm as nor- mal, and ache after slight exertions. Fibrillary contractions may be observed. The atrophy is usually first noticed in the interossei muscles and in those of the ball of the thumb. Motor weakness is proportionate to the extent of the atrophy, as there is in this disease no essential paralysis. Advanced atrophy of the interossei give the hand the " griffin-claw " appearance, in which flexion of the last two phalanges is associated with extension of the first phalanx at the metacarpal joint. Occasionally the deltoid is the first muscle to suffer, and its atrophy may present a deformity of contour closely resembling a subglenoid dislocation of the humerus. In 90 per cent, of the cases the disease begins in the hand or shoulder. More exceptionally the affection may first show itself in the lumbar or abdominal muscles, and still more rarely in the muscles of the legs. The atrophied muscles are flaccid, and usually retain their normal elec- tric reactions, for what muscle is left is good. In late cases, however, with rapid atrophy the R. D. may finally appear. Reflexes are diminished according to the amount of the atrophy. Fibrillary twitchings are not infrequently present. Atrophy proceeds from muscle to muscle in the order of the juxtaposition of their nerve-nuclei in the cord. Bilateral symmetry is usually preserved, al- though the wasting may be more marked on one side than the other. Owing to the contracture of unparalyzed muscles various deformities result; the " grififin-claw," or " main de griffe," has already been described. When the lumbar muscles are implicated the back is arched and the line of gravity falls behind the sacrum. When the abdom- inal muscles are affected the back is also arched, but the line of gravity falls in front of the sacrum. In course of time all the voluntary muscles may become implicated, so that the patient is practically reduced to " skin and bone." The normal appearance of the facial muscles is in strong contrast to the wasting of the rest of the body. Ophthalmoplegia externa and bulbar paralysis may develop toward the close of the disease. 730 MAXCAL OF THE rRACTJCE OF MEDICIXE. The diagnosis of " main de grifife " from lesion of the uhiar nerve is made by the absence of sensor\' symptoms. Tlie diagnosis from idiopathic muscular atroph\- is to be made by tlie different order of distribution of the atropliies in the latter disease, and by the fact that the latter condition usually occurs in \-oung children. Amyotrophic lateral sclerosis is to be excluded by the absence of spasm and rigidity. Prognosis. — The course of the disease is usually progres- sive. Death may result from exhaustion, from bulbar paral- ysis, or from respiratory affections. The disease may be- come quiescent at any time, and the patient may live for years. These cases are often seen as freaks in museums, under the name of " living skeletons." Treatment is of no avail. The general nutrition of the muscles should be maintained by massage and electricity, and strjxhnine, arsenic, and nitrate of silver may be given internally. If the muscles of respiration be affected, extra- ordinary care should be taken to avoid cold, as even a trifling bronchitis may terminate fatally. AMYOTROPHIC LATERAL SCLEROSIS. Etiology. — This condition is really one of progressive muscular atrophy in which sclerosis in the lateral columns is sufficiently marked to produce symptoms, and is not at present regarded as an independent disease. The etiology is therefore the same as that of progressive muscular atrophy, except that the disease may occur after the age of seventy as a senile change. Pathology. — The lesions are the same as those of pro- gressive muscular atrophy, except that the direct and crossed p\Tamidal tracts show degeneration and sclerotic change, and the motor nuclear cells of the pons and of the medulla are more frequently involved. The symptoms result from the combination of progres- sive muscular atrophy and lateral sclerosis. Wasting and weakness progress, with rigidity, contractures, and exagger- ated reflexes. In the hands and arms the atrophy and weak- ness are especially well marked, while in the legs typical spastic paraplegia develops early. Fibrillary twitchings of BULBAR PARALYSIS. 73 I the muscles are commonly observed. There are no sensory disturbances, and the bladder and the rectum are under full control. Ultimately the rigidity and muscular wasting be- come general, paralysis results, and symptoms of bulbar paralysis or of ophthalmoplegia externa make their appear- ance. The prognosis is not as good as in progressive muscular atrophy, as the disease is seldom if ever arrested. Death results in from one to four years. Treatment is of no avail. Long-continued rest in bed has been recommended. BULBAR PARALYSIS. Synonym. — Glosso-labio-laryngeal paralysis. Two forms of bulbar paralysis are recognized — the acute and the chronic. 1. Acute bulbar paralysis results (i) from small hemor- rhages into the medulla ; (2) from areas of softening follow- ing embolism or thrombosis ; (3) from an acute inflamma- tory affection analogous to anterior poliomyelitis ; (4) as a terminal lesion of Landry's paralysis. The lesion is almost regularly bilateral. The symptoms are those of the chronic form, differing only in their acuteness of onset. There may be hemiplegia or crossed facial paralysis. These acute cases prove rapidly fatal, although in rare instances the condition may become chronic. 2. Chronic bulbar paralysis is commonly associated with similar degeneration of the motor cells of the spinal cord. The condition is rare before the age of forty, and usually appears as the terminal event of progressive muscular atrophy, of amyotrophic lateral sclerosis, or of Duchenne's paralysis. Symptoms. — There is a progressive palsy of the tongue, lips, palate, pharynx, and laryngeal muscles, resembling in character the muscular changes of progressive muscular atrophy. The tongue becomes tremulous and is protruded with difficulty, and finally the lingual and dental consonants d, /, n, r, and t cannot be pronounced. The tongue atro- 732 J/AXr.lL OF THE PRACTICE OF MEDICLXE. phies. Chewing and swallowing are impaired. The lips be- come paralyzed and tremulous, the patient cannot whistle, and the lip-letters b, f, f, o, and // cannot be pronounced. Saliva drools from the mouth. There may be an emotion- less expression, from facial paresis and atrophy. The pharynx becoming paralyzed, food regurgitates or cannot be swallowed. The lar)'ngeal muscles waste, so that the voice is weak, almost inaudible, but extreme degrees of abductor paralysis are rare. Cough becomes impossible, and, the larynx being unprotected, aspiration- or deglutition- pneumonia is rendered possible. There are no sensory symptoms, and the mind is clear though emotional. Taste is not impaired. Pulmonary and cardiac crises occur when the nucleus of the vagus is affected. Severe dyspnoea appears on exertion, and, later, furious spontaneous attacks of suffocation, with cyanosis and a sense of extreme fulness in the chest, may appear. The cardiac crises consist of a rapid and excessively feeble heart-action, pallor, anxiety, and a sense of impend- ing death. The diagnosis is not usually one of difficulty. The condition, however, may be simulated by a bilateral lesion in the lower portion of the third frontal convolution (" pseudo-bulbar paralysis of cerebral origin"). Prognosis. — The duration of the disease is from one to four years, with periods of temporary inactivity. Death results from inanition, from aspiration-pneumonia, or from heart-failure during a cardiac crisis. Treatment. — The only thing that can be done is to advise the feeding of the patient by the stomach-tube when deglutition becomes impaired. OPHTHALMOPLEGIA. This rare disease is due to the progressive atrophy of the nuclei of the cranial nerves of the eye or the eyeball. Ac- cording to whether the external or the internal muscles are affected, there are described ophthalmoplegia externa and ophthalmoplegia interna. OpJithalnioplcgia cxtcr)ia may be found associated with LATERAL SCLE/WS/S. 733 generaf paresis, progressive muscular atrophy, and loco- motor ataxia, or the nuclear degeneration may be due to the pressure of tumors or to basilar meningitis. Mental disorders are present in about one-fifth of the cases, and atrophy of the optic nerve may coexist. There is a gradual loss of power in the extrinsic muscles of the eyeball, start- ing first in the levator muscles of the lid and in the superior recti. The loss of power finally becomes absolute. Ptosis, squint, and double vision appear during the earlier stages, but later the eyeball becomes fixed and immobile and may protrude. The disease is essentially chronic. Ophthalmoplegia interna causes loss of pupillary reflex and of power of accommodation, and is usually associated with locomotor ataxia or with general paresis. The con- dition may be combined with the external form. Ophthal- moplegia interna may result from nuclear degeneration or from disease of the ciliary ganglion. LATERAL SCLEROSIS (SPASTIC PARAPLEGIA). Lateral sclerosis may be primary or secondary. Primary lateral sclerosis is so rare a condition that by some its existence is doubted. It is said to be induced by syphilis, over-work, exposure, and sexual excesses, and to attack males of middle life. Secondary lateral sclerosis is the most frequent form of spastic paraplegia, and results from any lesion destroying the motor cells in the cerebral cortex or cutting off the pyramidal fibres from their trophic centres in the motor cortical cells. These lesions may be cerebral or spinal. Such lesions are — (i) Tumors, softening, or hemorrhage in the brain, destroying the motor tract in one hemisphere. Secondary sclerosis is found below the lesion in the anterior median column and in the opposite lateral pyramidal tract. (2) Congenital malformation, hydrocephalus, or bilateral meningeal hemorrhage affecting both motor tracts. In these cases the descending degeneration is bilateral, involv- ing both anterior median columns and crossed pyramidal tracts. (3) Any lesion in the cord, unilateral or bilateral, that separates the fibres of the motor tract from their trophic 734 MAXr.lL OF THE rKACTICE OF MEDICIXE. centre in the motor cortex of the brain. Such lesions are transverse myehtis, hemorrhage into the cord, or slow com- pression of the core! by tumor, disease, fracture, or dislocation of the vertebra, and menini^eal hemorrhage. (4) The lateral columns may be involved with other tracts in the cord — with the cells of the anterior horns causing amyotrophic lateral sclerosis, with the posterior columns causing ataxic paraplegia. These combined lesions will be individually described. Patholog-y. — The lesion is found to be limited to the lateral motor tracts. The anterior median columns may be involved in the case of a primary lesion in the brain. There is an increase in the connective-tissue framework, and a destruction and disappearance of the axis-cylinders of the nerve-fibres. Symptoms. — Of the Primary Form. — There are first noticed a loss of endurance in walking, and stiffness and rigidity of the muscles. The muscular weakness is pro- gressive, and merges into paralysis of voluntary motion. Coincident with the weakness there is a rigidity of the affected limbs from a more or less continual spasm of the muscles. From time to time clonic spasms occur, especially during the night, during which the legs are twitched or suddenly jerked out. The gait becomes " spastic " — the toes stick to the ground, the knees touch or overlap in ■walking, and the leg is in a condition of spasmodic tension, or even shows distinct clonus when the ball of the foot rests upon the ground. The trunk is usually thrown forward by tonic contractures of the calf-muscles, so that crutches or canes held far in advance of the body become necessary. The power of locomotion is finally lost. The affected muscles do not atrophy, and the R. D. is not present. The reflexes are regularly ijicreased. The knee-jerk is exces- sive and prolonged, and may be radiated to the arms or to the opposite leg. Ankle-clonus is easily obtained. There are no essential sensory symptoms, though there may be dull pains in the muscles, and the bladder and rectum are not usually involved until late in the disease. Ocular LOCOMOTOR ATAXIA. 735 symptoms are rare. The arms may escape altogether, or rigidity may appear as a late manifestation of the disease. Of the Secondary Form. — The symptoms are bilateral or unilateral according as to whether one motor tract or both are affected. Cerebral lesions usually lead to unilateral sclerosis. The symptoms appear rapidly or gradually ac- cording to the nature of the primary lesion. " Late rigid- ity " with hemiplegia following cerebral hemorrhage is synonymous with secondary lateral sclerosis. Spastic paraplegia of infants is usually a birth-palsy due to meningeal hemorrhage. In other cases the condition arises from an arrested development of the pyramidal tracts. The symptoms may be bilateral, and the arms are not infre- quently involved. Idiocy, imbecility, and other mental de- fects are usually present. The diagnosis from hysterical spastic paraplegia may be one of great difficulty, as the hysterical form may exactly reduplicate the symptoms of the organic disease. In favor of the hysterical condition are (i) the sudden development of symptoms, (2) the history of hysterical attacks in the past, (3) the presence of anaesthesia, hyperaesthesia, or other hysterical manifestations, and (4) the sudden remission of muscular contractions, which in the organic form should be more permanent. Prognosis. — The course of the disease is chronic, extend- ing over many years.' The disease is the least fatal of all the chronic spinal affections. Its progress may be arrested at any time. Treatment. — In syphilitic cases mercury and iodide of potassium may be tried ; strychnine is contraindicated ; the bromides may be of use in reducing the condition of over- reflexes ; otherwise^ there is no medicinal treatment of any value. LOCOMOTOR ATAXIA. Etiology and Synonyms. — This disease occurs in males ten times as frequently as in females, and is most common between thirty and fifty years of age. Its occurrence under the age of twenty-five is rare. The great predisposing cause is syphilis, which precedes the disease in two-thirds of the 73<3 M.LVL'AL OF THE PRACTICE OF MEDICE\E. cases. Amoiii::^ exciting causes are sexual excesses, great pln^sical exertion, and repeated exposures to wet and cold. Synonyms : Posterior spinal sclerosis ; Tabes dorsalis. Patholog-y. — There is a sclerosis, beginning first in the middle zone of the column of Burdach and in the column of Lissauer (the narrow marginal zone lying between the posterior horn and the pyramidal tract), and extending to the column of Goll and the remainder of the column of Burdach (Fig. 65). The network of fibres about the vesic- ular columns of Clarke are affected by the sclerotic pro- cesses early in the disease. The lesion begins in the lumbo- sacral region and extends upward throughout the cord. In long-standing cases the sclerosis extends to the lateral Fig. 65. — Localization of the lesion in successive stages of locomotor ataxia. columns and leads to the degeneration of the pyramidal and direct cerebellar tracts. The posterior nerve-roots show the lesions of a degenerative neuritis, and become small and atrophic. These nerve-changes are frequently first observed in the cutaneous filaments, and may even pre- cede the sclerosis of the posterior columns. The meninges over the lateral and posterior columns are thickened and abnormally adherent ; their blood-vessels show the changes of arterio-sclerosis. Besides neuritis there may be muscu- lar atrophy. Atrophy may occur in any of the cranial nerves, especially the optic, third, auditory, and pneumo- gastric nerves. There may be sclerosis of the restiform bodies or of the inferior peduncles of the cerebellum, or sclerotic areas in the hemispheres may resemble the lesions of general paresis. The disease is not yet thoroughly understood, and three theories are advanced to account for the lesions: (i) That there is a primary sclerosis of the posterior columns; (2) that the sclerosis is dependent upon arterial degeneration of the LOCOMOTOR ATAXIA. 73/ vessels entering the posterior root-zones ; and (3) that the disease originates in the gangha of the posterior nerve-roots, with secondary degeneration of the sensory fibres entering the cord from these ganglia, with secondary sclerotic changes in their course. The symptoms of locomotor ataxia may be divided into three stages: (ij The stage of pain; (2) that of ataxia, and (3) that of paralysis. I. Stage of Pain. — The following are the characteristic symptoms of this pre-ataxic stage : . ia) Pain, of a paroxysmal darting character, appears in 90 per cent, of the cases. The pains are bilateral, dart down the legs, and are generally referred to the deeper structures of the limb. Their distribution is irregular, rarely corre- sponding to the nerve-trunks. The characteristics of the pains are their " lightning " character and the absence of local tenderness. Occasionally trophic eruptions appear. In rarer instances the pain may be diffused and superficial, or the feeling may be described as one of intense heat or cold. Lightning pains in the arms occur when the lesion extends to the cervical enlargement of the cord. Pain may be absent or insignificant in a few cases beginning with rapid optic atrophy, and in these patients ataxia is not apt to be developed. {b) There are symptoms of perverted sensation. The patient may complain of numbness or tingling in the legs or the feet, or may feel as though he were walking on cotton or on air-bags instead of on solid ground. There may be a sensation of tightness and pressure about the waist. In some instances the " muscular sense " becomes so impaired that the patient cannot tell in what position the limbs are placed when the eyes are shut. During this first stage, however, the sensory symptoms are subjective, and areas of anaesthe- sia or of retarded sensation cannot be demonstrated. {c) Loss of kncc-jcrk (Westphal's symptom) is one of the earliest indications of the disease, and its association with the lightning pains and the ocular symptoms forms a symp- tom-group absolutely diagnostic of locomotor ataxia. The superficial reflexes remain good. 47 y^S MAXi'Al. OF THE PRACTICE OF MEDICINE. id) Ocular Symptoms. — There may be ptosis, strabismus, double vision, or in rare cases ophthalmoplegia externa. Contracted pupils (" myosis spinalis ") are frequent, but not constant. Optic atrophy may develop, causing dimness and restricted field of \ision and color-blindness, and the atrophy may progress until the vision is entirely lost. Cases in which the atropln- of the optic nerve appears early and pro- gresses rapidly do not seem to develop the second stage of ataxia. The Argyll-Robertson pupil occurs during the first stage in over 80 per cent, of the cases. In this condition the pupils do not react to light, but accommodation to dis- tance is preserved. {c) Bladder and Rectum. — There may be lightning pains referred to these viscera. Constipation is usually obstinate. Micturition may be frequent and painful, or there may be imperfect control of the bladder, with dribbling, partial re- tention of urine, and cystitis. Impotence may appear, oc- casionally preceded by priapism and sexual excitement. 2. Stage of Ataxia. — Old symptoms persist while new symptoms appear. The lightning pains may continue, but they tend to become less and less severe. Objective sensory disturbances can now be demonstrated ; there may be areas of anaesthesia or hyperaesthesia or of retarded sensation. The power of localizing pain may be lost, and the muscular sense becomes more and more impaired, so that motions cannot be made accurately without the aid of sight ; hence a blind ataxic patient may become almost totally helpless. The eye-symptoms noted above continue, or they may appear for the first time. Optic atrophy occurs in 20 per cent, of the cases, and its antagonism to the development of ataxia has already been noted. There is usually difficulty in emptying the bladder, and retention with cystitis is apt to result. Deafness may occur from neuritis of the auditory nerve. The characteristic symptoms of the second stage are ataxia, visceral crises, and trophic changes. Ataxia usually develops in the legs, although in rare instances the arms may be first involved. The patient loses the power to co-ordinate muscular movements so as to pro- duce a harmonious result There is an inability to stand LOCOMOTOR ATAXIA. 739 Steadily with the eyes shut (Romberg's symptom), to walk readily in the dark, or to turn quickly without fallinf;. In- co-ordination of the arms is usually apparent in writing, in buttoning the clothes, or in handling the knife and fork when at table. Ataxia is demonstrated by having the patient stand or walk with the eyes shut, or touch toe to Fig. 66.— Locomotor ataxia, showing Charcot's knee (personal observation). heel or heel to knee, or to rapidly touch the nose with the finger when the eyes are shut. The gait becomes character- istic. The legs are far apart ; the body is inclined forward, so that the support of a cane may be a necessity. The foot is lifted high at each step, and is planted forcibly upon the ground with a stamp or a slap. The muscular power is 740 .y.txr.iL of the practicf. of mkpiclxe. maintained, and the nutrition of the muscles, except toward the close, is usually unimpaired. Visceral crises are characterized b\- paroxs\-mal pain in the various viscera. Thus, gastric, laryngeal, renal, cardiac, rectal, and genital crises are described, of which the gastric and the laryngeal are the most common, and are due to neuritis of the pneumogastric nerve. A gastric crisis consists of severe paroxysmal pain, vomiting, and hyperacidity. There may be hn^matemesis. The laryngeal crisis gives rise to dyspnoea, hoarse coughing, and intense pains in the shoulder and spine. There may be fatal asphyxia, or the larynx may become anaesthetic, so that death may result from aspiration- pneumonia. Renal crises may reproduce the symptoms of calculus. Cardiac crises give rise to pain in the heart, ir- regular and feeble pulse, and syncope. Trophic CJiangcs. — Of these changes, the most common are the arthropathies or joint-lesions known as "Charcot's joints" (Fig. 66), which occur in from 5 to 10 per cent, of all cases. These changes are most common in the larger joints, especially the knee. The joint swells rapidly from serous effusion, the articular ends of the bones become absorbed, ligaments soften so that dislocations and unnatural mobility become evident, and there is an irregular produc- tion of new bone about the edges of the articular surfaces. These changes are essentially trophic in character, but an exciting cause may be found in some traumatism of which the patient is unconscious owing to the anaesthesia of the parts. The joint-lesions progress without fever and without pain, and the symptoms may develop in from twenty-four to forty-eight hours. The chief points of differential diagnosis from rheuma- toid arthritis are as follows : Rheumatoid Arthritis. Charcot's Joint. Hypertrophy. Atrophy. Painful. Painless. Limited mobility. Increased mobility. Slow process. Rapid process. Small joints. Large joints. Symmetry of lesions. No symmetry ; usually unilateral. No ataxia. Ataxia. LOCOMOTOR ATAXIA. 74 1 Besides Charcot's joint other trophic changes may occur. The bones may rarefy and be the seat of spontaneous frac- ture. Absorption of the articular ends of the bones leads to dislocation. There may be herpes, cedcma, local sweating, perforating ulcer of the foot, inflammation and falling of the nails, and atrophy of muscles. ■ij. The stage of paralysis occurs when the patient loses the power of walking. Paraplegia develops from involve- ment of the lateral columns. The patient may develop during the second or third stage of the disease general paresis, melancholia, or delusional insanity. Cystitis and pyelo-nephritis are apt to develop. Pneumonia or bed- sores may hasten the final issue. Prognosis. — The course of the disease is chronic, lasting from twenty to forty years. Ataxia is rarely developed until from five to eight years after the beginning of the dis- ease. There have been described rare instances of acute ataxia in which the patient became bedridden within a few months. Recovery never occurs, although the disease may be arrested at any time, especially during the first stage, and may even show periods of temporary improvement. The disease itself seldom causes death. Treatment. — A quiet and regular mode of life should be enjoined. Alcoholic and sexual excesses should be abso- lutely interdicted. Rest in bed for several months is some- times serviceable in modifying the neuralgic pains. Spinal douches, tepid or cool, may be ordered daily, but extreme temperatures should be avoided. The medicinal treatment is somewhat varied, as there seems to be no drug capable of exerting a beneficial effect upon the disease to any appreciable extent. The drugs that have been recommended are mercury and iodide of potas- sium, especially in recent syphilitic cases; arsenic in full doses ; nitrate of silver in gr. \ doses three times daily for periods of not longer than two months ; chloride of sodium and gold ; chloride of aluminum in 2- to 4-grain doses; and ergot in moderate doses. The pains may be relieved by counter-irritation to the spine, preferably by the thermo-cautery applied every two 742 MAXCAL OF THE PRACTICE OF MEDICIXE. or four weeks, but the application of counter-irritants should not be severe, especially o\'er anaesthetic portions of the skin, as destructive trophic changes may ensue. Pain may also be- relieved by phenacetinc or antipyrine, but opium should be given with caution, for fear of the habit being formed. The treatment by suspension is now being abandoned, as the published results do not agree with the first enthusiastic reports. Charcot's joints are to be treated by rest and apparatus. Morphine may be indicated during the visceral crises. HEREDITARY ATAXIA. Etiology and Synonym, — The disease may or may not be hereditary ; in the latter case a history of nervous dis- orders — insanity, inebriety, or nervous irritability — is gener- all\' obtained. The disease, which is apt to appear between the fifth and fifteenth years, rarely as late as the twentieth year, is one of defective development. Synioiyni : Fried- reich's ataxia. Pathology. — There is extensive sclerosis of the posterior and lateral columns of the cord ; this sclerosis may extend upwards to involve the medulla. Symptoms, — Ataxia is first developed in the legs, but the gait differs from that of locomotor ataxia in being more swaying and irregular and less stamping. Romberg's symp- tom may or may not be present, and the reflexes may be preserved. Ataxia appears in the arms, giving rise to irreg- ular choreiform movements. Rhythmical movements may also be observed during rest. Nystagmus and slow, scan- ning speech are commonly observed, but visceral symptoms and optic atrophy are uncommon. Trophic changes are not observed. There is a fairly characteristic deformity of the foot ; the patient walks on the outer edge of the foot, the big toe is flexed dorsally upon the first phalanx, and talipes cquinus is developed. There are no sensory symp- toms. The mind becomes impaired late in the disease. As the disease progresses paralysis appears ; this paralysis may become complete. MYKUrfS, ACUTE AND CHRONIC. 743 Prognosis. — The disease is incurable, but its course ex- tends over years. Treatment is unavailing. ATAXIC PARAPLEGIA. Etiology. — Males of middle age are most frequently affected. There may be a history of exposure to cold or of sexual excesses, but antecedent syphilis is rarely to be demonstrated. Pathology. — The lesion consists of a combined sclerosis of the posterior and lateral columns, beginning in the lum- bar region. The nerve-roots are not involved as in loco- motor ataxia. Symptoms. — There are slowly developing weakness and rigidity of the legs, with ataxia. The knee-jerk is exag- gerated, and ankle-clonus can easily be obtained. The Romberg symptom is generally well marked. A dull, aching pain in the sacral region is the only sensory symp- tom of importance. Eye-symptoms are rare. The ataxia and weakness may extend to the arms, and in many cases there may be developed mental symptoms resembling those of general paresis. The muscular weakness ultimately merges into paralysis. Prognosis. — The disease is incurable. Death results from complications rather than from the disease itself The treatment is that of chronic myelitis. MYELITIS, ACUTE AND CHRONIC. Etiology.^-Myelitis may occur (i) from excessive physi- cal exertion, from exposure to wet and cold, or from sexual excesses ; (2) from injury or disease of the vertebral bones causing compression or destruction of the spinal cord, or from tumors of the cord itself; (3) from acute infectious diseases, especially small-pox, measles, and tj^phus. fever ; (4) syphilis as an exciting or predisposing cause of myelitis is questionable. Pathology. — The affected area of the cord feels soft and may even be diffluent. The softened area may be grayish or reddish in color (" red" or " gray softening ") according to 744 M.lXrAL OF THE PKACT/CI-: OF MEDICIXE. whether or not small hemorrhages into the cord-substance have occurred. The nerve cells and fibres swell, under>^o fatty degeneration, and the nn-elin oozes out as fatty drop- lets. Large numbers of inflammatorx- corpuscles are every- where present, and " Deiters' spider-cells," due to prolifera- tion of the neuroglia, are to be seen. The laminated bodies known as " corpora amylacea " are also present. The blood- vessels are dilated and may rupture. The meninges may also be involved. After a time conservative changes assert themselves. The area becomes firm from an increase of connective tissue, so that the cord at the affected point be- comes converted to a mass of cicatricial tissue containing perhaps a few nerve-fibres and cells. To this condition the name of " chronic myelitis " is applied. Secondary degenerations result (i) in the lateral columns below the lesion, and (2) in the posterior column and direct cerebellar tract above the lesion. The affected area varies. In general myelitis the cord is involved along its entire length ; in disseminated myelitis various segments of the cord at different levels are affected ; in transverse myelitis one or two segments of the cord at one level are destroyed. The effects of a transverse lesion of the cord are — (i) Voluntary motion is cut off from the parts below the lesion — paralysis. (2) Sensation is cut off from the parts below — anaesthesia. (3) Inhibitory fibres from the motor cortex checking over-reflexes are destroyed at the site of the lesion — increased reflexes. (4) The nutrition of the parts supplied directly from the affected area is impaired, atrophic changes resulting in nerve, muscle, and skin. Symptoms. — Four stages are described: (i) A stage of premonition, (2) one of irritation, (3) one of destruction, and (4) one of descending degeneration. I. Prcnionitory Stage. — There may be peculiar sensations in the parts afterward to be more seriously affected, and motor weakness may be noticed. There may be the " girdle sensation " of a string tied about the waist, from irritation of the nerves at the upper level of the lesion. In MYELITIS, ACUTE AND CHRONIC. 745 Other cases these symi)toms are absent, or there may be only a chill and fever. 2. The irritative stai^c is of short duration. Sensory symptoms consist of hyperctsthesia and neuralgic pains below the lesion, and the girdle-sensation. Pain in the back is uncommon unless the meninges become inflamed. The sensory symptoms of irritation soon become admixed with those of destruction, and feelings of numbness and areas of anaesthesia appear. The motor symptoms consist of twitchings, cramps, and spasms, combined with some loss of voluntary power. The duration of this stage varies from several hours to one or two days. 3. Stage of Destruction. — Two groups of symptoms are recognized — one, direct, due to the destruction of cord- tissue, and one, indirect, due to the cutting off of impulses to and from the brain. Direct symptoms are observed in the parts supplied directly from the affected segments. There is muscular paralysis, with atrophy and the reaction of degeneration. Reflexes are lost. There is anaesthesia of the skin supplied by the affected spinal nerves, with vaso-motor symptoms (coldness, sweating) and atrophic changes, as bed-sores. The atrophic bed-sore's are deep and gangrenous. The distribution of the direct symptoms depends upon the extent of the lesion. In general myelitis they are universal : if disseminated, they are scattered ; if transverse, they are limited to one level, the arms being involved in cervical myelitis, the trunk in dorsal myelitis, the legs if the myelitis involve the lumbar enlargement. Indirect symptoms result from the severance of the motor pyramidal and the sensory fibres at the site of the lesion. Below the lesion there is paralysis, with increased reflexes and muscular rigidity. The paralyzed muscles do not atrophy, and there is no reaction of degeneration. If the myelitis involve the lumbar enlargement, direct symptoms may be present in the legs — paralysis, atrophy, loss of reflexes, and the reaction of degeneration. If the reflex centre for the bladder be destroyed, the bladder will no longer contract to expel its contents, but there will be 746 M.lXr.-lL Of THE rRACTICE OF MEDICINE. incontinence from over-distention. Usually, however, the lesion is higher up than this, so that the reflex bladder- centre is still intact; there will then be reflex and uncon- scious passage of urine. The danger of cystitis threatens every case of myelitis. The functions of the rectum are similarh' affected. There is regularly anrtsthesia below the lesion. The imper- fect sensation allows of the formation of bed-sores, from pres- sure or from dirt, over the sacrum, the glutei, or the heels. These pressure bed-sores are at first superficial, and can be prevented by careful nursing. The atrophic bed-sores in areas of skin supplied by nerves from the destroyed seg- ment cannot be prevented, and the}^ are large, deep, and gangrenous. Cerebral s)Mnptonis are rare. There ma\' be optic neur- itis with blindness. The pulse varies from 100 to 140; the temperature varies between 102° and 104° F. The fever quickly subsides unless cystitis, pyelitis, or acute atrophic bed-sores develop. During this stage the patient may die from paralysis of the respiratory muscles, pneumonia, cystitis, pyelitis, suppurative nephritis, or acute atrophic bed-sores. The majority of patients, however, pass into the stage of descending degeneration, or " chronic myelitis." 4. Stage of Descending Degeneration. — In a few cases some motor power is regained and some sensations are per- ceived, so that the patient is able to get about on crutches, although with spastic paraplegia and loss of bladder- control. In other cases no improvement is noted, and the patient remains bedridden, with parah'zed, twitching limbs and cystitis. Pain in the back develops in the majority of cases, from the occurrence of chronic meningitis. Death results from suppurative nephritis, pneumonia, or bed-sores. Prognosis. — In very acute cases death may result in five or ten days. Transverse myelitis in the cervical region is usually fatal from paralysis of the respiratory muscles. The majority of cases, however, pass into the chronic condition of spastic paraplegia, from which but trifling improvement can be expected. Treatment. — During the earlier stages the patient should ACUTE ASCENDING PARAL YSIS. 747 lie upon the side or face while the spine is cupped or is covered with a Chapman ice-bag. Active purgation by calomel or salts is indicated at the onset. Ergot in large doses has been recommended, but not too much is to be expected from its use. Morphine may be necessary for the relief of the pain. Great care should be exercised to prevent bed-sores and cystitis. The sheets should be drawn smooth, without wrinkles, and should be kept free from crumbs. The skin of the back is best hardened by daily frictions with alcohol and alum-water. The bed should also be kept dry, pads of absorbent cotton or a urinal being placed in position for the incontinence of the urine. Carefully padding the patient with small pillows may pre- vent a bed-sore, should a pressure-point become red and chafed, while in many cases a water-bed is indispensable. When bed-sores occur, simple antiseptic dressings are indi- cated. For the prevention of cystitis the urine should be drawn at regular intervals. The catheters should be kept surgically clean. If cystitis develop, the bladder should be washed out daily with a boric-acid solution (.5j : Oj). For the chronic condition counter-irritation of the spine has been advised, but blistering agents should never be used, as there is danger of bed-sores developing. Spasm of the limbs is relieved by heat to the spine or by general hot baths. Massage is indicated to keep up the nutrition of the muscles. Drugs are of no value in myelitis. Potas- sium iodide and mercury may be given to syphilitic subjects, and phosphorus and arsenic may be employed as nerve- tonics. Nitrate of silver (gr. ^) is often recommended. Strychnine is contraindicated if spasm exist in the paralyzed muscles. ACUTE ASCENDING PARALYSIS. Etiology and Synonym. — The disease is most common in men between the ages of twenty and thirty. Some cases have followed infectious fevers. Synonym : Landry's paralysis. Pathology. — In many of the cases an interstitial neuritis of the nerve-roots has been demonstrated, so that the disease has been classed- as a peripheral neuritis. In other 74 S M.IXCAL OF THE PKACriCE OF MEDICIXE. cases, however, no lesions have been found, so that it is supposed that the paralysis is due to some form of microbic poisoning. The disease bears a close resemblance to para- lytic rabies. Symptoms. — Weakness in the legs merges within a few hours into parah'sis, wliich spreads to involve the trunk, arms, and neck. Finally the muscles of respiration, deglu- tition, and articulation become affected, and there may be facial and eye-palsies. The reflexes are lost, but the mus- cles neither waste nor show the electrical reactions of de- generation. There may be numbness, tingling, or hyperaes- thesia, but sensory symptoms are neither constant nor essential. The bladder and rectum are seldom involved. Febrile reaction is trifling. Prognosis. — Death may result within two da\'s or may be postponed for one or two weeks. Recovery has occurred onh' in rare instances. Treatment. — Ergotin in 2-grain doses may be given every hour, and success has followed its administration; sodium salicylate and benzoate also have been recom- mended ; otherwise the treatment is symptomatic. SYRINGO-MYELIA. Etiology. — This rare disease is probably of congenital origin. Its exact cause is unknown. The symptoms usualh' appear in males between the ages of fifteen and twent\'-five. Pathology. — There is a development of embryonal neur- oglia-tissue about the central canal of the spinal cord ex- tending to involve the entire central gray matter. Degen- eration and liquefaction result in the formation in the spinal cord of a cavity filled with cerebro-spinal fluid ; the walls of the cavity are composed of gliomatous tissues. The usual situation is in the lower cervical and upper dorsal region. In other cases the cavity extends the entire length of the spinal cord. The cavity may invade the anterior horns, causing the symptoms of chronic anterior polio- myelitis, or may invade the posterior horns and columns, causing the symptoms of posterior sclerosis. COMPRESSION-M YKr.rflS. 'JA,/CEV£. — The pain is felt in one or more branches of the nerve, the ophthahiiic division being most frequently affected. Hyper- aesthesia of the skin and of the mucous membranes is com- mon, and vaso-motor phenomena are not infrcqucnth' pres- ent — flushing, sweating, salivation, increased nasal discharge, and lachrj-mation. There may be trophic changes — ery- thema, induration of the skin, loss of hair or local grayness. In severe cases there may be an associated spasm of the facial muscles — the " tic convulsif " Tender points corre- spond to the supraorbital, infraorbital, and mental foramina, less frequently to the occipital protuberance and the upper cervical spine. Trifacial neuralgia is frequently of reflex origin. Ccrvico-occipital Neuralgia. — The pain, which is usually dull and more or less constant, is localized over the back of the neck and the head, extending forward as far as the parietal eminences and the ear. There is frequenth' hj-pereesthesia of the scalp. The most important tender point is located mid- way between the mastoid process and the spine, where the great occipital nerve becomes superficial. Exposure to cold and cervical caries are the most frequent causes of this form of neuralgia. Cervico-bracJiial neuralgia, which involves the sensory nerves of the brachial plexus, is usually most intense in the axilla or along the course of the ulnar nerve. When the circumflex nerve is involved the pain is in the deltoid. The pain may be so increased by movement as to render the arm helpless. The most common tender points are the axillary, the circumflex at the posterior border of the del- toid, the superior ulnar behind the elbow, and the inferior ulnar in front of the wrist. Cervico-brachial neuralgia more frequently than any other form is the result of injury. Some severe forms are evidences of an occupation-neurosis. Intercostal neuralgia is very common in hysterica:l and anaemic women. Pain is felt along the intercostal nerves in aneurysm, caries, and pleurisy. There is usually a dull, constant pain, with acute stabbing exacerbations. Painful points are detected beside the vertebra, under the angle of the scapula, and under the breast. Pleurodynia differs NEURA/.(i/A. 775 from true intercostal neuralgia in being localized in one spot not corresponding with the course or exit of the inter- costal nerves. The pain is increased by expansion of the thorax rather than by lateral movements of the trunk. Herpes zoster occurs with the most aggravated form of intercostal neuralgia, which may persist after the eruption has subsided. The eruption and the neuralgia are due to neuritis. Ljuiibar neuralgia gives rise to pain along the crest of the ilium, the inguinal canal, and the spermatic cord, and in the testis, scrotum, and labium majus. Irritable testis is usually accompanied by syncopal sensations. Coccygodynia, which is common in women, is aggravated by the sitting posture. This form of neuralgia is usually very intractable. Sciatica. — The pain extends down the back of the thigh, often reaching as' far as the foot. The pain maybe uni- formly distributed along the course of the nerve, but not infrequently there are spots in which it is more intense. The pain is usually more or less constant and of a gnawing, burning character, but it may be paroxysmal, the paroxysms being usually more intense in damp weather and at night. The pain is regularly increased by walking; the knee is bent and the patient walks on the toes to diminish the ten- sion on the nerve. The painful points are located (i) above the hip-joint, near the posterior iliac spine, (2) at the sciatic notch, (3) about the middle of the thigh, (4) behind the knee, (5) below the head of the fibula, (6) behind the external malleolus, and (7) oh the back of the foot. Tenderness is usually also elicited by pressure along the course of the nerve. Muscular wasting and fibrillary twitchings compli- cate the severe cases. Sciatica is most common in those with a gout}^ or rheu- matic tendency. The nerve may be compressed by intra- pelvic growths or may be involved by spinal caries. The prognosis must be made with caution, as many cases of neuralgia prove intractable to treatment. Treatment. — All causes for reflex irritation must be dis- covered and removed if possible. A tonic and supporting "/■jd MAXCAL OF THE PRACTICE OF MEDICEVE. treatment is of the greatest importance. The patient should be built up in every possible way. Iron and arsenic are required for anaemic conditions ; gouty and rheumatic taints are to be treated ; quinine is to be given to malarial patients. The diet should be generous. Fats are indicated in nearly all of the cases, and a liberal amount of meat is to be allowed to all except those subject to gout. Many obstinate cases are benefited by residence in a dry inland climate. Strychnine, phosphorus, and cod-liver oil are of great service. For the pain, antipyrine, phenacetine, lactophenin, chloral, croton-chloral, the bromides, and cannabis indica may be given. Aconite and gelsemium are recommended for tri- facial neuralgia. Morphine, codeia, and hypodermic injec- tions of cocaine are to be withheld, because of the danger of forming the habit. Local applications are frequently of service. Heat, stimulating liniments, freezing of the skin by ether or methyl-chloride spray-s, blisters, or application of the actual cauter)^ may be employed. Surgical treatment may be required for obstinate cases. Nerve-stretching is not likely to be followed b}' permanent results. Neurectomy, or the excision of a portion of the affected nerve, is fre- quently followed by good results, but the pain may return in time. 7. GENERAL NERVOUS DISEASES. INFANTILE CONVULSIONS; INFANTILE ECLAMPSIA. Etiology. — Convulsions are so frequent in children that a special mention is justifiable. Owing to the lack of develop- ment of the higher cerebral centres of children, the lower centres are but improperly controlled, so that increased reaction to direct or reflex stimulation is permitted. The most important causes for convulsive seizures in children are the following : I. Rickets. — Convulsions, usually without marked febrile disturbance, occur from slight causes, and are apt to be repeated at mtervals for months. INFANTILE CONVULSIONS. yj7 2. G astro-intestinal Irritation. — This most common cause arises from dietetic errors, indigestion, or worms. The convulsions are usually accompanied by fever. 3. General exhaustion, especially if due to diarrhoea! disease. Convulsions may be part of a hydro-encephaloid condition. 4. MccJianical congestion of the brain ^ as with violent attacks of coughing. 5. Deficient aeration of blood, as with croup, diphtheria, or vitiated air in incubators. 6. During the first few days of life, from severe brain- injury during birtJi. If the convulsions be severe and per- sistent, meningeal hemorrhage should be suspected. 7. Peripheral irritation, as teething, phimosis, or otitis. 8. Acute febiile conditions, especially at the onset of measles, scarlet fever, and pneumonia. 9. Convulsions may usher in or accompany any serious disease of the nervous system in children. 10. Convulsions in infancy are not infrequently epileptic. The symptoms may be preceded by signs of irritation of the nervous system — restlessness, irritability, and twitch- ings. The attack begins with a fixation of the eyeballs ; the face becomes pale, the limbs and trunk become rigid and stiff. The fingers and toes are inverted (carpopedal spasm). Respiratory movement is impaired, so that the face becomes cyanotic. The spasm may relax, or may become clonic as in epilepsy. In some cases clonic spasms are marked from the start, and usually begin in the hands and face. The spasm may be followed by muscular rigidity for some little time. In convulsions due to indigestion the attack may be single ; in other cases attacks follow each other with great rapidity. Attacks coming irregularly and without assignable cause in children over two years of age are likely to prove to be true epilepsy. Convulsions may be followed by slight paresis or may lead to meningeal hemorrhage with hemiplegia. The prognosis is usually good. A dubious prognosis 77 S M.IXCAL OF rilE PRACTICE OF MEDIC I XE. should be given, however, in the case of weakly subjects, as fatal exhaustion may be induced. Treatment. — The first and most important measure is to search for the cause of the seizure, and to remove it if possible. If indigestion be the cause, a prompt emetic should at once be given, or the stomach may be washed out. For the attack itself, if severe, whiffs of chloroform should be given, and an enema containing chloral (gr. ij) and sodium bromide (gr. v-x) should be administered, these doses being suitable for a child of from six to twelve months. No time should be lost in immersing the child in a bath at 95° F. ; baths of a higher temperature are not suitable. After the bath an ice-cap should be employed or cold applications should be made to the head. Morphine may be necessary in case of recurring convulsions, but the drug should be administered with extreme caution, and should never be ordered for infants under six months of age. For a child of one year, gr. y^^- to y^- hypodermically will be a sufficient dose. EPILEPSY. Etiology. — Among the remote causes which induce this disease, heredity is the most important, a neurotic family history being obtained in about one-quarter of all cases. A direct inheritance of epilepsy is rare, but the parents are apt to suffer from nervous diseases or to be the victims of the alcohol habit. Any vicious influence deteriorating the parent stock predisposes to the development of epi- lepsy in the offspring. Consanguineous marriages exert a distinct influence upon the causation of the disease. Epilepsy may interchange with insanity in different gen- erations. An immediate exciting cause is determined in but one- third of all cases. There may be blows on the head, dissi- pation, fright, or continued reflex irritation. Many cases in children date from teething or from acute infectious diseases. Although in many cases the exciting cause may be removed, the nerve-centres may have formed the habit of discharging nerve-force, so that the seizures continue through life. EPILEPSY. 779 Males are more frequently affected than females. The disease appears before the thirteenth year in one-third of the cases, between the thirteenth and nineteenth years in one-third, and between the nineteenth and thirtieth years in one-third of the cases. After the thirtieth year idiopathic epilepsy is rare. " An epilepsy which develops after the thirty-fifth year of age is not idiopathic, but is due to some organic brain disease, to the abuse of alcohol, to reflex irrita- tion, or other causes, which in some cases may be so hidden as to be exceedingly difficult of recognition " (H. C. Wood). In the great majority of cases, recurring epileptic seizures in those over the age of thirty are due to brain syphilis. The pathology of epilepsy is obscure. A degeneration of the neuroglia in the brain has been described by some observers. The generally accepted theory is that the seiz- ures are due to a discharging lesion of the brain-cortex, so that an overflow of nerve-force occurs. Symptoms. — Loss of consciousness with general convul- sions is known as grand nial ; loss of consciousness with- out convulsions, as petit vial. Localized convulsions, usually without loss of consciousness, are described as Jacksonian or cortical epilepsy. Grand Mal. — The attack may be preceded by peculiar sensations, described as aurcB, which give warning to the patient that an attack is impending. Sensory aurae are the most common ; they differ in character in different patients, but are constant in the one subject. An aura consists of a peculiar sensation, felt in some part of the body, mounting upward to the head. Aurae of special senses are occasion- ally observed. An ocular aura consists of visual sensa- tions — flashes of light or of color, bizarre forms, double vision, or even blindness. In auditory aurae abnormal sounds or voices may be heard. An olfactory aura, which takes the form of a bad smell, is rather infrequent. Psy- chical aurae are not uncommon ; the patient may feel alarmed or may be in terror, or there may be a vague sense of strangeness or a dreamy sensation. In some cases the attack is preceded by forced movements ; the patient may run forward with great speed (" procursive epilepsy "), or 780 MAXr.-lL OF THE PRACTICE OF MEDICIXE. may turn rapidly around as if on a pivot. In many cases the aura is absent. The fit is usually abrupt; the patient falls to the ground unconscious. Preceding the attack there is generally a wild, harsh scream or groan. The fit occurs in three stages : 1. Totiic Spasm. — The head, eyes^ and mouth are rotated to the side on which the spasm is more intense ; the body is stiff and rigid. The hands are clenched, the arms and forearms flexed, the legs extended, and the feet extended and inverted. The body, however, is not always distorted in the same manner, as the muscular spasms may not be equally intense. The face, at first pale, becomes dusky or livid, owing to the respiratory spasm. The tonic stage lasts for from a few seconds to one or two minutes. 2. Clonic Stage. — Tremulous vibrations occur in the mus- cles ; the vibrations increase in range until the limbs are jerked and tossed violently about. The face is frightfully contorted, foamy saliva is forced from the mouth, and the tongue is apt to be severely bitten. Respirations are noisy and stertorous. Urine and feces may be passed involun- tarily, especially in nocturnal attacks. The pupils are im- movably dilated, and after the attack usually show remark- able oscillations. The temperature is usually normal, but in case the attack be prolonged a slight rise, rarely to 102° F., may be observed. The clonic stage lasts for three or four minutes, and the patient passes into the — 3. Stage of Coma. — The patient becomes quiet and passes into a deep sleep, awakening after a few minutes or hours with headache, mental confusion, and muscular soreness. After the attack the reflexes are usually increased. The urine is usually increased in quantity after the attack, and may contain albumin. In rare instances the patient passes from one spasm into another without regaining conscious- ness. In this status cpileptiais the temperature may rise to 107° F., and the patient is apt to die from exhaustion. Post-epileptic Syi)iptonis. — The patient may emerge from the coma in a peculiar trance-like condition, and may per- form purposeless and incongruous actions, at times so appar- EPir.KPSY. 781 ently rational that it may be impossible to believe that the patient is not conscious. At times this condition o{ epileptic autoviatisni passes into the condition of epileptic mania, in which condition the patient is dangerous or even homicidal. After the attack slight transient hemiplegia or aphasia may be noticed. Epilepsy is frequently succeeded by mental degradation which may ultimately lead to complete dementia. Nocturnal epilepsy may occur without the patient's know- ledge, so that the condition may exist for years before the diagnosis is suspected. 2. Petit Mal. — The ordinary type consists of sudden loss of consciousness. The patient suddenly stops what he is doing, the face becomes pale and fixed, the pupils dilate; but after a i^^sr seconds consciousness is regained and the patient resumes his work or conversation as if nothing had happened. Aurae are infrequent in petit mal. In some instances the attack consists of forced movements, such as the sudden running forward of procursive epilep.sy. In other cases, during the attack the patient may perform some automatic action, such as undressing himself or tear- ing to pieces whatever may be within reach. There may be sudden outbursts of maniacal excitement during which crimes and assaults may be committed : these cases of " masked epilepsy " are of great medico-legal interest. Somnambulistic epilepsy consists in the performance of accustomed acts while in a somnambulistic state. Attacks of petit mal terminate in some instances in facial twitchings or in hysteroid convulsive movements. The various manifestations of petit mal are exceedingly varied. In the majority of cases attacks of grand mal ultimately develop, and the two forms may alternate. 3. Jacksonian epilepsy, which is regularly due to irrita- tive lesions of the motor centres, especially of the motor cortical zone, differs from true epilepsy in the fact that con- sciousness is retained. The spasm occurs in limited groups of muscles, which are always the same in each patient. Preceding the attack there may be numbness or tingling of the affected part. 78: M.IXCAL OF THE PRACTICE OF MEDICLXE. In growing lesions the march of the spasm ma\- be observed, and accurate localization becomes possible. Diagnosis.^ Petit mal ma)- be mistaken for syncope, vertigo; or indigestion, but in these conditions conscious- ness is not lost. Jackson ian epilepsy is rarely mistaken for other conditions. Localized spasms ma}-, however, occur in uraemia and in progressive paresis. Grand mal is to be diagnosed from uraemia, simple convulsions in children, convulsions from organic brain disease, malingering, and hystero-epilepsy. Uraemia is diag- nosed by the high arterial tension, the scanty and albumin- ous urine, and the presence of fever during the attack. Simple convulsions in children are usually due to some recognized cause and are not apt to be repeated. Convul- sions due to organic brain disease, such as tumors of the cerebellum and progressive paresis, are to be diagnosed by attention to the history and the other symptoms. Malin- gerers may closely simulate epilepsy, but the tongue is not bitten, foaming at the mouth does not occur, and strong pressure by the thumbs over the supraorbital notches will rapidly cut short the attack. The diagnosis from' hystero- epilepsy is to be made by the following points, thus tabu- lated by Gowers : Epileptic. Hysteroid. Apparent cause . Warning . . . , Onset Scream Convulsion . . . Biting Micturition . . , Defecation . . , Talking . . . . , Duration . . . , Restraint necessary Termination . . . None. Any, but especially unilat- eral or epigastric aurce. Always sudden. At onset. Rigidity followed by "jerk- ing," rarely rigidity alone, Tongue. Frequent. Occasional. Never. A few minutes. To prevent accident. Spontaneous. Emotion. Palpitation, malaise, chok- ing, bilateral foot -aura. Often gradual. During course. Rigidity or " struggling," throwing about of limbs or head, arching of back. Lips, hands, or other people or things. Never. Never. Frequent. More than ten minutes, often much longer. To control violence. Spontaneous or induced (water, etc.). The prog-nosis for cure, except in Jacksonian epilepsy, is KPii.F.rsY. 783 bad, but the disease may be materially relieved by treatment. The pro^mosis is betterin cases coming on in adults, due to syphilis, and in children in cases where the convulsions have followed teething or acute fevers. L^jjilepsy does not tend materially to shorten life. The question of the intellectual future of the patient is always a serious one. Mental degradation occurs in a con- siderable proportion of cases, but epilepsy is not necessarily incompatible with an active and useful life. Treatment. — In cases of reflex or of Jacksonian epilepsy the cause of the irritation should be removed. In some cases the results are brilliant, but in many instances there is but partial improvement, the habit of nerve-discharge of the higher centres having been established. In cases of epilepsy in which the aura is slow, attempts should be made to check the spasm by the inhalation of amyl nitrite ; or in case of ascending sensory aura of an extremity, the patient should be taught to encircle the part firmly with the hand or with a tight bandage. Unfortunately, the aurae are usually of too short duration to allow of any preventive treatment. During the attack the patient should be placed in a horizontal position, the clothing loosened, and a gag firmly placed between the teeth, to prevent the tongue from being bitten. Inhalations of chloroform or of ether are per- missible in protracted or severe paroxysms, or a hypodermic injection of morphine may be administered. Dietetic and Hygienic Treatment. — The patient should do all things in moderation, never in excess. Marriage should be interdicted. Habits of firm but kindly discipline are im- portant for growing epileptic children. The diet should be chiefly, but not altogether, vegetable ; meat, however, may be allowed once a day. The patient should be restrained from going to bed until gastric digestion has been completed. Medicinal Treatment. — Bromides are the most serviceable drugs in the treatment of epilepsy. Of the various bromides, the salt of sodium is the most preferable. The bromide treatment should be pushed until mild affects of bromism — acne, mental depression, foul breath, and muscular weakness 7S4 M.IXLAL OF THE PR.ICT/CE OF MFD/C/XE. — ha\e been produced, and should then be reduced so that the patient is kept just within the physiological action of the drug, so that the palate- reflex is lost. As a rule, from 14 toi^ drams daily are sufficient for an adult. The drug should be largely diluted in water or in milk, and the liabil- ity to acne is said to be diminished b\' the joint administra- tion of arsenic. The bromide treatment should be continued for at least two or three years after the cessation of the attacks. The combination of antipyrine with the bromides is fre- quently of service. Wood claims that a mixture of bromide of ammonium (gr. xx-xxx), antipyrine (gr. vij), and Fowler's solution (TTL ij~iij) affords the best combination known for the majority of cases, the indicated doses being admin- istered twice daily. Sulphonal may also be given advan- tageously with the bromide treatment. Among other forms of treatment employed for their alleged specific action are valerian, belladonna, oxide of zinc, and nitrate of silver and borax, but these drugs prove almost worthless when tried. PARALYSIS AGITANS. Etiology and Synonyms. — Paralysis agitans usually ap- pears between the fiftieth and sixtieth years, and is rare be- fore the age of forty. Men are more commonly attacked than women, in the proportion of 5 : 3. Hereditary influences can be traced in 1 5 per cent, of all cases. In about one-third of all cases an exciting cause can be ascertained — emotion, fright, exposure to cold, physical fatigue, or acute disease. In other cases the disease begins without known cause. It is not a disease of vice. Synonyms: Shaking palsy ; Parkinson's disease. Pathology. — No lesions are found to account for the con- dition, but it is supposed that the symptoms are due to pre- mature senile changes in the cerebral cortex. Symptoms. — The characteristic symptoms are tremor and muscular rigidity. The tremor develops insidiously, and usually appears first in the hands or the fingers. At first the tremor may be PARALYSIS AG /TANS. 785 controlled by the will, but later it becomes more continuous and cannot be controlled. The tremors are short, rapid, (being about 5 to the second), and in the fingers may be rhythmical, so that the motion resembles that produced by rolling some small body between the thumb and the fingers. The handwriting shows the character of the fine tremors. It is peculiar for the tremor to continue when the hand or the limb is at rest and to cease during voluntary motions, so that the patient may safely carry a glass of water to the lips. In other cases the tremor cannot be thus checked, and in rare instances it may even be increased by voluntary motions. Emotions regularly increase the tremor. The tremor extends to various parts of the body without fixed order of progression, but the face is rarely involved. Vol- untary motions are performed slowly and with but little power. Muscular rigidity, which is characteristic of the advanced stages of the disease, gives rise to changes in the attitude, the gait, and the facial expression. The attitude is charac- teristic (Fig. 72) ; the body is inclined forward, and the ex- tremities are in a general condition of flexion. The inclination of the body forward may throw the patient in front of the cen- tre of gravity, so that he will have to walk faster and faster, or even to run, to avoid falling for- ward — the so-called " fes- tinating gait." The face is fixed, expressionless, and immobile ; the eye- brows are raised, giving a characteristic facies to which the name " Park- inson's mask " has been applied. The voice is a high-pitched monotone. Sensory symptoms consist of soreness and a sense of 50 Fig. 72. — Paralysis agitans (St. Leger). 786 J/./.\r.//, OF TJJE rKACTICE OF MEDICINE. fotigue in the afifected muscles. Various vaso-motor symp- toms may occur. The surface-temperature over the afifected muscles may be increased. Mental derangement does not occu,r, although the patients may become emotional. The urine may contain an excess of phosphates, or there may be pol\-uria. Diagnosis. — Disseminated sclerosis develops earlier in life, n\'stagmus is {)resent, the speech is scanning, and there is no characteristic attitude. The diagnosis from post- hemiplegic tremor is readily made by the history of the case, the increased reflexes, and the hemiplegic distribution of the latter disease. Senile tremor is rare under the age of seventy, and is usually marked in the muscles of the neck, producing slight movements of the head. Toxic tremors from alcohol or from tobacco usually occur only on motion, and the tremor is more pronounced, showing considerable range. Prognosis. — The condition is incurable, but it does not tend to shorten life. Treatment. — A number of drugs have been recom- mended, but no form of treatment seems to have any per- manent influence upon the disease. Mental and physical rest should be enjoined, and prolonged lukewarm baths may be advised. Hyoscine h)-drobromate (gr. y^-jj gradually increased) has been given with temporary benefit. Dana has used the bromide of uranium (gr. -g^) with apparently good results. Arsenic may also be used. ACUTE DELIRIUM. Etiology and Synonyms. — Acute delirium usually occurs during active adult life, and may be due to alcoholism, to profound grief, or to over-work ; or the condition may appear as a sequel to sunstroke, fevers, or injuries to the head. Synonyms : Bell's mania ; Acute periencephalitis. Pathology. — The nature of the disease is unknown. By some authors the lesion consists of hyperaimia and oedema of the brain and its membranes, with a choking of the lymph-channels of the pia and of the cortex by leucocytes. CHOREA 787 According to others, the symptoms are due to nerve- poisoning by unknown toxic products. tSymptoms. — The onset may be preceded by the prodro- mal symptoms of irritabihty, restlessness, and insomnia. The developed disease presents two stages, one of maniacal delirium, the other of apathy, collapse, and coma. The delirium comes . on rapidly and reaches a grade of wild frenzy with hallucinations and delusions. There is absolute insomnia. The temperature ranges between 102° and 105° F., but falls to subnormal in the advanced stages. The stage of mania lasts for from a few hours to several days and is succeeded by a stage of quiet in which the patient lies semi-comatose, responding incoherently when aroused. In the advanced stage the pulse fails and the symptoms of collapse become evident. There may be irregular desqua- mation of the skin, ulceration, gangrene, pemphigus, or areas of complete anaesthesia. The diagnosis should be made from the following con- ditions : (i) Masked pneumonia with maniacal delirium at the onset; (2) acute urzemia with mania followed by coma; (3) typhoid fever with marked cerebral symptoms at the onset; (4) delirium tremens; (5) acute meningitis. Prognosis. — The duration of the disease is about a week, but it may be protracted for two or three weeks. The disease is almost uniformly fatal. When recovery occurs the mind is almost regularly affected. Treatment. — During the maniacal stage the patient should be actively purged, and in robust cases free venesection should be resorted to. The patient is to be quieted by morphine, hyoscine, or chloral, and when tractable the cold bath or cold pack may be employed for its calmative effect. Good results are claimed for the hypodermic use of ergotine in large doses, 15 grains being given every eight hours. CHOREA, Etiology and Synonyms. — The disease is more common in females than in males, and three-fourths of all cases occur between the ages of five and fifteen. Chorea is rare ySS JJ.IXLAL OF TJIE PRACTiCE OF MEDICIXE. before the fourth year. Negroes arc usuall}' exempt. The disease is most eommon in high-strung, nervous, excitable children, especially these who are ambitious at school. The exciting cause in 15 per cent, of all cases is fright, but mental worry, grief, or sudden trouble may also pre- cipitate an attack. Ocular defects and reflex irritation do not seem to produce true chorea. An antecedent history of rheumatism is obtained in about one-fifth of the cases. In only 2 per cent, of the cases does chorea antedate the rheu- matic complaint. Chorea may occur after certain infectious diseases — scarlet fever, whooping-cough, gonorrhoea, sec- ondary syphilis, and septic infections — and may also com- plicate pregnancy, especially in primipara; during the first five months. Syiionyins : St. Vitus's dance ; Sydenham's chorea. Pathology. — There are no characteristic lesions in chorea. In some cases vascular changes are found in the nervous system — hyaline transformation, exudation of leucocytes, small punctate hemorrhages, and thrombosis of the smaller arteries — but these changes are inconstant. Endocarditis is the most frequent lesion found at autopsies, occurring in about 90 per cent, of the cases. The endocarditis may be of the malignant variety. The nature of the disease-pjveess in chorea is not yet accurately known ; three theories for its causation are advanced: (i) That chorea is a functional brain disorder, leading to an instability of the nerve-cells controlling the motor apparatus, induced by hyperasmia or anaemia, by psychical influences, or by central or reflex irritation. (2) That chorea is due to embolism of the smaller cere- bral arteries. This view is favored by the experimental production of chorea in animals by injecting fine insolu- ble particles into the carotids. All cases of chorea, how- ever, cannot be thus explained, as histological examination of the brain may be negative. (3) That chorea owes its origin to a microbic infection at present unknown. This view seems highly probable, although it does not explain why chorea is so frequently excited by fright or other psychical disturbance. CHOREA. 789 Symptoms. — The disease may begin abruptly or may be preceded by prodromata. The child becomes restless, is fidgety, irritable, and emotional. Three grades of the developed disease are described by Osier : 1. Mild cJiorca, in which the muscular affection is slight, speech is not seriously affected, and the general health remains good. In the mild cases there are constant irregu- lar, jerky motions involving usually a hand or a hand and the face. There may only be awkwardness or slight inco- ordination of voluntary motions. 2. The severe form, in which the choreic movements be- come general, and are so pronounced that the patient cannot get about, feed, or undress himself. The speech is usually affected, and there may be motor weakness on one side of in the limb most affected. 3. The maniacal form, ox chorea ijisam'e/is, characterized by profound cerebral disturbances and by violent choreic motions. There is active delirium, and there may be hyper- pyrexia, especially in the fatal cases. ■ The individual symptoms may be thus described : I. Motor symptoms may not pass beyond awkwardness or slight inco-ordination, or they may develop into unwilled clonic spasms of various parts. The hands are usually first involved, then the face and subsequently the legs. The movements may be confined to one side — hemichorea. The attack usually begins on the right side, but in rarer instances the movements may be general from the start. The muscles of the trunk and of the thighs are usually bilaterally affected. In about one-fourth of the cases the speech becomes affected, from involvement of the lips and tongue. In mild cases there is merely embarrassment or hesitancy ; in severer cases articulation becomes jumbled and incoherent, so that the child ceases from attempts to talk. The in- spiratory muscles may be affected, so that the patient will emit sighing or odd barking sounds. Choreic movements generally cease during sleep. There is no evidence that the muscles of the gastro-intestinal tract, the bladder, the rectum, or the bronchi are ever affected, and irregular con- 793 .y.ixr.iL of the practice of medicixe. tractions of the papillai')' hcart-nuiscles probabl)' do not exist. Muscular ivcakncss is not uncommon, and rarely amounts to more than an enfeeblement of. the grip or a dragging of the foot. In other cases there may be more evident paresis, either of the hemiplegic, paraplegic, or monoplegic type (" paralytic chorea "). 2. SiNSory Disturdauccs. — Pain in the muscles of the affected limbs is uncommon, but pain and tenderness along the nerve-trunks may be marked, especially in cases of hemichorea. Numbness and tingling or pricking sen- sations are occasionally encountered. Multiple neuritis may occur. Headache is frequent and may be persistent. Mental syniptoiiis are rarely absent, although rarely are they pronounced. There may be irritability of temper with emotional outbreaks, and a change in the moral character of the child. Memory and aptitude for study are impaired. Melancholia is not uncommon. In rare instances dementia develops. Aggravated cases of chorea, the chorea insanicns, are characterized by delusions, hallucinations, delirium, and even mania. The reflexes in chorea may be normal ; in one-half the cases the knee-jerk is diminished or lost. Cutaneous affec- tions are common in chorea, but are generalh' due to the arsenic treatment or to allied rheumatic affections. The skin affections embrace erythematous and papular pigmen- tations, rashes, herpes zoster, erythema nodosum, and pur- pura rheumatica. Fever occurs in about one-eighth of all cases, and is usually slight. Any febrile condition other than a slight transient rise of temperature is indicative of some complication — rheumatic arthritis, pericarditis, or en- docarditis. Fatal cases of chorea insaniens are usually accompanied by a high ante-mortem temperature. Heart Symptoms. — Neurotic palpitation is not uncommon. Cardiac murmurs occur in from 25 to 30 per cent, of all cases, and may be either of haemic or of organic origin. H?Emic murmurs are most commonly observed between the third and fourth weeks. Acute choreic endocarditis rarely CHOREA. 791 gives rise to symptoms. The following statements are given by Osier : " In thin, nervous children a systolic murmur of soft quality is extremely common at the base, particularly at the second left costal cartilage, and is probably of no moment. " A systolic murmur of maximum intensity at the apex, and heard also along the left sternal margin, is not uncom- mon in anjEmic, enfeebled states, and does not necessarily indicate either endocarditis or insufficiency. " A murmur of maximum intensity at apex, with rough quality, and transmitted to axilla or angle of scapula, indi- cates an organic lesion of the mitral valve, and is usually associated with signs of enlargement of the heart. " When in doubt it is much safer to trust to the evidence of eye and hand than to that of the ear. If the apex-beat is in the normal position, and the area of dulness is not increased vertically or to the right of the sternum, there is probably no serious valvular disease. " The endocarditis of chorea is almost invariably of the simple or warty form, and in itself is not dangerous ; but it is apt to lead to those sclerotic changes in the valve which produce incompetency. Of 1 10 choreic patients examined more than two years after the attack, 54 presented signs of organic heart disease. " Pericarditis is an occasional complication of chorea, usually in cases with well-marked rheumatism." The diagnosis is usually evident. Chorea should not be mistaken for spastic diplegia in children, for cerebral atrophy, or for Friedreich's ataxia. In the former case the onset in infancy, the steady and chronic course, increased reflexes and muscular rigidity, and the impaired intellect are distinguishing features. In Friedreich's ataxia the scanning speech, spinal curvature, nystagmus, deformities of the feet, and the slow, inco-ordinate movements render the diagnosis easy. Hysteria may closely resemble chorea, but the movements are rhythmic and not choreiform in character, and other hysterical symptoms are present. Prognosis. — Recovery is the rule, although there exists 79- M.ixr.iL OF THE pkactice of medicixe. in chorea a tendency to recurrences, especialh' in rheumatic cases. Recurrences are most frequent during the spring months. The total mortality is about 2 per cent. The mildest cases get well in two or three weeks. The ordinary duration is about two months, but cases may drag along for from three to six months. The ultimate prognosis, how- ever, is that of the associated cardiac lesions. Treatment. — Excessi\'e brain-work and eye-strain at school, and the competing for prizes, shoukl be prohibited in nervous children, especially in those who have had pre- vious attacks of chorea. The general nutrition of the child should be maintained, and anaemic conditions should promptly be met by the administration of iron and arsenic. For the attack itself rest and seclusion constitute important elements in the treatment, and are insisted upon by Osier. The child should be put to bed and kept quiet until the movements have ceased. By this procedure the liability to heart complication is materially diminished. The child should be kept quiet, and should not be excited by toys or by seeing too many people. The diet should be nourishing and abundant. Arsenic is the best form of medicinal treat- ment, and is given as a matter of routine practice. Chil- dren bear the drug well. Fowler's solution is to be given in 3-minim doses well diluted, after meals; the dose should be increased by 2 minims every second or third day until from 12 to 15 minims are taken at each dose. Should toxic symptoms appear — vomiting, diarrhoea, itching of the eye- lids, oedema, or skin affections — the drug should be stopped for three or four days and then be resumed at the same dose as that last taken. According to Osier, arsenic seems to exert no specific action upon the disease, but does good by improving the general condition. Of other remedies, cimicifuga, chloral, sulphonal, physo- stigmine, antipyrine in 20- to 60-grain doses throughout the day, and quinine in large doses have been recommended. The zinc compounds, stiychnine, and sodium bromide may also be tried in obstinate cases. Iron is required in nearly all cases to combat anaemic conditions. For chorea insaniens h}'drotherapy, in the form of the CJIOKEA. 793 wet pack or the bath, should be tried, and the patient should be quieted by chloral, morphine, or, in the severest cases, by whiffs of chloroform. The cardiac affections are to be treated on general principles. Obstinate cases may be benefited by change of air and by enforced rest and seclusion. Choreiform Affections. Habit-spasm (Habit-chorea ; Simple Tic). — This condition is common in childhood, and may persist during life. The patients are frequently over-grown children of a neurotic personal or family history. There may be twitching of the eyelids, facial grimaces, shrugging of the shoulders, or short inspiratory sniffs. In severer forms nearly all the muscles of the face are affected. A " generalized tic " occurs in children and in adults and may persist for years. The muscles of the extremities and of the trunk suddenly jerk, producing the effects of a general electric contraction (" electric chorea"). Tic Convulsif (Gilles de la Tourette's Disease). — In this form which usually occurs in nervous children with a neur- otic family history, in addition to motor spasms there occur explosive utterances of sounds or of words. A sound may be repeated over and over again {echolalia), or obscene and profane words may be used {coprolalia). In some cases fixed ideas are present ; of these, afithniomania is the most common, in which condition the patient feels obliged to count a certain number of figures before almost every action. Huntingdon'' s Chorea (Chronic Chorea). — This rare disease is characterized by its hereditary nature, a tendency to insanity and suicide, and its late onset between the thirtieth and fortieth years. When one or both parents have been subject to the disease, one or more of the offspring invari- ably become affected ; but the hereditary character of the disease is peculiar in that it never skips one generation to manifest itself in another. The pathology of the disease is obscure. The symptoms are first manifested in the hands by irreg- ular movements ; later the movements are disorderly and 794 .V.I.Vr.lL OF THE PRACTICE OF MED/CIXE. inco-ordinatc, and have not the jcrk\- character of the true choreic contractions. Slow involuntary facial ijrimaces occur ; the gait becomes swaying and irregular, and has been. aptly compared to that of a drunken man. The arms and hands are usually in more or less constant irregular motion. The speech is affected in the majority of cases, becoming slow, hesitating, and indistinct. Mental impair- ment becomes progressively marked, and ultimately termi- nates in dementia. TETANY; TETANILLA. Etiology. — This condition, \\liich is rare in the United States, most conimonh^ occurs before the twentieth year. In the great majority of cases an exciting cause can be dis- covered — exposure to cold, acute diseases, especially typhoid fever, fatigue, lactation ("nurse's contracture"), or preg- nancy. In young children the indications of rickets are seldom absent. Tetan}' occurs in about one-sixth of the cases of removal of the thyroid gland, and may be fatal. Epidemics of tetany are described as occurring on the Continent of Europe, and appear to be due to some un- known infection. A rare but fatal form complicates dilata- tion of the stomach. The pathology of the disease is unknown. It is prob- able that the disease depends upon the action of some toxic agent upon the motor centres. Symptoms. — The spasms are bilateral, and begin in the hands and feet. The fingers are flexed at the metacarpo- phalangeal joints, extended at the others ; the thumb is flexed and adducted; the palm is hollowed. The vvri.st is flexed, and the arm may be folded over the chest. The feet are extended and inverted ; the toes are flexed. In severe cases the muscles of the trunk and of the face may be involved, -and there may be trismus. Dyspnoea and cyano- sis may result from spasm of the respiratory muscles. The spasms are usually paroxysmal, lasting from several minutes to several hours or even da)-s, but in some severe forms the symptoms are continuous for several weeks. In the acute forms there may be a moderate fever, a feeling of " pins- MIGKAfNE. 795 and-needles " in the hands, and a cramp-like pain in the affected muscles. During the height of the paroxysm, and persisting for several weeks afterward, there is a greatly increased excitability of the affected nerves to the galvanic and the faradic current, tetanic contractions following the application of a current which in health would produce no appreciable reaction. The slightest tap on the affected muscle causes also a conspicuous contraction. The cha- racteristic spasm may also be induced by pressure oh the artery, sometimes by pressure on the nerves of the limb (" Trousseau's phenomenon "). Diagnosis. — From tetanus the disease is distinguished by the fact that the earliest symptom in tetanus — trismus — is the latest in tetany. Hysterical contractures are almost invariably unilateral, while tetany never is. Cases of carpo- pedal spasms in rickety children should not be regarded as cases of true tetany. The prognosis is favorable except in those cases following thyroidectomy or dilatation of the stomach. Future attacks are liable to occur, however, if the exciting cause be repeated. Treatment. — The cause of the disease should be traced and removed. Lactation should be stopped, and in all cases a tonic form of treatment, with baths and cold sponging, should be advised. Sodium bromide relieves the spasm most effectively, but cannabis indica or chloral may also be used. Ice to the spine has been recommended. Electrical treatment is disappointing. Faradism is contraindicated. Massage under chloroform-narcosis has been followed by good results in obstinate cases. MIGRAINE. Etiology and Synonyms. — This affection, which is often inherited, is more common in women and in members of neurotic families. In many of the cases there is a history of rheumatic or gouty taint. The existing cause may be mental or bodily fatigue, emotions, indigestion, or the eating of some particular article of food. Among reflex causes should be mentioned uterine disease, eye-strain, abnormal conditions of the nose or of the naso-pharynx, and carious 796 MAXL'.IL OF THE PRACTICE OJ MEDICIXE. teeth. A reflex source of irritation should always be suspected in the migraine of young patients. The attacks often appear with striking periodicity, and usually cease after the climacteric, or in men after the fiftieth }'ear. Synonyms: Hemicrania; Sick headache. Pathology. — The nature of the disease is unknown. Liveing's theory is that it is a nerve-discharge from sensory centres — the sensory equivalent of epilepsy ; according to others the disease is a vaso-motor neurosis. Symptoms. — Premonitory symptoms are present in many cases. There may be malaise, lassitude, and a sense of chilliness. Visual prodromes are not uncom- mon — hemianopia, spots of dimness of vision or scoto- mata, apparitions, balls or flashes of light, and zigzag lines. Sensory prodromes consist in numbness or tingling of a hand or an arm, or of peculiar sensations in any part of the body. There may be a condition of intense emo- tional activity. Motor prodromes consist in temporary weakness of certain groups of muscles or of aphasia. The prodromal symptoms are not always present. In some cases they may comprise the entire attack, not being followed by headache. The characteristic symptom of migraine is the violent paroxysmal headache. Beginning over one side, usually most intense over the frontal region or over the eye, the pain grows more and more unendurable. In rarer instances the headache is bilateral. The pain is usually described as of a sharp, boring cha- racter, and is regularly increased by the slightest sound or light. Prostration, though temporary, is extreme. During the early part of the attack the face may be pale and pinched, and there may be a marked difference between its two sides. Subsequently the face becomes flushed from vaso-motor dilatation. During the attack there is usually mental confusion, or even temporary loss of memory. The pulse may be slow and the temporal artery contracted and in a condition of arterio-sclerosis. When the headache reaches its climax nausea and \omiting commonly appear; the OCCUPA TION-NE UR OSES. 797 vomiting generally affords relief, so that the patient may- fall at orce into a sound sleep and awal, female, natural size ; c, male, enlarged. like teeth to the intestinal wall, and sucks blood from the blood-vessels. The symptoms consist of digestive disorders and progressive anaemia (" Egyptian chlorosis ; " " St. Go- thard's disease "). Treatment. — Thymol should be given in 30-grain doses in capsule, the dose to be repeated in two hours and followed by a brisk purgative. Trichocephalus Dispar (Whip- worm). This parasite, which is from ^ to 2 inches long, is cha- racterized by a filiform anterior portion which occupies two- thirds of the entire length. The posterior portion is blunt and curved. Its habitat is in the caecum, where the parasite is frequently found in great numbers. The worm possesses no clinical significance. Trichina Spiralis. When raw or imperfectly cooked ham or pork contain- ing muscle-trichinae is taken into the human stomach, the undeveloped trichinae are liberated. The parasites become perfectly developed by the third day, appearing as small silvery threads barely visible to the naked eye. New-born trichinae migrate into the muscles by the sixth day, and there assume a spiral form and become encysted, the cap- sule being composed of connective tissue which may be 824 M.LXf.lL OF THE PRACTICE OF MEDICIXE. infiltrated by linic-salts. ]\Iusclc-trichina; so encapsulated HKw li\e for years. Symptoms of trichinosis appear if trichina: are ingested in any considerable number. The symptoms appear in two stages : I. Gastro-iutcstinal symptoms occur one or two clays after the ingestion of the infected ham. There are nausea, vomiting, abdominal pain, and serous diar- rhoea. In severe cases the symptoms may resemble cholera. There may be considerable fever. In this stage very severe cases may terminate fatally. 2. Muscular' symptoms develop in from one to two weeks. The muscles become swollen, tender, and excessively painful; the skin over the affected muscles is usu- ally cedematous. Involvement of the respiratory muscles leads to impairment of respiratory power, dyspnoea, and liability to bronchitis and broncho-pneu- monia. G^ldema of the cN'elids usually appears by the seventh day, and is the most characteristic of the early .symp- toms. Fever of an irregular type is usu- ally present, and profuse sweating is com- monly observed. Albuminuria occurs in the majority of cases. The knee-reflexes are usually lost. The diagnosis is aided by the fact that a number of individuals are usually affected at the same time. In doubtful ca.ses a small piece of muscle may be excised under cocaine-anaesthesia and examined. The duration of the acute symptoms is from two to eight weeks. Recovery is slow and tedious. The prognosis is grave, 30 per cent, of the cases termi- nating fatally, chiefly by pulmonary complications. Treatment. — Prophylactic treatment consists in the gov- ernmental inspection of ham and pork and the thorough cookin": of the meat. Fig. 77. — Male intesti- nal trichina {a) ; female intestinal trichina (F) ; muscle-trichina (c) (Von Jaksch). FILARIA SANGUINIS I/OMINIS. 825 During the gastro-intestinal stage brisk purgatives should be administered. The use of glycerin in 5ss doses every hour has been recommended. Thymol in 3j doses in cap- sule is also of service. When migration into the muscle has occurred the treatment can only be palliative. 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ADDITIONAL VOLUMES IN PREPARATION. 17 NOTHNAGEL'S ENCYCLOPEDIA OF PRACTICAL MEDICINE Edited by ALFRED STENGEL. M. D. Professor of Clinical Medicine in the University of Pennsylvania ; Visiting Physician to the Pennsylvania Hospital IT is universally acknowledged that the Germans lead the world in Internal Medicine ; and of all the German works on this subject, Nothnagel's " Ency- clopedia of Special Pathology and Therapeutics" is conceded by scholars to be without question the best System of Medicine in existence. So necessary is this book in the study of Internal Medicine that it comes largely to this country in the original German. In view of these facts, Messrs. W. B. Saunders & Com- pany have arranged with the publishers to issue at once an authorized edition of this great encyclopedia of medicine in English. For the present a set of some ten or twelve volumes, representing tiie most practical part of this encyclopedia, and selected with especial thought of the needs of the practical physician, will be published. The volumes will contain the real essence of the entire work, and the purchaser will therefore obtain at less than half the cost the cream of the original. Later the special and more strictly scientific volumes will be offered from time to time. The work will be translated by men possessing thorough knowledge of lioth English and German, and each volume will be edited by a prominent specialist on the subject to which it is devoted. It will thus be brought thoroughly up to •date, and the American edition will be more than a mere translation of the Ger- man ; for, in addition to the matter contained in the original, it will represent the very latest views of the leading American specialists in the various departments of Internal Medicine. 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Therefore, in purchasing this encyclopedia, physicians will be given the opportunity of subscribing for the entire System at one time ; but an\- single volume or any number of volumes may be obtained by those who do not desire the complete series. This latter method, while not so profitable to the pub- lisher, offers to the purchaser many advantages which will be appreciated by those who do not care to subscribe for the entire work at one time. This American edition of Notlinagel's Encyclopedia will, without question, form the greatest System of Medicine ever produced, and the pulilishers feel con- fident that it will meet with general favor in the medical profession. NOTHNAGEL^S ENCYCLOPEDIA VOLUMES JUST ISSUED AND IN PRESS VOLUME I Editor, William Osier, M. D., F. R. C. P. Professor of Medicine in Johns Hopkins Uniiiersiiy CONTENTS Typhoid Fever. By Dr. H. Curschmann, uf Leipsic. Typhus Fever. By Dr. H. Curschmann, of Leipsic. Handsome octavo volume of about 600 pages. Just Issjifd VOLUME II Editor, Sir J. W. Moore, B. A., M.D., F.R.C.P.I., of Dublin Professor of Practice of Medicine, Royal College of Surgeons in Ireland CONTENTS Erysipelas and Erysipeloid. By Dr. H.Len- HARTZ, of Hamburg. Cholera Asiatica and Cholera Nostras. By Dr. K. von Lieeer- meister, ot Tiibingen. "Whoooing Cough and Hay Fever. By Dr. G. Sticker, of Giessen. Varicella. By Dr. Tn. von JiJR- GENSEN, of Tiibingen. Variola (including Vaccination). Ey Dr. H. Immermann, of Basle. Haudsome octavo volume of over 700 pages. Just Issued VOLUME VII Editor, John H. Musser, M. D. Professor of Clinical Medicine, University of Pennsylva n ia CONTENTS Diseases of the Bronchi. By Dk- F. A. I I'-i-f- MANN, of Leip.sic. Diseases of the Pleura. By Dr. Rosenbach, of Berlin. Pneumonia. By Dr. E. Aufrecht, of Magdeburc,'. VOLUME VIII Editor, Charles G. Stockton, M. D. Professor of Medicitie, University of Buffalo CONTENTS Diseases of the Stomach. By Dr. F. Riegel, of Giessen. VOLUME EX Editor, Frederick A. Packard, M. D. Physician to the Pennsylvania Hospital ajzd to the Children' s Hospital, Philadelphia CONTENTS Diseases of the Liver. By Drs. H. Quincke and G. Hoppe-Seyler, of Kiel. VOLUME m Editor, William P. Northrup, M. D. Professor of Pediatrics, University and Bellevue Medical College CONTENTS Measles. By Dr. Th. von Jurgensen, of Tiibingen. Scarlet Fever. By the same author. Rotheln. By the same author. VOLUME X Editor, Reginald H. Fitz, A.M., M. D. Hersey Professor of the Theory and Practice of Physic, Harvard University CONTENTS Diseases of the Pancreas. By Dr. L. Oser, of ^'ienna. Diseases of the Suprarenals. iJv Dr. E. Neusser, of Vienna. VOLUME VI Editor, Alfred Stengel, M.D. Professor of Clinical Medicine, University of Pennsylva7iia CONTENTS Anemia. By Dr. P. Ehrlich, of Frankfort- on-the-Main, and Dr. A. Lazarus, of Char- lottenburg. Chlorosis. By Dr. K. von NOORDEN, of Frankfort-on-the-Main. Dis- eases of the Spleen and Hemorrhagic Diathesis. By Dr. M. Litten, of Berlin. VOLUMES rV, V, and XI Editors announced later Vol. IV.— Influenza and Dengue. By Dr. O. Leichtenstern, of Cologne. MalarialDis- eases. By Dr. J- Mannaberg, oi \'ienna. Vol. \ . — Tuberculosis and Acute General Miliary Tuberculosis. By Dr. G. C' 'RNEt, of Berlin. Vol. XI. — Diseases of the Intestines and Peritoneum. By Dr. H. Xothnagel, of Vienna. 19 CLASSIFIED LIST OF THE MEDICAL PUBLICATIONS or W. B. SAUNDERS 6? COMPANY ANATOMY, EMBRYOLOGY, HISTOLOGY. Bbhm, Davidofif, and Huber — A Text- Book of Histology ClarkBon — A Text-Book of Histology, . . Haynes— A Manual of Anatomy Heisler— A Text-Book of Embryology, . . Leroy — Essentials of Histology Nancrede — lisscntials of Anatomy Nancrede — ]-2ssentials of Anatomy and Manual of Practical Dissection BACTERIOLOGY. Ball — Essentials of Bacteriology Frothingliain — Laboratory Guide, .... Gorliam — Laboratory Course in Bacteri- olouy Leliinann and Neumann — Atlas of Bacte- riology Levy and Klemperer's Clinical Bactcr - ology Malloryand Wright— Pathological Tech- nique McFarland — Pathogenic Bacteria CHARTS, DIET-LISTS, ETC. Griffith— Infant's Weight Chart, Hart — Diet in -Sickness and in Health, . . Keen— Operation Blank Laine — Temperature Chart Meigs — Feeding in Early Infancy Starr— D:ets for Infants' and Children, . . Thomas — Diet-Lists CHEMISTRY AND PHYSICS. Brockway— Essentials of Medical Physics, Wolff — Essentials of Medical Chemistry, . CHILDREN. An American Text-Book of Diseases of Ciiildrcn Griffith— Care of the Baby Griffith- Infant's Weight Chart Meigs — Feeding in Early Infancy, .... Powell — Essentials of Diseases of Children, Starr— Diets for Infants and Children, . . DIAGNOSIS. Cohen and Eshner— Essentials of Diag- nosis, Corwln — Physical Diagnosis Vlerordt — Medical Diagnosis DICTIONARIES. The American Illustrated Medical Dic- tionary The American Pocket Medical Dictionary, Morten — Nurses' Dictionary 17 13 15 EYE, EAR, NOSE, AND THROAT. An American Text-Book of Diseases of the l-^se. Ear, Nose, und Throat I De Schweinitz— Diseases of the Eye, . . 6 Friedrich and Curtis — khinology, Laryn- Liology and Otology 6 Gleason — ]£s.seiuials of Diseases of tlie Ear, 15 Gleason — Ess. of Dis. of Nose and Throat, 15 Gradle — Ear, Nose, and Throat 22 Griinwald and Grayson— Atlas of Dis- eases of tiic Larynx 16 Haab and De Schweinitz — Atlas of Exter- nal Di'^ea.es of tli.' Ey 16 Haab and De Schweinitz— Atlas of Oph- thalmoscopy, 17 Jackson — Manual of Diseases of the Eye, 8 Jackson — Essentials of Diseases of Eye, 15 Kyle — Diseases of the Nose and Throat, . 9 GENITO-URINARY. An American Text-Book of Genito-L'ri- nary and Skin Diseases 2 Hyde and Montgomery — Syphilis and the Venereal Diseases 8 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, ... 15 Mracek and Bangs — Atlas of Syphilis and the Venereal Diseases 16 Saundby — Renal and Urinary Diseases, . . 11 Senn — Genito-Urinary Tuberculosis, ... 12 ■Vecki — Sexual Impotence 14 GYNECOLOGY. American Text-Book of Gynecology, . . 2 Cragin — Essentials of Gynecology 15 Garrigues — Diseases of Women 6 Long — Syllabus of Gynecology 9 Penrose — Diseases of Women 10 Pryor — Pelvic Inflammations II S3haeffer & Norris — Atlas of Gynecology, 17 HYGIENE. Abbott — Hygiene of Transmissible Diseases 3 Bergey — Principles of Hygiene, 22 Pyle — Personal Hygiene 11 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. American Text-Book of Therapeutics, . . i Butler — Text-Book of Materia Medica, Therapeutics, and Pharmacology, ... 4 Morris — Ess. of M. M. and Therapeutics, 15 Saunders' Pocket Medical F'ormulary, . . 11 Sayre — Essendals of Pharmacy, 15 Sollmann — Text- Book of Pharmacology, . 22 Stevens — Manual of Therapeutics, ... 13 Stoney — Materia Medica for Nurses, . . 13 Thornton — Prescription-Writing 13 20 MEDICAL PUBLICATIONS OF IV. B. SAUNDERS 6- CO. 21 MEDICAL JURISPRUDENCE AND TOXICOLOGY. Chapman — Medical Jurisprudence and Toxicology, 5 Golebiewskl and Bailey — Atlas of Dis- eases Caused by Accidents 17 Hofmann and Peterson— Atlas of Legal Medicine 16 NERVOUS AND MENTAL DISEASES, ETC. Brower — Manual of Insanity 22 Chapin — Compendium of Insanity, ... 5 Church andPeterson — Nervous and Men- tal Diseases 5 Jakob & Fisher —Atlas of Nervous System, 17 Shaw — Essentials of Nervous Diseases and Insanity 15 NURSING. Davis — Obstetric and Gynecologic Nursing, 6 Griffith— The Care of the Baby 7 Hart — Diet in Sickness and in Health, . . 7 Meigs — Feeding in Early Infancy 10 Morten — Nurses' Dictionary, 10 Stoney — Materia Medica for Nurses, . . 13 Stoney — Practical Points in Nursing, ... 13 Stoney — Surgical Technic for Nurses, . . 13 Watson — Handbook for Nurses 14 OBSTETRICS. An American Text-Book of Obstetrics Ashton — Essentials of Obstetrics, Boislini6re — Obstetric Accidents, Borland— Modern Obstetrics, . Hirst — Text-Book of Obstetrics, Norris — Syllabus of Obstetrics, . Schaeffer and Edgar — Atlas of Obstetri- cal Diagnosis and Treatment 17 PATHOLOGY. An American Text-Book of Pathology, . 2 Durck and Hektoen — Atlas of Pathologic Histology, 16 Kalteyer — Essentials of Pathology, ... 15 Mallory and Wright — Pathological Tech- nique 9 Senn — Pathology and Surgical Treatment of Tumors 12 Stengel — Text-Book of Pathology, ... 12 Warren — Surgical Pathology and Thera- peutics 14 PHYSIOLOGY. An American Text-Book of Physiology, 2 Budgett — Essentials of Physiology, ... 15 Raymond — Text-Book of Physiology, . . 11 Stewart— Manual of Physiology, .... 13 PRACTICE OF MEDIQNE. An American Year-Book of Medicine and Surgery, 3 Anders — Practice of Medicine, 4 Eichhorst— Practice of Medicine 6 Lockwood — Manual of the Practice of Medicine 9 Morris — Ess. of Practice of Medicine, . . 15 Salinger and Kalteyer — Modern Medi- cine, II Stevens — Manual of Practice of Medicine, 13 SKIN AND VENEREAL. An American Text-Book of Genito- urinary nnd Skin Disease;-,, 2 Hyde and Montgomery — Syphilis and the Venerea) Dise-ases, 8 Martin — lissentials of Minor Surgery, ]5andnging, and Venereal Diseases, . . 15 Mracek and Stelwagon — Atlas of Diseases of the Skm 16 Stelwagon — Essentials of Diseases of the Skin 15 SURGERY. An American Text-Book of Surgery, . . 2 An American Year-Book of Medicine and Surgery 3 Beck — Fractures 4 Beck — Manual of Surgical Asepsis, ... 4 Da COBta — Manual of Surgery 5 International Text-Book of Surgery, . . 8 Keen — Operation Blank 8 Keen — The Surgical Complications and Sequels of Typhoid Fever 8 Macdonald — Surgical Diagnosis and Treat- ment 9 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . . 15 Martin— Essentials of Surgery 15 Moore — Orthopedic Surgery 10 Nancrede — Principles of Surgery, .... 10 Pye — Bandaging and Surgical Dressing, . 11 Scudder — Treatment of Fractures, ... 12 Senn — Genito-Urinary Tuberculosis, ... 12 Senn — Practical Surgery 12 Senn — Syllabus of Surgery 12 Senn — Pathology and Surgical Treatment of Tumors 12 Warren — Surgical Pathology and Thera- peutics 14 Zuckerkandl and Da Costa — Atlas of Operative Surgery, 16 URINE AND URINARY DISEASES. Ogden — Clinical Examination of the Urine, 10 Saundtoy — Renal and Urinary Diseases, . 11 Wolff — Handbook of Urine-Examina- tion, 22 Wolff — Essentials of Examination of Urine 15 MISCELLANEOUS. Bastin^ — Laboratory Exercises in Botany, . 4 Golebiewski and Bailey — Atlas of Dis- eases Caused by Accidents 17 Gould and Pyle — Anomalies and Curiosi- ties of Medicine 7 Grafstrom — Massage, 7 Keating — How to Examine for Life Insur- ance s Saunders' Medical Hand-Atlases, . . 16,17 Saunders' Pocket Medical Formulary, . . 11 Saunderb' Question-Compends, . . . 14.15 Stewart and Lawrence — Essentials of Medical Electricity 15 Thornton — Dose-Book and Manual of Prescription-Writing 13 Van Valzah and Nisbet — Diseases of the Stomach, 13 THE LATEST BOOKS. Bergey's Principles of Hygiene. The Principles of Ilxi^iene: A Practical Manual for Students, Physicians, and Health Officers. Hy D. H. Bergev, A. M., M. D.. First Assistant, Laboratorj- of H)-gicne, University of Pennsyl- vania. Handsome octavo volume of about 500 pages, illustrated. Brower's Manual of Insanity. A Practical Manual of Insanity. By Daniel R. Brower, M. D., Professor of Nervous and Mental Diseases, Rush Medical College, Chicago. i2mo volume of 425 pages, illustrated. Gorham's Bacteriology. A Laboratory Course in Bacteriology. By F. P. Gorham, M. A., Assistant Professor in Biology, Brown University. i2mo volume of about 160 pages, handsomely illustrated. .Gradle on the Nose, Throat, and Ear. Diseases -of the Nose, Throat, and ICar. By Henry Gradle, M. D., Professor of Ophthalmology and Otology, Northwestern University Medical School, Chicago. Handsome octavo volume of 800 pages, profusely illustrated. Sollmann's Pharmacology. A Text-Book of Pharmacology. By Torald Sollmann, M. D., Lecturer on Pharmacolog}', Western Reserve University, Cleve- land, Ohio. Royal octavo volume of about 700 pages. Wolfs Examination of Urine. A Handbook of Physiologic Chemistry and Urine Examination. By Chas. G. L. Wolf, ?kI.D., Instructor in Physiologic Chemistry, Cornell University Medical College. i2mo volume of about 160 pages. \^ad^t. ^ [^^\^^^^