Columbia (HnitJers^ftp mtljeCilpofBfttigork Collese of S^fiv^imni anti ^urseonsi Hihravv ^ THf \i SCIENCES LIBRARY Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/lecturesonpractiOOdela LECTURES ON Practical Medicine and Pathology BY FRANCIS DELAFIELD, M.D., LL.D. 1894 NEW YORK TROW DIRECTORY, PRINTING & BOOKBINDING COMPANY 201-213 East Twelfth Street INFLAMMATION. The phenomena which are embraced under the name of in- flammation are : Changes in the circulation of the blood. Escape of the elements of the blood from the vessels. Degeneration or death of tissue. Growth of new tissue. The growth of pathogenic micro-organisms and the formation by them of toxic substances. These different morbid changes occur either separately or combined in a variety of ways. We have, therefore, to consider, first, separately degeneration, necrosis, transudation, congestion, emigration, production, and the growth of micro-organisms ; and, secondly, the different com- binations of these morbid processes. Degeneration. Definition. — We mean by this term changes in the substances which compose the cells of the viscera, the nerve-fibres, and the muscular fibres. We do not include the so-called waxy, hyaline, fatty, glycogenic, mucous, colloid, and calcareous degenerations. Etiology. — It is characteristic of such a degeneration as this that it does not occur by itself, but is always caused by the pres- ence of some toxic substance. The poison may be an inorganic one, such as arsenic, phosphorus, or mercury ; or an organic one, such as is produced by the growth of pathogenic micro-organ- isms. How the poisons are carried to the different parts of the body, and in what way the changes in the cells are effected, we do not know. The poisons of the different infectious diseases vary as to the part of the body which they habitually select. In typhoid and typhus fevers the muscles are degenerated ; in diphtheria the ^ INFLAMMATION. Active congestion is often followed by exudative inflamma- tion. Chronic congestion is often followed by productive in- flammation. Emigration. The escape of the white blood-cells from the capillaries and veins is usually associated with the transudation of blood-serum, but may occur without it. One cause for emigration is the presence in the tissues near the blood-vessels of substances produced by bacteria which are positively chemotactic, that is, of substances which attract white blood-cells toward them. It is also found that a variety of irritating substances in the tissues are capable of causing an emigration of white cells. Ap- parently whenever the emigration of white blood-cells is very large it is due to the presence of pathogenic bacteria, especially the streptococci and staphylococci. The white blood cells which have emigrated into the tissues may remain for a time as pus-cells and afterward degenerate and be absorbed. Or they may change into connective-tissue cells and form permanent new tissue. Furthermore these cells are capable of taking into themselves bacteria and other foreign bodies, and it is probable that in this way they may be of use in limiting infection. It is also to be noticed that when a local emigration of white blood-cells is caused by bacteria there is at the same time an in- crease in the number of white cells in the blood throughout the body — leucocytosis. Production. With or without other inflammatory changes there may be a growth of new tissue. This tissue follows the general type of connective-tissue cells and basement substance. It is known by the names of granulation tissue, round-celled tissue, connective tissue, fibrous tissue, tubercle tissue, etc. As a rule the more acute the process the greater the number of cells; the more clironic the process the greater the quantity of basement sub- stance. In an acute inflammation the production of new tissue may occur by itself, but is more frequently associated with exudation and emisfiation. In chronic inflammations the growth of new INFLAMMATION. 7 tissues is often not attended with congestion, emigration, or exu- dation. Whenever in any inflammation there is at the first a produc- tion of new tissue that inflammation regularly goes on to assume the sub-acute or chronic form. Micro-organisms. Concerning the whole subject of micro-organisms the student should read the article on " The Biology of Bacteria, Infection, and Immunity," by Dr. Welch in tlie " American Text-book of the Theory and Practice of Medicine." As regards the relationship of micro-organisms with inflam- mation, it has been demonstrated that the organisms tliemselves and the products of their growth are capable of causing exuda- tion, emigration, degeneration, necrosis, and the growth of new tissue. They seem to be of most importance in connection witli the purulent and necrotic inflammations. The particular form of inflammation excited by the organisms seems to depend upon the number of organisms present and the virulence of the toxines which they produce. In the severer local inflammations, which are accompanied by fever and other constitutional symptoms, these symptoms are principally due to the toxines produced by the growth of the organisms. In classifying and naming the different forms of inflammation it is convenient to name them according to the most prominent of the different changes which go to make up the whole process. We distinguish : I. Exudative inflammation. (a) Simple exudative inflammation. (/^) Purulent exudative inflammation. I 2. Productive inflammation. (a) Simple acute productive inflammation. {3) Productive inflammation with exudation. (c) Chronic productive inflammation. 3. Necrotic inflammation. I. Exudative Inflammation. — An exudative inflammation is one characterized by the presence of an exudate — serum, fibrin, and pus. The production of such an exudation may or may not be attended with changes in the inflamed tissues. The process may 6 INFLAMMATION. run an acute, a subacute, or a chronic course. The character of the inflamed tissue, whether connective tissue, a mucous mem- brane, or a viscus, modifies the character of the inflammation. We distinguish, therefore : (a) Simple exudative inflammation. {b) Exudative inflammation with large quantities of pus. {a) So far as the exudate is concerned, we know by direct observation what it is and how it finds its way into tlae tis- sues. In the inflamed tissue there is first a dilatation of the arteries, veins, and capillaries, and an increased rapidity of the circulation of the blood. Then the blood-current becomes slower ; while white blood-cells accumulate in the veins and capillaries, and ad- here to their walls. This is the condition of "acute congestion," and the morbid process may not advance beyond this If it does advance farther, the white blood-cells change their shape, find their way between the endothelial cells of the blood-vessels, through their walls, and appear on the outside of the vessels in the tissue. This is called "emigration" Red blood-cells in smaller numbers may also pass through the walls of the capillaries and veins, and this is called " diapedesis." At the same time the plasma of the blood transudes through the walls of the vessels and infiltrates the tissues as serum ; while by the union of sub- stances contained in the blood-plasma and in the white blood- cells, fibrin is formed. In this manner are elaborated the inflammatory products — pus, serum, and fibrin. The pus-cells are emigrated white blood- cells ; the serum is part of the plasma of the blood ; the fibrin is produced by a union of the fibrinogen in solution in the blood- plasma with substances contained in the white blood-cells, and appears coagulated in the form of granules, amorphous masses, or a reticulum. The relative quantity of pus, serum, or fibrin varies in differ- ent cases. In "simple exudative inflammation " we find no other morbid changes than the congestion and the exudation ; the tissues re main unaltered When the inflammation has subsided all the parts return to their natural condition. It is in connective tissue that a simple exudative inflammation is seen in its most typical form. The structure of connective tissue is simple — a basement substance, cells, blood-vessels, lym- INFLAMMATION. 9 pliatics, and nerves. The inflammation is attended with an in- creased quantity of blood in the vessels, more or less swelling of the basement substance and cells, and the exudation collected in the natural cavities of the tissue. The structure of the mucous membranes is more complex. They are all composed of a layer of epithelium, of a connective- tissue stroma containing the blood-vessels, nerves, and lymphatics, and of glands which produce mucus. The inflammation not only causes the same congestion and exudation in the stroma, but there are also changes in the epithelium and the glands. In the epithelium there is a more active desquamation of old cells and growth of new cells ; sometimes superficial ulcers are formed. The function of the mucous glands is interfered with At first the production of mucus is stopped, later it is increased and altered. The increased production of mucus is regularly attended with a diminution of the congestion and swelling of the mucous membrane. Such an inflammation in a mucous membrane is often called "acute catarrhal inflammation " The viscera are composed of a connective-tissue stroma con- taining the blood-vessels, lymphatics, and nerves, and of cells. The cells are peculiar to each viscus, and are concerned in per- forming the functions of the A'iscus. The principal changes effected by the inflammation are the congestion and consequent swelling and the inability of the vis- ceral cells to perform their proper functions. The quantity of exudation is small. {i>) In exudative inflammation with an excessive quantity of pus, or purulent inflammation, the excessive number of pus-cells may, or may not, be accompanied by serum and fibrin. Such an excessive number of pus-cells is due to an increased emigration of white blood-cells. The inflammation is of a more severe type than a simple ex- udative inflammation. The pus-cells infiltrate connective tissue, they are mixed with the serum in the serous cavities and with the mucus on the surfaces of the mucous membranes, but they do not form abscesses. II. Productive Inflammation : [a) Simple acute productive inflammation. — In this form there is no exudation, no serum, fibrin, or pus. Congestion is sometimes visible after death, but by no means always. The inflammatory product consists of new cells formed from the old lO INFLAMMATION. conpective-tissue cells. The pia mater and the peritoneum ofter the best examples of this form of inflammation. {b) Productive inflammation with exudation. — In this form of inflammation the changes in the blood-vessels, the exudation and emigration, the formation of serum, fibrin, and pus are well marked, but in addition there is from the first a growth of new tissue. This new tissue at first consists principally of cells, later a basement substance and blood-vessels are added. This form of inflammation has a marked disposition to continue for a long time in a sub-acute or chronic form. In connective tissue the serum, fibrin, and pus are found in varying quantities. The new tissue forms thickenings, and ad- hesions. In the mucous membranes the inflammation involves the stroma, and it is in the stroma that the exudation is infiltrated and the new tissue formed. The glandular coat may remain un- changed, or be the seat of catarrhal inflammation. In the viscera the quantity of the inflammatory product varies. The new tissue is formed in the stroma. The visceral cells undergo more or less atrophy or degeneration. {c) In chronic productive inflammation the inflammatory product is round celled tissue, granulation-tissue, or connective tissue. In some cases this is the only change, in others there is added an exudation from the blood-vessels, or degeneration of cells. The new tissue that is formed may degenerate or become calcified. In connective tissue this form of inflammation produces thicken- ings and adhesions, and serum in the serous cavities. In mucous membranes the growth of new tissue is in the stroma. This is thickened, either diffusely, or in the form of polypoid growths. The layer of epithelium may be thickened or thinned. The mucous glands are atrophied, or hypertrophied, or become cystic. The production of mucus is diminished, or increased, or altered. This condition in the mucous membranes is commonly called a "chronic catarrhal" inflammation. In the viscera there is a growth of indifferent tissue, or of con- nective tissue, in the stroma. The visceral cells are compressed, or degenerated, or fatty, or disappear. The functions of the vis- cus are seriously interfered with. In the viscera this is often called an " interstitial " inflammation. The most marked features of this form of inflammation are its INFLAMMATION. 1 1 slow course and its tendency to continue. The lesions of chronic productive inflammation, especially in old persons, are by some believed to be due to chronic degeneration. III. Necrotic Inflammation. — In this form of inflammation, in addition to the congestion and exudation, there is added death or degeneration of parts of the tissues in which the inflammation exists. This character of the inflammation is given to it by the presence and growth of pathogenic bacteria. The bacteria regu- larly present are the staphylococcus pyogenes aureus and albus, and the streptococcus pyogenes. They frequently occur together in the same inflammatory process. Such an inflammation, when it occurs in connective tissue, produces abscesses. A circumscribed portion of tissue is con- gested, infiltrated with serum, fibrin, and pus, and parts of the tissue die. Tlie dead tissue softens, breaks down, and cavities are formed which contain serum, pus-cells, and portions of dead tissue. In mucous membranes there are congestion, exudation of serum rich in fibrino-plastic substances, emigration of white blood-cells, and necrosis of tissue. The fibrin infiltrates the stroma, and coagulates on the sur- faces of tlie mucous membranes so as to form false membranes. The pus-cells are entangled in the fibrin. The necrosis involves only the epithelium, which passes into the condition of coagula- tion necrosis, and forms part of the false membranes ; or it in- volves also the stroma. The death of the epithelium forms superficial erosions, that of the stroma ulcers of varying size and depth. Such an inflammation of the mucous membranes is called " croupous." or "diphtheritic." We also find with catarrhal and productive inflammations circumscribed necrosis of the epi- thelium. In the viscera we find congestion, exudation of albuminous serum, and emigration of white blood-cells. In addition there may be degeneration or death of the visceral cells ; or death of portions of the stroma with groups of cells, and the formation of abscesses. This variety of inflammation is of severe type, is accompanied with marked symptoms, and after it has subsided, leaves changes in the tissues. In connective tissue the cavities of the abscesses are filled 12 INFLAMMATION. first with granulation tissue, and afterward with cicatricial tis- sue. In the mucous membranes the dead epithelial-cells may be replaced by new cells of the same kind, but the ulcers formed by the death of the stroma have to be filled first with granulation tissue, and later by cicatricial tissue. In the viscera the degenerated cells may be replaced by new visceral cells, but the abscess cavities are filled first with granu- lation tissue, and later with cicatricial tissue. The treatment of the different forms of inflammation is a matter of practical importance. In exudative inflammation the most efficient treatment is the use of local means which cause contraction of the blood-vessels. Such a contraction can be caused by the application of cold, of heat, and of astringents. Somewhat less certain as a local treat- ment, although apparently often of service, is the use of counter- irritation, or of local blood letting, by which the congestion of the inflamed tissues seems to be relieved. Whether a local in- flammation is favorably affected by general blood-letting is un- certain. In some cases, by no means in all, this form of exudative inflammation seems to be favorably affected by the use of drugs. If we dilate the small arteries throughout the body, it seems probable that we can diminish the congestion of any one circum- scribed part of the body, and so we give aconite, veratrum viride, and nitro-glycerine. In the mucous glands we see that, as a larger quantity of mucus is produced the congestion subsides, and so we give drugs which are likely to increase the production of mucus, such as ipecac, antimony, and pilocarpine. Then there are certain drugs which we use empirically : calo- mel or sulphate of magnesia in small doses frequently repeated for a few hours; opium given for a longer time : in the case of some of the mucous membranes, large doses of ipecac. In the forms of exudative inflammation with death of tissue, suppuration, and the growth of pathogenic bacteria, it has been conclusively shown that, if the bacteria can be excluded the inflammation will not assume this character. When, however, such an inflammation is once established, it is not easy to destroy the bacteria and subdue the inflammation by the local use of germicides. On the other hand, the evacuation of collections of THE PIA MATER. 13 pus and of serum with antiseptic precautions and complete clos- ure of the wound, is regularly followed by subsidence of the in- flammation. When a production of new tissue is added to an exudative inflammation, we employ the same means of treatment as for an exudative inflammation, but without the same probability of suc- cess. Such inflammations are much more likely to become chronic, or to cause permanent changes. The chronic productive inflammations are much less amen- able to treatment. The internal administration of drugs, except in the case of syphilis, is of little avail. We rely principally on local treatment, regulation of the diet and mode of life, and cli- mate ; but it has long been believed that preparations of mer- cury, and the iodide of potash, are of use in some examples of this form of inflammation. The Pia Mater. The external surface of the brain is overlaid by a connective- tissue membrane which covers the convolutions, dips down into the sulci, and extends into the ventricles. This membrane is abundantly supplied with blood-vessels, and from it numerous vessels extend into the brain, so that any disturbance in the cir- culation of the blood in the pia mater involves a disturbance in the circulation of the blood in the brain also. The connective tissue which makes up the pia mater is ar- ranged in a series of membranes and fibres reinforced by elastic tissue, so arranged as to form a spongy membrane containing numerous cavities more or less filled with fluid. These cavities are continuous with the perivascular spaces which surround the vessels that pass from the pia mater into the brain. The outer layers of the pia mater are the most compact, and are covered on their outer surface by a continuous layer of endothelial cells. This external layer of the pia mater is often described as a sepa- rate membrane called the " arachnoid," but it is really only part of the pia. The deeper layers of the pia contain the blood-vessels. The membranes and fibres which compose the pia mater are partly coated with cells, which have irregular and delicate cell-bodies and large, distinct nuclei. In all inflammations of the pia mater the inflammatory prod- 14 THE PIA MATER. ucts regularly collect in the spaces within it. Only occasion- ally do we find them on its free surface. The pia mater is frequently thickened, opaque, and white, either in diffuse patches, or along the course of the vessels. In other cases, single or multiple white spots of the size of a pin's head, or smaller, may be seen in the membrane, not appreciably elevated above the surface, but due to localized thickening. These slight opacities of the pia mater are commonly believed to be dependent upon repeated congestions of the membrane, or upon chronic meningitis, but there is no evidence that this is always the case. They are most frequently found in old persons, but may exist at any age, and do not necessarily indicate the pre- existence of disease, although similar appearances are common in the chronic insane and in drunkards. Congestion and Anemia. — There can be little question that the quantity of blood contained in the vessels of the pia mater varies at different times, and that any considerable increase or diminution of the quantity of blood is likely to give cerebral symptoms. In the human subject, however, our knowledge of this subject is as yet indefinite. CEdema. — The quantity of serum beneath the pia mater and in its cavities is very variable. It may accumulate as a result of atrophy of the brain-substance or of venous hyperaemia, and may be accompanied by oedema of the brain-substance also. It is not infrequent to find in hospital patients suffering from chronic nephritis, cardiac or pulmonary disease, or chronic alcoholism, a very considerable quantity of serum in this situation, and yet the patient has been free from cerebral symptoms. In other cases, again, this same effusion affords the only explanation of grave cerebral symptoms. ACUTE MENINGITIS. Lesions. — The ordinary form of acute inflammation of the pia mater is the exudative, but occasionally the inflammation is of pure productive type without exudation. Either form of inflam- mation, however, is attended with the same symptoms. In acute productive, or cellular, meningitis the pia mater is congested, its surface is dry and lustreless, it is somewhat opaque, it is not at all infiltrated with serum. These changes in the gross appearance of the membrane are not marked and are easily over- looked, but the minute changes are more decided. There is an THE PIA MATER. 1 5 abundant production of cells somewhat resembling the cells which coat the surfaces of the membranes and fibres which make up the pia mater. This cell-growth is general, involving the pia mater over most of the surface of the brain, but the cells are much more numerous in some places than in others. The in- flammation, then, is one which results in the production, not of fibrin, serum, or pus, but of new connective-tissue cells. In acute exudative meningitis there is an accumulation of serum, fibrin, and pus in the meshes of the pia mater and along the course of the vessels, rarely on the surface of the pia. Some- times one, sometimes another of these exudations preponderates, giving rise to serous, fibrinous, or purulent forms of the inflam- mation. The absolute quantity of the exudation varies greatly. The quantity of exudation may be so small that the pia looks nearly normal to the naked eye, and the pus and fibrin can only be seen with the microscope. More frequently the quantity of exudation is considerable, and often very large, even sufficient to flatten the convolutions of the brain. The cortical portion of the brain may be oedematous, or degenerated, or infiltrated with minute hemorrhages. Very often the inflammation extends to the ventricles, which then contain purulent serum. In children the ventricular lesion is regularly well marked, the ventricles are dilated, and contain large quantities of purulent serum. In adults such a distention of the ventricles occurs less frequently. The inflammation of the ventricles may persist for days and weeks after the subsidence of the meningitis. The exudation may cover the whole surface of the brain, or be confined to the base, or to the convexity. It often extends down in the pia mater of the cord, and the roots of the cranial nerves may also be involved. In the purulent forms of acute meningitis, bacteria have been found. The ordinary streptococcus of purulent inflammation, the diplococcus pneumoniae, the diplococcus intra-cellularis, a bacillus like that of typhoid fever, have been described. In an epidemic of cerebro-spinal meningitis Bonome has found a spe- cial form of streptococcus. Causes. — Acute meningitis occurs under four entirely different conditions. It is produced by injuries, by the extension of in- flammations from the cranial bones, the ear, the dura mater, and by infection from streptococcus inflammation in other parts of the body. l6 THE PIA MATER. It complicates pneumonia, rheumatism, nephritis, and many of the infectious diseases. It occurs as a primary lesion without discoverable cause. It is the characteristic lesion of the infectious disease called epidemic cerebro-spinal meningitis. Syt7ipto7ns. — The idiopathic cases. It is difficult to distinguish these cases from sporadic cases of cerebro-spinal meningitis, and our descriptions of idiopathic meningitis are probably very much modified by our observations of the epidemic disease. The idio- pathic form seems to be more common in children. The invasion of the disease may be preceded by a prodromic period characterized by conjunctivitis, nausea and vomiting, headache, irritability of temper, sleeplessness, and general ma- laise ; or it may be sudden, with fever, headache, convulsions, delirium, and vomiting. The cases vary as to which one of these symptoms is the prominent one at the outset. Either the head- ache, the convulsions, the delirium, or the vomiting may be es- pecially marked. When the disease is fairly developed the headache is contin- ued and severe. Throughout the disease perhaps the most prominent symptoms are restlessness and stupor. The restless- ness ranges from irritability and sleeplessness up to violent de- lirium ; the stupor from apathy up to coma. In many patients the restless condition occupies the earlier days of the disease, and the stupor is gradually developed later. In others the rest- lessness and stupor alternate ; or either one may predominate throughout the disease. Involuntary contractions of groups of muscles, especially of those of the face, are often present. Unilateral or general con- vulsions occur in some of the cases. Localized or general hyperaesthesia of the skin may exist. If the inflammation extends down to the pia mater of the cord, there is tenderness and contraction of the muscles of the neck. As the inflammation involves the roots of the cranial nerves, photophobia, blindness, strabismus, painful hearing, and deaf- ness are developed. The vomiting which belongs to the outset of the disease may continue, or it may not begin until later. The tongue is coated, and in bad cases becomes dry. Constipation is the rule, but diarrhoea and involuntary move- ments may come on in the last days of fatal cases. THE PI A MATER. 1 7 The urine is diminished in quantity ; it may contain a little albumin and a few casts. The temperature usually runs between ioo° F. and 104° F. ; it is apt to follow an irregular course. The pulse is at first rapid, then slow, and, in the fatal cases, again rapid and weak, but it may be rapid throughout the dis- ease. In children the course of the disease may be the same as in adults. Often, however, the excessive development of the in- flammation of the lateral ventricles and their distention with se- rum, causes a difference in the symptoms. In some children almost the only symptoms are a febrile movement and convul- sions alternating with stupor. In others the course of the dis- ease is like that of tubercular meningitis. The duration of an acute meningitis is from thirty-six hours to four weeks. The ordinary duration is from seven to fourteen days. The prognosis is bad, but not hopeless. Secondary Acute Meningitis. — First there are the symptoms of the primary inflammation, and then those of the meningitis. If the meningitis is secondary to an acute otitis there are first the fever, prostration, and severe pain belonging to the otitis. Then the patients become worse, the prostration is more marked, the temperature is higher, alternating delirium and stupor are developed, there are contractions of the muscles of the face, slow pulse, and finally coma. But it must be remembered that a se- vere acute otitis, especially in children, may give marked cere- bral symptoms without meningitis. If the meningitis follows a chronic otitis there will be the his- tory of the ear trouble extending back for months or years ; then suddenly come on the symptoms of the meningitis — fever, head- ache, alternating delirium and stupor, coma. Complicating Meningitis. — The diseases which are liable to be complicated by meningitis are all of them capable of givino- marked cerebral symptoms without any inflammation of the pia mater. When a complicating meningitis really is developed, the only difference is that the symptoms are more marked and ap- proach more closely to those of an idiopathic meningitis. Treatment. — The indications for treatment are to diminish the severity of an acute exudative inflammation, to alleviate the pain, and to nourish the patient. 15 THE PIA MATER. The measures directed toward the inflammation are most effi- cacious during the early days of the disease. We employ continu- ous cold over the head by ice-bags or the rubber coil, sometimes blood-letting from the temples and the back of the neck, and the internal administration of calomel, sulphate of magnesia, opium, the iodide of potash, or ergot. The pain and restlessness may be controlled by the bromides, chloral, or opium. The patients are to be kept perfectly quiet in a darkened room, on a fluid diet, with the addition of alcoholic stimulants when the heart's action begins to fail. The bowels are kept open by mild laxatives or enemata. CHRONIC MENINGITIS. True chronic meningitis is a very real and serious lesion. It is not to be confounded with tlie simple opacities and thickenings of the pia mater which are so common in adult life. Lesions. — Either the pia mater or the base of the brain alone may be inflamed (basilar meningitis), or the pia mater over the convexity alone or the entire pia mater, or circumscribed patches of the membrane. The pia mater is thickened and opaque, the thickening being sometimes very considerable. There is a for- mation of new connective tissue and a production of pus, fibrin, and serum ; the relative quantity of these inflammatory products varies in different cases. Firm and extensive adhesions may be formed between the dura mater and the pia mater. Not infre- quently the cortical portions of the brain participate in the mor- bid process, and we find an infiltration of small spheroidal cells around the blood-vessels, thickening of the walls of the vessels, and degenerative changes and atrophy of the brain tissue. New connective tissue may also form in the brain substance, and the latter may become adherent to the pia mater. The ventricles of .the brain may be much dilated and distended with serum, their ependyma may be thickened and roughened. Causes. — Chronic meningitis may be caused by blows on the head, and by fractures and inflammations of the cranial bones. Sometimes the injury to the head antedates by several years the symptoms of the meningitis. It is often associated with pachy- meningitis, with tumors of the brain, and with chronic endar- teritis of the cerebral arteries. It is the direct result of syphilis. THE PIA MATER. I9 It occurs with chronic nephritis, with chronic alcoholism, and in persons who are badly nourished and of dissipated habits. It is regularly found in the general paralysis of the insane. Symptoms. — The course of the disease is that of an inflamma- tion, chronic from the outset, and with exacerbations from time to time. The symptoms are at first obscure and intermittent, and vary much in different individuals as to their number and dis- tinctiveness. So the diagnosis is always difficult and sometimes quite impossible. The patients complain of more or less headache — continuous or intermittent. The mental faculties and the temper gradually deteriorate, and such a change may go on to complete insanity. From time to time there are attacks of unconsciousness, of stu- por, of delirium, of muscular contractions or rigidity, of aphasia, of general convulsions, or of vomiting. After a time the nutrition is impaired, and there is a gradual loss of flesh and strength. At the times when the symptoms are most marked there may be a moderate rise of temperature. Chronic meningitis usually lasts for a number of years, but it may happen that the early symptoms are slight and that at some time severe symptoms are suddenly developed, as if of an acute cerebral lesion. The patients become insane, or die with marked cerebral symp- toms, or in a condition of emaciation and exhaustion. Treatme7it. — The first point to determine is whether the patient has had syphilis. If this is the case, the use of mercury and the iodide of potash may be of much service. In the cases due to other causes there seems to be no direct treatment for the menin- gitis. The improvement of the general health, and the allevia- tion of symptoms must be attempted, but as a rule the patients get worse. TUBERCULAR MENINGITIS. Tubercular inflammation of the pia mater behaves differently in children and in adults, so that it is necessary to describe the disease separately according to tlie age of the patient. I. Tubercular Meningitis in Children. Lesions. — The dura mater is usually unchanged, but there may be miliary tubercles on its inner surface. The surface of the brain is flattened by the pressure of the fluid which distends the ventricles. The inflam- matory process is a combination of tubercular and of exudative 20 THE PIA MATER. or cellular inflammation, either one of which may predomi- nate. The tubercles are very small and transparent, or large and white. They are composed of simple aggregations of small cells, or of well-formed tubercle tissue arranged around blood-vessels. The vessels show tlie changes of obliterating endarteritis. The cellular inflammation produces new connective-tissue cells, the exudative inflammation produces serum, fibrin, and pus. The in- flammation is often confined to the base of the brain, but may extend over its entire surface, or be confined to the convexity. The tubercles are most numerous in the pia mater over and in the sulci. The ventricles of the brain are much dilated and distended with serum. Their ependyma is thickened and studded with very small miliary tubercles. The brain tissue around the ventricles is softened. There ma}^ be similar lesions in the pia mater of the cord. Such a tubercular meningitis is regularly, but not always, only part of an acute general tuberculosis with similar lesions in many different parts of the body. Causes. — The children affected are usually under five years of age. There is often a family history of tubercular disease. The meningitis is regularly only one of the lesions belonging to an acute general tuberculosis. Such a general tuberculosis may be a primary disease, or secondary to a localized tuberculosis. Symptoms. — It is important to remember that the tubercular meningitis is usually only part of a general tuberculosis, and tliat the intensity of the inflammation of the pia mater varies much in different cases. So we find that in some cases the symptoms are more like those of a general tuberculosis, in others like those of a meningitis, and that the meningitis may have the characters of an acute or a sub-acute inflammation. There may be a prodromic period, probably due to the devel- opment of the general tuberculosis, which usually lasts only for a few days, but may be protracted for several weeks. During this period there are loss of flesh and strength, slight evening fever, irritability, sleeplessness, frontal headache, vomiting, con- stipation, and a coated tongue. These symptoms are not contin- uous, but are interrupted by periods of improvement. When the disease is established the child lies in bed, the face flushed, in a condition of alternating stupor and delirium, either one of which may predominate. During the periods of restless- THE PIA MATER. 21 ness the child seems to have severe pain in the head ; tliere is photophobia and hyperaesthesia of the skin. There is often fre- quent and active vomiting. The child rolls its head, moans and cries out, it may be actively delirious, there may be one or more general convulsions. During the period of stupor it lies quietly in bed, taking no notice, but apparently placid and comfortable. The bowels are constipated. The pulse is slow, in proportion to the temperature, but irregular. The breathing also is irregular. There is a febrile movement which runs a very irregular course, but is not necessarily at any time very high. The urine is scanty and contains albumin. At the end of the first week, or a little earlier or later, strabis- mus, inequality of the pupils, and ptosis are developed. In the second week the stupor deepens into coma, which may be continuous or alternate with active delirium. The head is drawn back, there are convulsive movements, or paralysis, or rigidity of the limbs and face, which may be transient or perma- nent. There may be automatic movements of the arms and legs. The patients constantly pick at tjie nose and lips. The pupils are dilated, and vision is lost. The pulse becomes very rapid and feeble. The course of the disease is interrupted by short periods of improvement ; it lasts for from two to four weeks. The pa- tients die in an attack of convulsions, or they become very feeble and emaciated ; the urine is suppressed, the pulse and breath- ing are very rapid, the temperature remains high, or falls below the normal. This is the history of the cases with general tuber- culosis and a moderate meningitis. With a more intense meningitis the cerebral symptoms are more active, the temperature is higher, and the disease runs its course within a week. If the meningitis is confined to the convexity of the brain there is no strabismus and little vomiting. The headache, delirium, convulsions, and rigidity of the muscles are the chief symptoms. The disease runs its course within a week. T7-eatment. — The treatment varies with the acuteness of the meningitis. In cases which run an active course, like that of an acute meningitis, we employ the same methods of treatment as for that disease. In the cases which behave more like general tuberculosis with subacute cerebral symptoms, the nursing, feed- ing, and alleviation of symptoms constitute the entire treatment. As a rule, the patients do not recover, but from time to time 2 2:- THE PI A MATER. we see cases which behave like tubercular meningitis and yet do recover. Whether in these cases the meningitis really is tuber- cular it is impossible to say, 2. Tubercular MeninCxItis in Adults. — The changes in the pia — the combinations of tubercular, exudative, and cellular inflam- mation — are the same as in children. There is, however, one im- portant difference between adults and children. In children the inflammation of the ependyma of the ventricles, the distention of the ventricles with serum, and the consequent compression of the brain are the rule ; while in adults they are the exception. In adults, as in children, the tubercular meningitis may only be part of a general tuberculosis. But more frequently it occurs as a localized tubercular inflammation, either primary or second- ary to a localized tubercular inflammation of some other part of the body. Causes. — The greatest liability to the disease seems to be between the ages of fifteen and twenty-five years. Persons who inherit the tubercular disposition, or who have chronic pulmonary phthisis, are especially liable tg* the disease. It may very well happen that the pulmonary lesion is small and insignificant. Symptoms. — It is convenient, in describing the symptoms of tubercular meningitis in adults, to divide the cases into three clinical groups : . (i) Cases of acute general tuberculosis with tubercular men- ingitis, but without the symptoms of meningitis. The history of these patients belongs to general tuberculosis. (2) Cases with well-marked symptoms of meningitis, which come on more or less suddenly, and are developed in persons whose health was apparently good up to the time of the attack. Of these cases there are a number in which a localized tubercu- losis has existed in some part of the body, but has given so little trouble that it has not been recognized, so that when the second- ary meningitis is developed it seems to be a primary inflamma- tion. In other cases, however, the meningitis is a primary, local- ized, tubercular inflammation. In all these cases the invasion of the symptoms may be sud- den or gradual. If it is sudden there are chill, fever, headache, vomiting, and so much prostration that the patient is at once confined to bed. If it is gradual the patients do not feel sick enough to go to bed for several days. They have a little fever, headache, loss of appetite, and general malaise. THE PI A MATER. 23 Wlien the disease is fairly established the lieadache is severe and continuous. The patients are sleepless, restless, and go on to mild or active delirium. The delirium alternates witli stupor, or coma. There are conjunctivitis, photophobia, ptosis, strabis- mus, involuntary ccjntiactions of the muscles of the face, arms, and legs. From two to five days before death there may be per- manent hemiplegia, monoplegia, or facial paralysis. Hyperaesthe- sia of the skin is present in some cases. Vomiting is often per- sistent and troublesome. A few days before death there may be difficulty in. swallowing. In some cases there is pain and con- traction in the muscles. The urine contains albumin and casts. The temperature may run low or higli, and follows a very irregu- lar course. Generally speaking, the cases of short duration have high temperatures, and those of long duration low tem- peratures. The pulse is irregular, sometimes slow, sometimes rapid. The symptoms may be intense, continuous, and the patients die in from seven to fourteen days ; or they may be less severe, with intervals of improvement, and the patients may go on for from thirty to fifty days. (3) Cases with a well-marked history of pulmonary phthisis may at some time develop the symptoms of tubercular menin- gitis. The prognosis of tubercular meningitis in the adult is regu- larly bad, but yet we see patients with characteristic symptoms of the disease who recover. Treatment. — ^The indications for treatment are the same as in the tubercular meningitis of children. Inflammation of the Cerebral Arteries. The arteries throughout the body are frequently the seat of chronic inflammation. In the cerebral arteries the ordinary changes are as follows : 1. There is an increase in tlie size and number of the endo- thelial cells. This is best seen in the small arteries surrounded by miliary tubercles, or by small gummata. 2. There is a growth of new connective tissue, apparently originating in the endothelium, which narrows the lumen of the artery and may finally occlude it. The growth is composed of branching cells, small round cells, and basement substance ; 24 THE PIA MATER. later the cells become smaller and less numerous, the basement substance denser. The growth forms a ring on the inside of the intima which is not symmetrical, but is thicker in some places than in others. This is often called obliterating endarteritis. 3. There is a thickening of the inner coat beneath the endo- thelium. The change begins by a growth of cells and a split- ting up of the basement substance in the intima immediately beneath the endothelium. Then there is a growth of basement substance with but few cells, which renders the inner coat thicker and thicker until the lumen of the artery is considerably narrowed. These changes may occur by themselves or there may be, in addition, thickening of the muscular and outer coats, replacement of the muscular coat by dense connective tissue, thinning of portions of the arterial wall and irregular dilatations, deposition of the salts of lime in the new tissue. As a result of these changes the arteries are rendered very irregular channels for the passage of the blood — narrowed in some places, dilated in others, or completely occluded. The blood-supply of the corresponding portions of the brain is vari- able or cut ofif altogether. The diseased arteries may rupture, with extravasations of blood. Portions of the brain may become softened from the oc- clusion or thrombosis of the arteries. Either small or large aneurisms may be formed. The changes may be confined to the larger arteries at the base of the brain, or they may involve nearly all the branches of the cerebral arteries. Marked cerebral SN^mptoms are seen during life in persons in whom after death no changes are found in the brain, nothing can be made out except the endarteritis. Thei^e may be similar changes in the arteries in other parts of the body, or the cerebral arteries are the only ones affected. Causes. — Chronic endarteritis is especially common in per- sons over forty years old. It is frequently associated with chronic gout, constitutional syphilis, pulmonary emphysema, chronic Bright's disease, and chronic endocarditis. But it may also occur by itself and without discoverable cause. The symptoms presented by these patients are at first in the form of temporary attacks, which last for hours or days, and then disappear. Such attacks are repeated at irregular intervals THE BRAIN. 2$ during months or years, the patient presenting few or no cere- bral symptoms during the intervals. As time goes on the attacks become more severe and more frequent. It is, however, possible for the patient to die during the first attack. The temporary attacks are not all of the same character. There may be only headache, or anxiety, restlessness, and insom- nia, or vertigo, or aphasia, or hemianopia, or loss of conscious- ness, or general convulsions, or spasmodic contractions of groups of muscles, or paralysis of one arm, of one leg, or of the whole of one side of the body, or loss of sensation in different areas of the skin. The first attack may prove fatal, but the patient often con- tinues to live for months or years. Even after recovering from the first attack, however, there is a perceptible change in the patient's mental and bodily condition, sometimes very marked. The attacks are repeated until finally the patient develops the symptoms of chronic meningitis, or becomes completely hemi- plegic, or dies with general convulsions or coma. Treat7nent. — Apart from antisyphilitic treatment in the proper cases, the most important points to enforce are abstinence from all alcoholic drinks, and exercise in the open air. The Ventricles of the Brain. Inflammations of the pia mater are often accompanied by lesions of the A'entricles of the brain. Less frequently we find lesions of the ventricles occurring by themselves, with little or no change in the pia mater. We distinguish : Acute ependymitis. Acute dilatation of the ventricles in adults. The chronic hydrocephalus of children. Chronic hydrocephalus due to injuries, or secondary to men- ingitis. I. Acute Ependymitis. — Of this v^e find two varieties : an acute and a subacute form. In the acute form w^e find the ependyma congested, infiltrated with pus-cells, and coated with a layer of fibrin and pus. The ventricles contain purulent serum. The patients exhibit a decided febrile movement, general convulsions, alternating stupor and delirium, local paralysis, and finally coma. The disease runs its course within a few days. 26 THE BRAIN. The symptoms resemble those of an acute tubercular menin- gitis. So few of these cases have been observed that we are igno- rant of the prognosis. The treatment would seem to be the same as that for acute meningitis. In the subacute form the ventricles are dilated and full of serum. The ependyma is thickened, the endothelial cells on its surface are multiplied, and there is a growth of cells around the blood-vessels. The patients have headache ; vomiting ; at first photophobia, later dilated pupils ; hyperaesthesia of the skin ; an irregular rise of temperature, never very high, and sometimes below the normal ; finally coma. The disease lasts for weeks or months. The symptoms resemble those of a subacute tubercular menin- gitis. These cases again are so seldom recognized that we do not know how many of them may recover. 2. Acute Dilatation of the Ventricles in Adults — Serous Apoplexy. — Lesions. — Either one lateral ventricle, or botli, or all the ventricles are dilated and filled with clear serum. The ependyma is white, somewhat thickened, its surface smooth or finely granular. The convolutions of the hemispheres are some- what flattened. Causes. — The disease is, in New York, not an uncommon one. It occurs both in strong and vigorous adults and in persons who have suffered from chronic diseases. In some persons there is a previous history of injuries to the head, or of mental or bodily overwork. In som.e cases the condition is complicated by chronic endarteritis, or chronic meningitis. It is said that there may be an obstruction of the veins or of the passages between the ven- tricles. The disease may be confounded with cerebral apoplexy, em- bolism, chronic endarteritis, or tumors of the brain. Syjnptoms. — The patients suffer from headache, noises in the ears, loss of memory, dulness of the mental faculties, slowness of speech, sleeplessness, disturbed digestion, sometimes temporary aphasia, or local paralysis. Tliese symptoms may only last for a few hours, or they may continue for a number of weeks. At the end of this time some of the patients recover completely. Others, however, either rapidly or gradually pass into the con- THE BRAIN. 27 dition of complete coma. In this condition they remain for a few days and then die, the temperature rising before deatli. Others, on the contrary, develop an active delirium, blind- ness, internal strabismus, convulsive movements of groups of muscles, a febrile movement, and finally become comatose. Treatment. — Recoveries from the disease are reported after treatment with mercury and potassium iodide. 3. The Chronic Hydrocephalus of Children. — Lesions. — There is an accumulation of serum in the ventricles of the brain, so large in quantity that the brain is thinned, the dura mater stretched, and the cranial bones separated from eacli other. The ependyma appears to be normal, or is somewhat thickened. Causes. — We are ignorant of the causes of this lesion. It seems to begin during intra-uterine life. It may reach a consid- erable development before birth, or remain latent for months or years after birth. Symptons. — If the disease is so much developed during intra- uterine life that the large head prevents the birth of the child, craniotomy must necessarily be performed. If the disease is moderately developed during intra-uterine life, the child can be born alive. But it is at once evident that the head is too large ; the child does not perform its functions well, and dies in a short time. In many cases, at the time of birth the child shows no evi- dences of the disease, and it is not till after months or years that its symptoms are developed. Of these later developed cases we may distinguish a mild and a severe form of the disease. In the mild cases the head is usually large, the fontanelles and sutures open, the face small. The intelligence remains good. From time to time, for periods of several days, the child suffers from disturbances of digestion and nutrition, a febrile move- ment, fits of crying, restlessness, and drowsiness. In these mild cases the disease is not of itself fatal, but the children are apt to be carried off by some of the diseases of childhood. In the severe cases there is marked impairment of nutrition ; the children are dull and stupid, irritable and drowsy ; there are often strabismus, nystagmus, dilated pupils, protruded eyeballs, blindness, deafness, general convulsions, and paraplegia. There may be a febrile movement. These symptoms are interrupted by periods of improvement, but the course of the disease is usu- 28 THE BRAIN. ally downward, and the children die in an attack of convulsions, or of inanition, or from some intercurrent disease. Rarely they grow up to adult life, but remain more or less idiotic. The treattnent is mainly directed to the general condition of the patient. Careful feeding, a clean skin, good air, the admin- istration of iron and of cod-liver oil are the essentials. During the exacerbations of the symptoms the iodide of potash may be of service. 4. Chronic Hydrocephalus in Older Children. — In older children and in adolescents we meet with cases of chronic hydro- cephalus, not congenital, but occurring after meningitis, after injuries, and without discoverable cause. In some cases of acute meningitis, the patient, after going through the symptoms of this disease and beginning to improve, makes only an attempt at convalescence, again becomes worse, is alternately delirious and stupid, has a moderate febrile move- ment, and emaciates. After continuing in this condition for weeks, he may recover or die. In the cases which occur after injury and without discovera- ble cause, the clinical history is like that of the chronic hydro- cephalus of young children, but without the enlargement of the head. THE PHARYNX AND TONSILS. The nose, the pharynx, and the mouth are lined with a contin- uous tract of mucous membrane, which, on account of its situa- tion, exposed to a great variety of irritants, is very often the seat of acute and chronic inflammations. The chronic inflammations are best treated by the specialist ; the acute inflammations are usually left in the hands of the general practitioner. Throughout this whole tract the structure of the mucous membrane is essentially the same — an outer covering of epithe- lium, a vascular stroma, a large supply of mucous glands. On each side of the pharynx is a lymphatic gland of some size — the tonsil. The shape of the tonsils is peculiar; it is that of a flat mass of lymphatic glandular tissue folded on itself so as to form a wrinkled ovoid body, of which the outer surface is cov- ered with a layer of epithelium. The wrinkles are the crypts of the tonsils. We will consider : Acute catarrhal pharyngitis. Acute tonsillitis. Acute croupous tonsillitis. Suppurative tonsillitis. Acute Catarrhal Pharyngitis. This is a simple, acute, exudative inflammation which involves circumscribed portions of the pharynx, or the entire throat with the tonsils, or extends also into the nose. Lesions. — Tlie mucous membrane is congested and swollen. The function of the mucous glands is at first arrestedj so that the surface of the mucous membrane is dry ; after some hours or days the function of these glands is stimulated. There is then an increased quantity of mucus, which is thin and easily dis- 30 THE PHARYNX AND TONSILS. charged from the surface of the mucous membrane, or thick and tenacious, so that it adheres to it. Causes. — Some individuals, and the members of some families, are especially liable to acute pharyngitis ; this liability is most marked in young people. The inhalation of irritating gases, or of irritating substances floating in the air, is a frequent cause of pharyngitis. Prolonged exposure to cold and wet and disturb- ances of the stomach also seem to be efficient causes. Symptoms. — The symptoms are constitutional and local. The principal constitutional symptom is a rise of temperature, with the accompanying chills, prostration, vomiting, headache, and pains in the limbs. This fever often precedes the sore throat, and disappears before the latter has subsided. The local symptoms are the characteristic appearance of the throat and the pain, which is increased by any movement of the muscles of the pharynx. The pain is most annoying when the inflammation involves the pillars of the fauces, the upper surface of the soft palate, and the uvula. The cases vary as to the height of the temperature and the severity of the constitutional symptoms. In the worst cases the temperature reaches 104° F., and the patients look seriously ill. The inflammation is a self-limited one, lasting for from four to seven days, but occasionally it continues for a longer time. Treatment. — As the inflammation is a self-limited one, and naturally terminates in recovery, treatment is directed to short- ening its duration and making the patient more comfortable. The best local application at the beginnmg of the disease seems to be cocaine ; later the mild astringents are of service. The milder cases require nothing but the local treatment. In the more severe cases a variety of drugs are given : opium in small doses, calomel or the sulphate of magnesia in small doses, tincture of aconite in drop doses, salicylate of soda in doses of ten to twenty grains every three hours, or salol in the same doses. Profuse sweating of the entire skin may be of service. Acute Tonsillitis. Synonyms.— Yo\Y\c\x\2,x tonsillitis, ulcerative tonsillitis, spotted sore throat. Lesions. — There is a simple exudative inflammation of one or both tonsils. These bodies are swollen so that thev can be seen THE PHARYNX AND TONSILS. 3 1 projecting into the throat, and are congested. The crypts are filled with little Avhite masses of mucus and epithelium, which contrast with the congested tonsils. There are no real ulcers. The causes, symptoms, and treatment of acute tonsillitis are the same as those of acute pharyngitis. Croupous Tonsillitis. SynoJiym. — Diphtheritic sore throat. Lesions. — The tonsils are congested and swollen. Their sur- faces are partly or completely covered with patches of false membrane. The false membrane is composed of fibrin, pus, and necrotic epithelium. The stroma of the mucous membrane is infiltrated with fibrin and pus. The lymphatic glands in the neck may be swollen. In bad cases there is gangrene of portions of the tonsils and of the tissues of the neck. Streptococci and staphylococci are found in the inflamed tis- sues and the false membrane. Causes. — This form of tonsillitis is due to local infection with streptococci and staphylococci. It is a complication of many of the infectious diseases, but especially of scarlet fever. Less fre- quently it occurs by itself. Symptoms. — A croupous tonsillitis gives the same symptoms as does a simple tonsillitis, but much more severe. The temperature is higher, the prostration greater, the ap- pearance of the inflamed tonsils is quite different. The inflam- mation regularly runs its course within a week, but the prostra- tion left after the disease is more marked and lasts longer. The gangrenous forms, however, are attended with septic symptoms, and are usually fatal. Treatment. — The most efficient treatment is the frequent and thorough local application of large quantities of weak solutions of bichloride of mercury, or peroxide of hydrogen. Suppurative Tonsillitis. Synonym. — Quinsy sore throat. Lesions. — There is in one or both tonsils an acute exudative inflammation with necrosis of tissue, which goes on to the for- mation of an abscess in the substance of the tonsil. A catarrhal pharyngitis accompanies tlie tonsillitis. 32 THE PHARYNX AND TONSILS. Causes. — There is a decided predisposition in some persons and in some families to this form of tonsillitis. Apparently, the exciting causes are the same as for simple tonsillitis, with the ad- dition of the bacteria of suppuration. Symptoms. — There is a febrile movement which precedes and accompanies the tonsillitis. Accompanying the fever are chills, headache, vomiting, pains in the back, and prostration. The inflamed tonsil becomes gradually more and more swol- len, it fills up the pharynx, pushes the soft palate forward, and. projects outward into the neck. From the beginning there is a good deal of pain in the throat, and, as the swelling increases, the pain is greater, the mouth and throat are constantly filled with mucus and saliva. The patients can hardly swallow any- thing, they feel as if they might suffocate, they are unable to sleep. If both tonsils are inflamed and the uvula swollen, or if there is oedema of the glottis, there is real danger of suffocation. All the symptoms continue and increase until the abscess breaks and the pus is discharged. Then there is an abrupt change for the better, and in a few days the patient is well. The inflammation regularly runs its course and terminates in rupture of the abscess within a week. If both tonsils are in- flamed successively the disease lasts longer. The patients almost uniformly recover, but it is possible for death to be produced by oedema of the glottis. Treatment. — During the first twenty-four hours of the tonsilli- tis we may try to abort the inflammation bv the use of calomel, sulphate of magnesia, aconite, salicylate of soda, salol, or cold applied to the neck. After the abscess has been formed, the inhalation of hot steam and the application of moist heat to the neck are of ser- vice. The excessive production of mucus can be partly con- trolled by astringent washes and the administration of belladon- na. The pain and distress can be alleviated by local applications of cocaine and the internal use of opium. Swelling of the uvula and oedema of the glottis demand free scarification. THE LARYNX. Laryngismus Stridulus. This name is given to two different forms of spasmodic con- traction of the muscles of the larynx. 1. There is a spasmodic closure of the glottis, which is almost complete, lasts for a few seconds, and is then followed by a loud, stridulous inspiration. This occurs in young children, usually under two years of age, who are badly nourished, or who suffer from rickets. It occurs in attacks, which are repeated after short or long intervals. The child suddenly stops breathing, the face and lips become pale, or slightly livid, the appearance is almost that of a dead person. Then, after a few seconds, there is a long, stridulous inspiration, and the attack is over. Sometimes the attacks are accompanied by rigidity of the muscles, or by general convul- sions, or by unconsciousness. Occasionally the attacks are fatal. At the time of an attack, if it is an alarming one, we may give inhalations of nitrite of amyl, or pass a tube through the larynx. To prevent the attacks the nutrition of the child is to be im- proved in every possible way. 2. There is a spasmodic partial closure of the glottis, attended with difficult and stridulous breathing, which lasts for several' hours. This occurs in young children of all kinds, whether their pre- vious health has been good or not. There is a decided predis» position in families and in individuals. Some of the attacks are due to indigestion, for others no cause can be discovered. The attacks usually begin in the night and last until the next day. The child wakes up in the night with laryngeal dyspnoea, which after a time is followed by more or less venous congestion of the skin. But there is no fever, and, except for the dyspnoea, 34 THE LARYNX. the child does not look ill. Although the dyspnoea may appear alarming, it always eventually subsides, even if it is left to itself ; but an emetic will cause it to disappear more rapidly. The best emetics are those which act the quickest ; the yellow sulphate of mercury, apomorphia, ipecac, and antimony are those ordinarily used. Acute Catarrhal Laryngitis. Lesiojis. — The mucous membrane of the larynx is congested, and at first dry. The stage of dryness lasts for from twelve to forty-eight hours, and is then succeeded by an increased produc- tion of mucus. With the production of the mucus the conges- tion and swelling of the mucous membrane diminish. The in- flammation may extend to the trachea and bronchi or to the pharynx. It occurs both in adults and children. 1. In Adults. Causes. — The inflammation occurs without dis- coverable cause, after exposure to cold, from the inhalation of smoke or steam, with syphilis, phthisis, measles, scarlatina, vari- ola, erysipelas, typhus and typhoid fevers. Symptoms. — In the more severe cases there is a febrile move- ment, in the milder cases this is absent. The patients have a laryngeal cough, at first dry, afterward with mucous expectoration. The voice is husky, or stridulous, or reduced to a whisper. There is more or less discomfort or pain in the larynx. In some of the cases there is laryngeal dysp- noea, continuous, but with exacerbations. The most alarming feature about this dyspnoea is that occasionally the patients stop breathing suddenly and die. The inflammation usuall)' runs its course within two weeks, but it may be protracted for a much longer period. Treatment. — During the acute stages of the laryngitis the con- tinuous application of hot sponges to the neck, and the inhala- tion of steam, are of decided service. The internal administra- tion of tartarized antimony, or of the iodide of potash, may also be useful. When the dyspnoea is urgent the patients are to be constantly "^'■atched, in order that intubation or tracheotomy may be performed, if necessary. If the inflammation is prolonged the mineral acids, quinine, iron, and change of climate may hast- en the subsidence of the disease. The local application of as- tringent sprays is of much service. 2. In Children. — The catarrhal laryngitis of children is often THE LARYNX. 35 called catarrhal croup. It is one of the most common diseases of childhood. It occurs often without discoverable cause, sometimes after exposure to cold and wet, from the inhalation of steam and smoke, and as a complication of measles and scarlatina. The disease is most common in children between the ages of one and five years, less frequent in older children. There is a well-marked predisposition to the disease in some children and in some families. The changes in the mucous membrane of the larynx are the same as those observed in adults, but the smaller size of the larynx in children causes the swollen mucous membrane to be a still greater obstruction to the act of breathing. Syrnpto77is. — The local symptoms are : Dyspnoea, which is con- tinuous, but with exacerbations ; in some cases attacks of laryn- gismus stridulus ; stridulous voice or loss of voice ; and stridulous cough. The general symptom is a rise of temperature with its accom- panying disturbances. The fever may precede, or follow, or be simultaneous with, the local symptoms. The invasion of the disease is often sudden, and then usually occurs in the night, with the continuous dyspnoea, or an attack of laryngismus stridulus as the first symptom. In other cases the invasion of the disease is gradual, with a croupy cough as the first symptom. The ordinary cases last for three days and nights, the symp- toms worse during the night and better during the day. The patients vary as to the height of the temperature and the degree of the dyspnoea. Most of the patients are decidedly better by the fourth day, the improvement beginning with the produc- tion of mucus from the inflamed membranes. Occasionally, how- ever, the laryngitis is protracted for one or two weeks, or it may be succeeded by a bronchitis. The Prognosis is good, even the severe cases are seldom fatal. Treatment. — For the laryngitis we apply moist heat to the neck, and give internally five- or ten-drop doses of the wine of antimony every one or two hours. For the attacks of laryngismus stridulus we give emetics. For the fever it may be proper to use small doses of antifebrin or tincture of aconite ; for the restless- ness, small doses of opium. In the protracted cases small doses of calomel may be of service. 36 THE LARYNX. Croupous Laryngitis. Synonym. — Membranous croup. Lesions. — The mucous membrane of the larynx is congested, swollen, and infiltrated with fibrin and pus. Its free surface is coated with a false membrane composed of fibrin, pus, and ne- crotic epithelium. Streptococci and staphylococci are found in the false mem- brane and the inflamed tissues, except in the cases in which tlie laryngitis is caused by a local irritant. Causes. — Children are more liable to the disease than are adults. Most of the cases are examples of a streptococcus inflammation complicating measles and scarlet fever. But it may also occur in the same way with the other infectious diseases and by itself. A similar inflammation may be excited by the inhalation of irritative vapors, such as hot steam or smoke, and by swallowing irritating fluids which find their way into the larynx. The Symptotns are the same as those of a catarrhal laryngitis, but are more severe, more continuous, and last for a longer time. The temperature is higher, the dyspnoea is more severe, and the evidences of imperfect aeration of the blood are more marked. In the favorable cases, after from four to seven days the inflam- mation subsides, the false membrane becomes loosened, is coughed up, and the dyspnoea is relieved. In the unfavorable cases the dyspnoea continues and causes the death of the patient. The Prognosis is unfavorable, especially in children under three years of age. The Treatment is the same as that for a catarrhal laryngitis, but in addition it is often necessary to employ intubation or tracheotomy to relieve the dyspnoea. The inhalation of the fumes of calomel may be of great service. THE PLEURA. In the study and treatment of the diseases of the pleura and of the lungs we are very much assisted by percussion and auscul- tation, by the aid of which we determine the so-called physical signs. The Physical Signs of the Pleura and of the Lungs. Percussion. — When we percuss the wall of the chest we obtain certain sounds, and of these sounds we note the quality, the pitch, the intensity, and the duration. 1. Pulmonary Resonance. — This is characterized by pulmonary quality, low pitch, considerable duration, and variable intensity. It is heard over the healthy lung. 2. Dulness. — Of this the quality is imperfectly pulmonary, the pitch is higher, the duration is short, the intensity is small. It is heard over the normal lung where the chest-wall is thickened by bone or muscle, and where the liver and heart are in contact with the lung. It is heard over pleuritic adhesions, over small quan- tities of fluid in the pleural cavities, over consolidations of the lung, emphysema, enlargements of the heart, liver, and spleen, aneurisms of the aorta, abscesses, and tumors, 3. Flatness. — The quality is fiat, the pitch is high, the duration is short, the intensity is small. It is heard over the liver, where it is uncovered by the lung, over thick pleuritic adhesions, fluid in the pleural cavities, complete consolidation of the lung, aneu- risms, abscesses, tumors, and rarely over a lung which is not consolidated, but of which the bronchi are completely obstructed. 4. Tympanitic Resonance. — The quality is tympanitic, the pitch is high or low, the duration is considerable, the intensity is marked. It is heard over the stomach and intestines, over air in the pleural cavities, over cavities in the lungs, over solidified and compressed lung, and with emphysema. 38 THE PLEURA. 5. The Cracked Pot Sound. — The quality is metallic, the pitch is high, the duration and intensity are not very great. It is heard over cavities, and over consolidated and compressed lung. 6. Amphoric Resonance. — The quality is amphoric, the pitch is low, the duration and intensity are considerable. It is heard over air in the pleural cavity, over large cavities in the lung, and occasionally over consolidations of the lower lobe of the left lung. The Breathing. — In listening to the breathing we distinguish the sound of inspiration and that of expiration, and of each we note the quality, the pitch, the intensity, and the duration, 1. Pulmonary, or Vesicular Breathing. — Of inspiration, the qual- ity is pulmonary, the pitch is low, the duration is considerable, the intensity is variable. Of expiration, the pitch is low and the duration is shorter. 2. Bronchial Breathing. — Of inspiration, the quality is bron- chial, the pitch is high, the intensity and duration are variable. Of expiration, the pitch is higher and the duration is longer than those of inspiration. It is heard over consolidated and com- pressed lung, and over cavities. 3. Bro7icho-vesicular Breathing. — This is of a character inter- mediate between that of vesicular and that of bronchial breathing. It is heard over the normal lung in the interscapular region, and over the lesser degrees of consolidation and compression of the lung. 4. Cavernous Breathing. — Of the inspiration, the quality is cavernous, the pitch is low. The expiration is longer and lower- pitched than the inspiration. It is heard over cavities and over consolidated or compressed lung. 5. Amphoric Breathing. — The quality is amphoric, the pitch is low, the expiration is prolonged. It is heard over large cavities in the lungs, and over pleural cavities which contain air, with perforation of the lung. 6. Sibilant Breathing. — The quality is sibilant, the pitch is high, the intensity is great, the expiration is prolonged. Sonorous Breathing. — The quality is sonorous, the pitch is low, the intensity is great, the expiration is prolonged. Both these forms of breathing are produced by a contraction of the calibre of the larger and medium-sized bronchi. The ordinary causes of such a contraction are bronchitis and spasmodic asthma. A special form of sibilant and sonorous breathing is pro- THE PLEURA. 39 duced by narrowing of the lumen of the trachea, or of the large bronchi. Rales. — These are abnormal sounds which accompany the breathing and are not heard over the healthy lung. 1. The Crepitant Rale. — This is a very fine, dry, crackling sound. It is heard at the end of inspiration, is produced in puffs, and seems to be close to the ear. It is heard with dry pleurisy, with pneumonia, and with phthisis. 2. The Subcrepitant Rale. — This is a fine, moist sound ; heard with inspiration, or with expiration, or with both. It accom- panies dr}^ pleurisy, bronchitis, pneumonia, phthisis, and oedema of the lungs. 3. The Coarse, or Mucous, Rales. — These are loud, moist sounds, heard both with inspiration and expiration. They are heard with pleurisy, with bronchitis, with pneumonia, and with phthisis. 4. The Gurgling Rales. — These are loud, coarse, moist sounds, of gurgling quality. They are heard over small cavities, over compressed lung, and occasionally over pleuritic adhesions. Friction Sounds. — These are produced by the rubbing of op- posed surfaces of pleura coated with fibrin, or by the movement of pleuritic adhesions. They have the characters of the crepitant, the subcrepitant, the mucous, or the gurgling rale ; the sound is a grazing, or rubbing, or creaking one. The Voice. — The Pulmonary Voice. — The quality is pulmo- nary, the pitch is low, the intensity and the thrill differ with the individual. Increased Vocal Resonance. — The quality is pulmonary, the pitch is higher, the intensity and the thrill are greater. It is heard over the normal lung in the right infra-clavicular and in both the interscapular regions. It is also heard over consoli- dated or compressed lung, over cavities, and over lung which is adherent to the wall of the chest. Diminished Vocal Resonance. — The intensity and the thrill are diminished, the quality and the pitch are the same as with the pulmonary voice. It is heard over small effusions in the pleural cavities, over thick pleuritic adhesions, over consolidated lung, and over lungs of which the bronchi are occluded. Suppressed Vocal Resonance. — There is absence of the voice- sound with fluid in the pleural cavities, with intra-thoracic 40 THE PLEURA. tumors, with consolidation of the lung, and with obstructions of the bronchi. Bronchophony. — The quality is bronchial, the pitch is high, the intensity and the thrill are variable. It is heard over consoli- dated and compressed lung, and over cavities. ^^gophony. — This is a form of bronchophony characterized by its peculiar, shrill quality. It is heard over lung compressed by fluid in the pleural cavity, at the level of the fluid. Pectorilogy. — Not only the sound of the voice is heard, but the articulation of words can be distinguished. It is heard over large cavities, and sometimes over consolidated lung. Pleurisy. The pleura is a connective-tissue membrane composed of fibrillated connective tissue, with its basement substance and cells, and covered over its free surface by a layer of endothelial cells. Imbedded in it are nerves, blood vessels, and lymphatics. According to its distribution, we speak of the pulmonary, costal, mediastinal, and diaphragmatic pleura. The pleura may become inflamed in several different ways, and we describe : Pleurisy with the production of fibrin. Pleurisy with the production of fibrin and serum. Pleurisy with the production of fibrin, serum, and pus. Pleurisy with adhesions. Tubercular pleurisy. In pleurisy with the production of fibrin alone, or of both fibrin and serum, the morbid changes in the pleura are essen- tially the same, differing only in the presence or absence of the serum. The first change in the pleura is simply a congestion and a falling off of the endothelial cells. Then the pleura loses its smooth, shining appearance, and looks dull and rough, this change being due to the presence of small knobs and threads of coagulated fibrin on its surface. At tlie same time, if serum is to be present, it begins to collect in the pleural cavity. Next there is a swelling of, and a new growth from, the con- nective-tissue cells of the pleura, and an emigration of white blood-cells from the vessels. Then we find the pleura coated with a layer of fibrin in which are entangled pus-cells and new THE PLEURA. 41 connective-tissue cells. After this the new connective-tissue cells entangled in the fibrin become more numerous, a basement substance and new blood-vessels are formed. Finally, the fibrin and the serum are absorbed and disappear, and the pleura is left thickened and with connective-tissue adhe- sions binding together its opposed surfaces. Pleurisy with the Exudation of Fibrin. Dry Pleurisy. Lesions. — The inflammation begins in the costal or pulmonary- pleura, according to the cause producing it. It extends regularly to the portion of pleura opposite to it. Usually only a circum- scribed portion of the costal, pulmonary, mediastinal, or dia- phragmatic pleurals involved, but sometimes the entire pleura of one side of the chest is inflamed. The inflamed pleura is coated with fibrin, and bands of fibrin form adhesions between the op- posed pleural surfaces. In rare cases the quantity of fibrin is so great as to compress the lung. When the inflammation has subsided, the fibrin is absorbed, but permanent connective-tissue thickening and adhesions are left. Causes. — Exposure to cold and wet, wounds of the chest-walls, inflammations of the lung, peritonitis, the infectious diseases, and Bright's disease are regular causes of pleurisy. In some cases there seems to be an individual predisposition to pleurisy, and the same person suffers from several attacks. Symptoms. — The most constant physical sign is a friction sound — a crepitant, subcrepitant, or mucous rale, or a rubbing sound. This is heard over the inflamed portion of the pleura. It cannot be heard if only the mediastinal or diaphragmatic pleura is in- flamed. It is heard only with inspiration, or with expiration also. It is usually not continuous, but requires a forced inspiration to develop it. In some cases there is also dulness over the inflamed portion of the pleura. In the mild cases the only constitutional symptom is pain over the inflamed pleura. In the more severe cases there is a febrile movement attended with prostration and headache, shallow breathing, and a dry cough. These symptoms only last for a few days. 42 THE PLEURA. The exceptionally severe cases, with very large exudations of fibrin, resemble cases of lobar pneumonia. The ordinary cases recover after a short time, but the patient is left with permanent thickenings and adhesions of the pleura. Such adhesions may give no further trouble, except for occasional pain ; or they may form the starting-point for a chronic pleurisy with adhesions, followed by interstitial pneumonia and chronic bronchitis. Treatment. — For the pleurisy we employ wet, or dry, cups, or blisters over the inflamed pleura. For the pain we use opium. While the febrile movement is present the patients should be kept in bed. So long as the friction sound persists the patient must be kept in the house if the weather is cold, but in warm weather this is not necessary. Pleurisy with the Exudation of Fibrin and Serum. Pleu- risy WITH Effusion. The inflammation involves the greater part of the pleura on one side of the chest. Occasionally both sides of the chest are inflamed, and when this is the case the pericardium is apt also to be inflamed. The pleural cavity contains more or less clear, or turbid, serum. The surface of the pleura is coated with fibrin, and bands of fibrin join together its opposite surfaces. The lung is more or less compressed, according to the quantity of fluid. After the inflammation has subsided the serum and fibrin are absorbed, and thickenings and adhesions of connective tissue are left. The compressed lung expands partially or completely. Ac- cording to the expansion of the lung, there is left more or less retraction of the affected side of the chest. The Causes are the same as those which produce dry pleurisy. Symptoms. — The disease may run an acute or a subacute course. I. The Acute Form. — The symptoms begin abruptly with chills, fever, full and frequent pulse, pains in the head and limbs, vom- iting, and prostration. The breathing is frequent and shallow, there may be a dry cough, there is severe pain. The pain is re- ferred to the inflamed pleura, or to some point in the back, or in the abdomen, or even to the opposite side of the chest. It THE PLEURA. 43 usually becomes less severe with the accumulation of serum in the pleural cavity. After a few days the acute symptoms subside. The inflam- matory products remain in the chest for some time longer. They may then be absorbed, or the pleurisy may take on the subacute form and last for a long time. 2. The Subacute Form. — The symptoms are developed gradu- ally and slowly. The patients complain of pain in the side, of dyspnoea on exertion, of a dry cough, of loss of appetite, flesh, and strength, and they become anaemic. They are, for a time, not confined to bed, and often continue at their work. They have a little fever, the temperature normal in the morning, but running up to ioo° in the afternoon. In some cases, however, the temperature runs higher : ioo° in the morning, and 101° to 103" in the afternoon. With these higher temperatures the patients lose flesh and strength more rapidly, and may sweat at night. The Physical Signs. — At the beginning of the inflammation, when the pleura is coated with fibrin and but little serum has been exuded, there is a friction sound, which is a rubbing sound, or a crepitant or subcrepitant rale. After the fluid has been absorbed there is again a friction sound — a subcrepitant or coarse rSle, or a creaking sound. When a considerable quantity of fluid has accumulated in the pleural cavity there are physical signs due to the presence of the fluid and the compression of the lung. Below the level of the fluid there is flatness on percussion, absence of voice, of breathing, and of vocal fremitus. The fluid accumulates in the lower part of the pleural cavity, compressing the lung upward and against the vertebral column ; or in the posterior part of the pleural cavity, compressing the lung against the anterior wall of the chest ; or it may be shut in by adhesions. The compression of the lung is in proportion to the quantity of the fluid. At the level of the fluid there is dulness on percussion and segophony. Above the level of the fluid, over the compressed lung, the percussion resonance is pulmonary, or exaggerated and high- pitched, or tympanitic. The breathing is pulmonary, or exag- gerated, or broncho-vesicular, or bronchial. The affected side measures more than the opposite side of the 44 THE PLEURA. chest, the diaphragm is pushed down, the intercostal spaces may- be forced outward, the heart may be displaced toward the oppo- site side of the chest. As the fluid is absorbed the voice and breathing can be heard lower and lower down, the flatness disappears, but dulness on percussion remains for some time after all the fluid has been absorbed. Exceptional Physical Signs. — The vocal fremitus may not be lost below the level of the fluid. Bronchophony alone, or both bronchial voice and breathing, may be heard below the level of the fluid, especially if the quantity of fluid is large and the lung much compressed. Above the level of the fluid, over the compressed lung, there may be cavernous breathing and gurgling rales. The sacculated effusions give very irregular physical signs, varying with the position of the fluid. The acute cases of pleurisy with effusion may last for only a few weeks, but more frequently, whether acute or subacute, they last for weeks or months. In a few cases the disease terminates fatally. Death is then often sudden, and seems to be due to congestion and oedema of the other lung, or to interference with the action of the heart. In a moderate number of cases the inflammation changes its character, pus is added to the other inflammatory products, and the patients have empyema. Most of the patients recover, but with a damaged pleura, and with a lung which expands more or less incompletely. In many of them the only subsequent inconvenience is some pain on the affected side of the chest ; but in others there is marked retrac- tion of the wall of the chest, chronic pleurisy with adhesions, in- terstitial pneumonia, or chronic bronchitis. It may also happen that such a pleurisy will be succeeded by chronic phthisis. The displaced heart may return to its natural position, or it may remain fastened in its new place by adhesions, or it may be drawn over to the retracted side of the chest. Diagnosis. — Pleurisy with effusion may be mistaken for em- pyema, tubercular pleurisy, pneumonia, phthisis, abscess of the liver, or tumors of the pleura. In many cases we are warranted in drawing off fluid from the pleural cavity with a fine needle, in order to establish the diagnosis. TreaUnent. — Of the acute form of pleurisy with effusion, the THE PLEURA. 45 treatment is that of an acute exudative inflammation. Wet or dry cups, or blisters, over the affected side of the chest, calomel, and the sulphate of magnesia given internally, are the most efficient remedies. The patients are to be kept in bed and on a fluid diet. The pain and restlessness may be relieved by opium combined with aconite or veratrum viride, or by chloral hydrate with one of the bromides. In subacute pleurisy with effusion we have to treat the inflam- mation and the accumulation of fluid within the pleural cavity. The only direct means of treating the inflammation is the use of counter-irritation over the affected side of the chest. The indi- rect means are keeping the patients in bed, or getting them out of doors in a suitable climate, according to the case ; the use of iron, quinine, and the mineral acids ; and the regulation of the diet. If the quantity of fluid in the pleural cavity is moderate it can be removed by diuretics — the iodide or acetate of potash, the diuretic pill, chloride of sodium, cafiein, convallaria, digitalis. At the same time the urine is to be measured every day, and the ingestion of fluids somewhat restricted. If the chest is distended with fluid this must be removed by the aspirator. In doing this the strictest cleanliness must be ob- served, and only a moderate quantity of the serum withdrawn. Immediately after the aspiration the use of diuretics should be begun. Pleurisy with the Production of Serum, Fibrin, and Pus. Empyema. Lesions. — The inflammation regularly involves the whole of the pleura on one side of the chest, less frequently a circum- scribed portion of the pleura. The inflammation follows two different forms : 1. The pleura is coated with fibrin and pus, and its cavity contains purulent serum, but the pleura itself is but little changed. This form is most common in children. 2. The pleura is coated with fibrin and pus, its cavity con- tains purulent serum, and in addition the pleura itself is much changed. It is split up by great numbers of new cells, so that it resembles granulation tissue. In either case the fluid accumulates in the lower part of the pleural cavity, pushing the lung upward and toward the verte- 46 THE PLEURA. bral column ; or in the posterior part of the pleural cavity, push- ing the lung forward ; or it is sacculated in any part of the pleural cavity. The lung is usually much compressed. In old cases the pleura becomes much thickened, and may be infil- trated v^ith the salts of lime. The suppurative process may extend from the pulmonary pleura to the lung, and the pus then escape at intervals from the bronchi ; or it may extend from the costal pleura to the wall of the chest, and the pus escape externally. In a few cases the inflammatory products and the superficial layers of the pleura become gangrenous. The micro-organisms regularly found are either streptococci or pneumococci. Thex"e seems to be no special difference in the clinical symptoms whether the infection is effected by one or the other of these organisms. Symptoms. — i. The inflammation may be primary, after expos- ure to cold, or without discoverable cause. The patients are suddenly attacked with chills, a high temperature, marked pros- tration, headache, pains in the back and limbs, pain over the in- flamed pleura, shallow and painful breathing, sometimes cough. The symptoms may continue acutely and the patients die in a short time, or they may subside and the inflammation pass into the chronic condition. 2. The inflammation may be secondary to a pleurisy with ef- fusion, or to a lobar pneumonia. A pleurisy with effusion may change suddenly or slowly into an empyema. The patients lose flesh and strength more rapidly, and have higher temperatures. A lobar pneumonia may run its course, convalescence be estab- lished and continue for several days, and then the temperature goes up, and there are the physical signs of fluid in the pleural cavity. 3. An empyema, after running its course for a shorter or longer time, will suddenly change, the inflammatory products become gangrenous, the patients pass into the pyaemic condition and die in a few days. 4. Abscesses in the wall of the thorax, in the liver, in the abdominal cavity, or in the lung, may rupture into the pleural cavity and set up a purulent inflammation. The physical signs of empyema are the same as those of pleurisy with effusion, but sacculation of the fluid and irregular physical signs are more common. THE PLEURA. 47 The Course of the Disease. — Some of the acute cases continue without any abatement of the symptoms, and terminate fatally within a short time. More frequently the course of the disease is clironic. The patients go on for months or years with fever, gradual loss of flesh and strength, and dyspnoea and cough. In some the lung is perforated and the pus from time to time coughed up through the bronchi ; in some the wall of the chest is perforated and the pus imperfectly evacuated ; in some there is septic poisoning. Very rarely does spontaneous recovery take place ; somewhat more frequently there is partial recovery, with absorption of some of the pus and sacculation of the remainder. Most of the patients, if not cured by proper treatment, die exhausted by the disease, or with pulmonary phthisis, or with waxy viscera. The most difficult cases to make out are those with a saccu- lated empyema. The patients have more or less fever and go on week after week not getting well. The physical signs are vari- able and deceptive. Rather a favorite seat of such an empyema is at the root of the lung. The Prognosis is more favorable in children than in adults ; in those operated on early than in those operated on later. It is un- favorable after septic poisoning has begun, and when the empyema is caused by the rupture of an abscess into the pleural cavity. The Diagnosis is between empyema, pleurisy with effusion, lobar pneumonia, broncho-pneumonia, tubercular pneumonia, and abscess of the liver. The Treatment. — In children the disease can be cured by as- piration ; but if after two or three aspirations the improvement is not decided, it is better to open the chest. In the smaller sacculated collections of pus in adults a cure can often be effected by aspiration. In the ordinary cases of empyema in adults the rule is to open the chest as soon as the diagnosis is made. The regular procedure is to feel for the first rib below the angle of the scapula, to cut down on this rib and remove it up to its cartilage, to put in a large drainage-tube, sew up the wound, and dress with bichloride. The dressings are to be changed as seldom as possible, the chest is not to be washed out, and the drainage-tube should be removed at the end of the fourth week. 48 THE PLEURA. Chronic Pleurisy with Adhesions. Lesions. — There is a chronic inflammation of the pleura with the production of new connective tissue, but without fibrin, serum, or pus. The inflammation begins at some part of the pleura, and then extends until first one lung and then both are completely covered with adhesions and fastened to the wall of the chest. It is not to be confounded with the old adhesions found over so many lungs after death, but is a chronic inflammatory process with the progressive formation of more and more adhesions. Causes. — The disease usually originates in the adhesions which have been left behind by previous attacks of dry pleurisy, pleurisy with effusion, or pneumonia ; but in some cases no history of such previous acute attacks can be obtained. The Symptoms vary with the extent of the lesions. In the early stages the only symptoms are occasional pain over the affected part of the chest, dulness on percussion, and friction sounds. When the disease is farther advanced, the pain continues, there is a dry cough, the breathing is imperfect, there is dyspnoea on exertion, and the area of dulness on percussion and of the friction sounds is larger. In the advanced cases the difficulty in breathing becomes very marked, the cough is more troublesome, the heart is diminished in size and sometimes displaced, the circulation is feeble, the pa- tients lose flesh and strength. They usually die from some in- tercurrent disease, but occasionally the pleurisy is the only dis- coverable cause of death. Treatment. — The patients should live as much as possible in the open air. They may be benefited by the use of cod-liver oil, iron, quinine, or the mineral acids. They should practice daily the filling and emptying of the lungs with air in as complete a manner as possible. Tubercular Pleurisy. Apart from the tubercular inflammation of the pleura, which accompanies general tuberculosis and chronic phthisis, we find tubercular pleurisy occurring as a localized tubercular inflamma- tion. Lesions. — The inflammation involves regularly the whole of THE PLEURA. 49 the pleura on one side of the chest, the costal pleura being prin- cipally involved. Tiie pleura is of a bright-red color mottled with small white points, or is only thickened and coated with fibrin. The tissue of the pleura is split up by the growth of new connective-tissue cells, and contains numerous tubercle granula. There is a large quantity of fluid in the pleural cavity, which is blood-stained, or purulent, or clear. Symptoms. — The clinical history is that of pleurisy with effu- sion, or of empyema, but the patients do badly. They lose flesh and strength, the fluid accumulates rapidly after it has been drawn off, the inflammation of the pleura persists, and the pa- tients die, either suddenly or exhausted by the disease, within a few weeks or months. Treatment. — It would seem, from our experience of the treat- ment of tubercular peritonitis, that in tubercular pleurisy it would be good practice to open the chest. HVDRO-PNEUMOTHORAX. This name is used to designate the presence of both air and fluid in the pleural cavity. Such a condition may be established in several different ways. There may be a gangrenous empyema with the formation of gas in the pleural cavity. There may be an empyema with an opening through the wall of the chest or into the lung. There may be abscesses or gangrene of the lung, perforating the pulmonary pleura. There may be pulmonary phthisis, with softening of cheesy nodules and perforation of the pleura. Symptoms. — The only cases of hydro-pneumothorax which have a special clinical history are those due to the rupture of ab- scesses or phthisical nodules in the lung. There is first the his- tory of the previous lung disease. Then, suddenly, at the time of the perforation, there is severe pain, a feeling as if something had given way within the chest, urgent dyspnoea, a rapid and feeble heart action, and great prostration. The patients may die in collapse within a few hours of the commencement of the at- tack ; or the urgent symptoms may subside, and the patients continue to live for some time with the symptoms of empyema and phthisis. 50 THE PLEURA. Physical Signs. — The affected side of the chest is larger than the other, and moves but little with respiration. The heart and the diaphragm are displaced. Vocal fremitus is absent. Percus- sion gives, above the level of the fluid, exaggerated pulmonary or tympanitic resonance, or flatness ; below the level of the fluid, fiatiiess. Auscultation gives, above the fluid amphoric breathing, or absence of breathing ; below the level of the fluid, absence of breathing. If the patient is shaken, we get the splashing sound of the fluid in the chest called " succussion." We may also get the sound resembling drops of liquid falling into liquid, called "the metallic tinkle." THE LUNGS. The lungs first appear as two small protrusions on the front of the oesophagus. They are diverticula of the hypoblast sur- rounded by mesoblast. The formative process consists in the budding of hypoblastic into mesoblastic substance ; tlie hypo- blast furnishing the lining epithelium and the mesoblast the stroma. As the lungs continue to develop they look like glands with acini and ducts. Just before birth the lungs are fully formed, but the air- spaces are not dilated and are completely lined with cuboidal epithelium. After birth the air-vesicles are dilated and their epithelium is flattened. As the child becomes older the air-spaces occupy a larger, and the bronchi and the stroma a smaller, part of the lung. In the adult lung the stroma is arranged so as to divide the lung up into lobules, six or seven-sided blocks, each side 5 to 15 mm. long. But few of the lobules are entirely separated from each other by the stroma. The small bronchi enter the lobules irregularly and break up into terminal bronchioles. The bron- chioles terminate in the air-passages. The air-passages are tubular spaces of irregular shape with air vesicles surrounding and opening into them on every side. Some air-vesicles, how- ever, are given off directly from the bronchioles. The air-pas= sages constitute the larger part of the lung, their walls have the same structure as those of the air-vesicles, their function in the act of breathing is the same as that of the vesicles. The walls of the air passages and of the air-vesicles are com- posed of a thin connective tissue membrane, reinforced by elas- tic fibres, with an abundant system of capillary vessels. These walls are no longer covered, as at birth, with a continuous layer of epithelium. Only a few scattered cells of epithelial type are left as indications of the fcetal epithelium. 52 BRONCHITIS. The important portions of the lung are : 1. Its stroma, which holds together all the component parts of the lung, and, as the pulmonary pleura, invests its external surface. In the stroma are imbedded blood-vessels, lymphatics, and nerves. The stroma may be the seat of exudative, purulent, or productive inflammation. 2. The bronchi, of which the walls are composed of connec- tive tissue, muscle, and cartilage, and are lined with a mucous membrane. The bronchi constitute the larger part of the lungs during foetal life ; in the young child they continue to pre- dominate, but in the adult they occupy a relatively smaller space. They may be the seat of acute catarrhal, of chronic ca- tarrhal, of croupous and of productive inflammation. 3. The air-passages and air-vesicles, by which the actual breathing and blood-aerating function of the lungs is performed. The structure of the walls of the air-spaces in the adult is that of a simple connective-tissue membrane which may be attacked by exudative or productive inflammation. 4. The blood-vessels, which are large and numerous and form a network of capillaries in the walls of the air-spaces. Any ob- struction of the blood-vessels interferes with the breathing func- tion of the lung, and, if long continued, causes changes in its structure. 5. The lymphatics — vessels throughout the lung and large nodes at the root of the lung. Inflammation of the bronchi is regularly attended with inflammation of the lymph-nodes, espe- cially in children. The stroma, the bronchi, and the air-spaces may be inflamed separately or together. Bronchitis. Causes. — Inflammation of the bronchi occurs at all ages. The acute form is. more common in children, the chronic form is more common with emphysema, with heart disease, and in old. persons. Persons living in cities, those who are much confined to the house, and those whose health has been enfeebled are especially Ii.able to the disease. There is in some persons a very well-marked predisposition' to inflammation of the bronchi. BRONCHITIS. 53 The disease is especially prevalent in cold and damp cli- mates, and during the cold and wet months of the year. During some years it is much more prevalent than during others. As exciting causes of bronchitis we recognize exposure to cold, the inhalation of irritating gases and substances, and of pathogenic bacteria. Measles, whooping-cough, influenza, and many of the infec- tious diseases are often complicated by bronchitis. I. The Acute Catarrhal Bronchitis of Adt^lts. Definition. — An acute exudative inflammation of the mucous membrane of the bronchi. Lesions. — The inflammation involves the trachea, the larger bronchi and the medium-sized bronchi, not as often the smaller ones. As a rule the bronchi of both lungs are equally inflamed. The mucous membrane of the bronchi is congested and swollen, at first it is dry, afterward coated by an increased production of mucus. There are also desquamation of the epithelial cells, emigration of white blood-cells, diapedesis of red blood-cells. The lumen of the bronchi may be narrowed either by the con- gestion and swelling of the mucous membrane or by the con- traction of the muscular coat. Symptoms. — The mild cases of acute bronchitis are attended with cough, accompanied by scanty mucous sputa, by pain over the sternum, and a moderate feeling of indisposition. There may be no physical signs, or a few coarse rales, or sibilant and sonorous breathing. The natural duration of the inflammation seems to be about a week, but it is often prolonged for a much longer time. In the more severe cases there is a troublesome cough with mucous or muco-purulent sputa, often streaked with blood. The quantity of expectoration is sometimes very large — more than a pint in twenty-four hours. The febrile movement precedes and accompanies the cough. It is usually not over ioi°, but there are cases with temperatures of 103° to 104° throughout the disease. In some patients bronchial asthma is the most prominent and distressing symptom. The physical signs are coarse rales and sibilant and sonorous breathing. As a rule these sounds are equally distributed over 54 BRONCHITIS. both lungs, but occasionally they are confined to one side of the chest. Tiie cases vary as to their severity and duration. The pa- tients are sometimes very ill, but do not often die. The ordinary duration of the disease is two weeks, but it may last much longer. In some of the cases a localized broncho-pneumonia is de- veloped, with dulness and increased vocal resonance over the consolidated portion of the lung. There are cases in which the bronchitis continues for weeks and months. The cough and muco-purulent expectoration con- tinue. There is an irregular fever with evening exacerbations and sweating at night. The patients lose flesh and strength, and •sometimes look very badly. In these cases the sputum should always be examined for tubercle bacilli. Treatment. — The milder cases are not confined to bed, they can eat solid food, but are to be cautioned against undue exposure. Many of them recover without treatment, but in some remedial measures are necessary. The severe cases have to be kept in bed, and mainly on a fluid diet. For the cases of bronchitis which need treatment we employ : (i) Counter-irritation. The most efficient counter irritation is by dry cupping ovsr the entire chest. More moderate counter- irritation can be effected' by large mustard plasters, irritating lini- ments, and poultices frequently renewed. (2) Drugs. The specific drug for acute bronchitis is ipecac. It seems to be most efficient when given frequently in small doses — gr. ^-'pth every hour. There may be an advantage in combin- ing the ipecac with other drugs : extr. belladonna, gr. -^-^ ; pulv. Doveri, gr. ■^-^\ pulv. ipecac, gr. ■^^\ quinise sulph., gr. 1 made into a pill or tablet, taken every hour. When there is a large expectoration of mucus with a good deal of pus mixed with it, 10- to 20-drop doses of tr. of nux vomica are of much service. The bronchial asthma seems most frequently to be due to contraction of the walls of the bronchi. If this is the case, nitrite of amyl, nitro-glycerine, chloral hydrate, or opium- are indi- cated. Sometimes, however, the asthma is associated with congested, swollen, but dry bronchi, then is indicated the use of muriate of BRONCHITIS. 55 pilocarpine, gr. y^^ ; fl. extr. quebracho, ni, x. ; ti. extr. grindelia ro- busta, 1U X., or larger doses of ipecac. In the protracted cases there is much advantage in sending the patient to a dry inland climate. Of useful drugs for chronic bronchitis there is a considerable number, sometimes one sometimes another proving the most ser- viceable : the mineral acids, the preparations of turpentine, iodide of potash, strychnia, and inhalations of creosote. 2. THE ACUTE CATARRHAL BRONCHITIS OF OLD PERSONS. The lesions are the same as in the bronchitis of adults. The symptoms are more severe in proportion to the extent of the bronchitis, and the disease is not as well borne as it is in adults. There are, from the first, much prostration ; an irregular febrile movement ; a rapid and feeble pulse ; difficult and op- pressed breathing ; cough with mucous expectoration ; restless- ness, sleeplessness, sometimes delirium ; loss of appetite, nausea, vomiting. There are coarse and subcrepitant rales over both lungs, or only over a portion of one lung. In some cases no rales^can be heard. An acute bronchitis in old persons is often alarming and sometimes fatal. The treatuient is the same as in adults ; but the nursing is even more important, the difficulty in feeding the patients is greater, and stimulants are more likely to be necessary. 3. THE ACUTE CATARRHAL BRONCHITIS OF CHILDREN. The lesions are tlie same as in adults : congestion and swelling of the mucous membrane, after a time an increased production of mucus with some subsidence of the swelling. But as the lungs of children are smaller, as the bronchi constitute a relatively larger portion of the lung, as the bronchi are smaller and more easily occluded, as such an occlusion may even be complete with unaeration of portions of the lung, so we find bronchitis in chil- dren to interfere seriously with the function of breathing and to constitute a serious disease. Symptoms. — An acute bronchitis may be preceded by coryza, pharyngitis, tonsillitis, or laryngitis ; it may occur as a primary inflammation ; or it may complicate measles, whooping-cough, or one of the infectious diseases. 56 BRONCHITIS. In the mild cases there is no fever, the children hardly feel sick ; but they cough, and coarse rales can be heard over both lungs. The inflammation regularly runs its course and subsides within one or two weeks. In the majority of these mild cases no treatment is necessary, not even for the cough. It is wise, however, to keep these pa^ tients in the house until the bronchitis has subsided, unless the weather is warm and good. In the more severe cases the invasion of the inflammation may be marked by general convulsions. There is a well-marked febrile movement, the temperature higher in tlie afternoon, sometimes falling even to the normal in the morning. The pulse is rapid, but usually not feeble. The breathing is rapid, some- times insufficient ; it may be made worse for a time by distention of the stomach with food. There may be alternating restless- ness and drowsiness. There are subcrepitant and coarse rales heard over both lungs, sometimes early, sometimes late in the disease. The inflammation regularly runs its course within two weeks, and tlie patients recover. But they are often alarmingly ill for several days, and may die from the disease. In infants only a few weeks old, rapid breathing, fever, and prostration are the only symptoms, and the disease proves fatal within a few days. Treatment. — During" the first days of the inflammation we em- ploy counter-irritation over the chest by turpentine, croton-oil, or poultices, and give small doses of calomel or sulphate of mag- nesia. Later ipecac, aconite, and opium may be of service. But it is to be remembered that in young children all drugs may do liarm, and that too little treatment is better than too much. 4. CHRONIC CATARRHAL BRONCHITIS. Chronic catarrhal bronchitis may from the first have the character of a chronic inflammation ; it may follow one or more attacks of acute bronchitis ; it may complicate gout, emphysema, chronic endocarditis, interstitial pneumonia, pleuritic adhesions, phthisis ; it may be produced by the inhalation of irritating sub- stances. Lesions. — The mucous glands produce too much mucus, they may be hypertrophied ; the walls of the bronchi are thickened PNEUMONIA. 57 or thinned ; the lumen of the bronchi may be narrowed or di- lated. Sympto7ns. — In the mild cases the patients are onl)' troubled by the cough and expectoration, while their general health re- mains good. In the severer cases the cough is more troublesome, the ex- pectoration more profuse. There may be constant or spasmodic dyspnoea. There is an irregular fever, with loss of flesh and strength. There are coarse and subcrepitant rales, sometimes sibilant and sonorous breathing. The disease runs a protracted course, better in the summer and worse in the winter. The patients are more likely to die from some intercurrent disease than from the bronchitis. The Treatment is the same as that for the protracted form of acute bronchitis. Pneumonia. The terms pneumonia or pneumonitis are employed to desig- nate the inflammations of the parenchyma of the lung as distin- guished from those of the bronchi and the pleura. By the pa- renchyma of the lung we mean the air-vesicles, the air-passages, and the smallest bronchi. There are a number of different forms of pneumonia, distin- guished from each other by their causes, their lesions, and their symptoms. In the present state of our knowledge we cannot make a scientific classification of these, but have to be contented to describe the different varieties of pneumonia under arbitrary names. We distinguish, therefore : Primary lobar pneumonia. Secondary lobar pneumonia. Lobar pneumonia, with the formation of new connective tis- sue. Broncho-pneumonia. Pneumonia of heart disease. Interstitial pneumonia. Tubercular pneumonia. Syphilitic pneumonia. 58 PNEUMONIA. PRIMARY LOBAR PNEUMONIA. Definition. — An infectious inflammation, with exudation from the blood-vessels and the growth of pathogenic bacteria, which involves principally the air-spaces of the lungs. Synonyms.^Q>XQ\x^o\xs pneumonia, fibrinous pneumonia, lung fever, pneumonitis. Etiology. — Lobar pneumonia is a very widely distributed dis- ease. There are few countries in which it does not prevail, the mortality ranging from i.io to 2.30 per cent, for each 1,000 in- habitants. In the United States the disease is of more frequent occur- rence in the South than in the North. This, the following table, based on the eighth and ninth census reports, conclusively shows : States wholly or in great part above the 39th parallel. Maine . New Hampshire Vermont Massachusetts . . Rhode Island . .. Connecticut New York New Jersey . Pennsylvania . . . Ohio , Indiana Illinois Michigan Wisconsin Minnesota , Iowa Nebraska Oregon Colorado Average 1,000 Deaths. 51.22 62.46 58.58 56.29 58.23 55-96 60.55 Si-6i 44.84 60.27 80.66 77-94 69.64 54.55 55-3° 75-32 87.30 55.76 50.67 61.43 Per 1,000 Inhab- itants. 0.62 0.96 0.59 0.98 0.78 0.72 0.87 O.S9 0.58 0.65 0.88 0.96 0.67 0.50 0.39 0.61 0-93 0-34 0.48 0.69 States wholly or in great part below the 39th parallel. 1. Delaware 2. Maryland 3. Virginia | West Virginia j 4. North Carolina 5. South Carolina 6. Georgia , 7. Florida 8. Alabama , 9. Mississippi 10. Louisiana. '. 11. Texas 12. Arkansas 13. Kansas 14. Kentucky 15. Tennessee 16. Missouri 17. Nevada 18. California 19. District of Columbia Average Excess over Northern States 1,000 Deaths. 56.41 59-59 75-66 71-34 102.58 99-54 113-55 123.81 127.21 94-15 105-43 183.42 112. 13 78.49 84.03 103.96 81.30 46.77 60.87 93.70 32.27 Per 1,000 Inhab- itants. 0.70 0.94 0.80 1.26 1. 17 1-39 1-47 1.68 1-75 1.58 2.98 1.49 0.95 1.04 1.41 1.18 0.65 0.98 1.27 0.58 In most countries in the temperate zone the maximum fre- quency of the disease is from February to May. As regards New York City, I compiled from the records of the Board of Health the deaths from pneumonia from March i, 187 1, to March i, 1875, 7,873 cases. Nearly half the entire num- PNEUMONIA. 59 ber was in children under five years of age. The smallest mor- tality was in persons from ten to twenty years old. The majority of the cases occurred in March, April, and May, December, January, and February, the minority in June, July, and August. In persons over five years old the curves of mortality are very regular, and the difference between the spring and winter months and the rest of the year very striking. In persons over seventy years of age the same law prevails. In children under five years of age the curves are much less regular. The curves of mortality in general correspond with those of temperature, the greatest mortality with the lowest temperature and the greatest daily range of temperature. The disease may occur in epidemics, confined to prisons, barracks, asylums, or involving certain districts. There seems to be no question that persons living an out-of-door life in the country are less liable to the disease than are persons living in cities. It has always been a matter of importance to determine whether pneumonia is contagious, whether a person suffering from the disease can communicate it to others. The disease cer- tainly occurs in circumscribed local epidemics and from time to time we see several persons in one house successively attacked. On the other hand it is well known that physicians, nurses, and relations, who take care of cases of pneumonia, are not often attacked by the disease. For the present the question must be considered an unsettled one. For the production of a lobar pneumonia there must be a cause of inflammation, such as exposure to cold, and the growth of pathogenic bacteria. The organism most frequently found is the bacillus described by Fraenkel ; it is said to be found in over ninety per cent, of all the cases. This same bacillus is also found with pleurisy, pericarditis, peritonitis, and cerebro-spinal menin- gitis, and is regularly present in the saliva and nasal secretions of healthy persons. Much less frequently the bacillus of Fried- lander, or other streptococci of suppuration are found. The old conception of pneumonia was that it was simply an inflammation of the lung. Within a few years the opinion that, on the contrary, it is a general disease, of which the inflammation of the lung is the characteristic lesion, gained very general accept- ance. With our present knowledge it seems most probable that 6o PNEUMONIA. pneumonia belongs to the class of infectious inflammations. That is, it is an inflammation of the lung accompanied by the growth of pathogenic bacteria. The growth of these bacteria is attended with the formation of poisonous chemical products, and according to the quantity and virulence of these products the symptoms of general poisoning are more or less marked. When exposed to the same exciting causes children under five years of age usually have broncho-pneumonia ; children between the ages of five and fifteen have either broncho-pneu- monia or lobar pneumonia ; adults usually have lobar pneu- monia. Morbid Anatomy. — The inflammation regularly involves the whole of one lobe, or the whole of one lung, or portions of both lungs. Juergensen, from a study of 6,666 cases, gives the following table to show the relative frequency of the situation of the lesion : Per cent. Right Lung 53-7o " " upper lobe 12.15 " " middle lobe 1.77 " " lower lobe 22.14 " " whole lung 9.35 Left Lung 38.23 " " upper lobe 6.96 " " lower lobe 22.73 " " whole lung 8.54 Both Lungs 8.07 ** " both upper lobes 1.09 " " both lower lobes 3 34 The inflammation in acute lobar pneumonia is of pure exu- dative type, characterized by congestion, emigration of white blood-cells, diapedesis of red blood-cells, and exudation of blood- plasma, and formation of fibrin, while the tissue of the lung remains unchanged. For clinical purposes it is important to have as distinct an idea as possible of the condition of the lung while it is the seat of such an exudative inflammation, so that we de- scribe the condition in which the lung is found while tlie inflam- mation is going through its regular stages of congestion, exuda- tion, and resolution. During the first hours of the inflammation only irregular PNEUMONIA, 6l portions of the lobe which is to be inflamed are involved; later, tlie entire lobe. The king is congested, cedeniatous, tough, but not consolidated. The air-spaces contain granular matter, fibrin, pus-cells, red blood-cells, and epithelial-cells. Tlie epithelium remaining on tlie walls of the air-spaces is swollen ; there are large numbers of white blood-cells in the capillaries. The larger bronchi are congested, dry, or coated with mucus ; the small bronchi contain the same inflammatory products as do the air- spaces. Tlie pulmonary pleura, as a rule, is not coated with fibrin. This is called the stage of " congestion." The stage of congestion regularly only lasts a few hours, but it may be pro- tracted for several days. When the exudation of the inflammatory products has reached its full development, the presence of these products within the air-spaces and bronchi causes the lung to be solid, and at this time the lung is said to be in the condition of "red hepatization." The lung is now consolidated, red, its cut section looks granular, the granules corresponding to the plugs of inflammatory matter within the air-spaces. For some time after death the inflamma- tory products remain solid, and the cut section of the lung dry, but later, with the commencement of post-mortem changes, these products soften and the cut section is covered with a grumous fluid. The air-vesicles, the air-passages, the small bronchi, and sometimes the large bronchi, are filled, and dis- tended with fibrin, pus-cells, red blood-cells, and epithelium. In spite of the pressure on the walls of the air-spaces, the blood- vessels in their walls remain pervious. The pulmonary pleura is coated with fibrin and the interstitial connective tissue of the lung is infiltrated with fibrin. The hepatized lobe is increased in size, sometimes so much so as to compress the rest of the lung. About one-fourth of the fatal cases die in the stage of red hepatization, at any time from twenty-four hours to eleven days after the initial chill. After the air-spaces have become completely filled with the exudation, if the patient continues to live, there follows a period during which the exudate becomes first decolorized, and then degenerated. This is the period of "gray hepatization." The lung remains solid, its color changes, first to a mottled red and gray, then to a uniform gray. The coloring matter is discharged from the red blood-cells and the exudate begins to degenerate and soften. The lung is found passing from red to gray hepati-- 62 PNEUMONIA. zation at any time between the second and the eighteenth day of the disease. It is found completely gray at any time from the fourth to the twenty-fifth day. About one-half of the cases die in the condition of mottled red and gray hepatization ; about one-fourth in the condition of gray hepatization. If the patients recover the exudate undergoes still further degeneration and softening, and is removed by the lymphatics. This is the stage of "resolution." It should commence immedi- ately after defervescence and be completed within a few days. But it may not begin until a number of days after defervescence, or it may be unusually protracted. Modificatiom of the Injiamniation. — The lung, instead of being freed from the exudate at the regular time, may remain in the condition of gray hepatization for weeks. The quantity of inflammatory products may be so great that the blood-vessels are compressed and portions of the lung be- come necrotic. There may be an excessive production of pus-cells, with infil- tration of the walls of the air-spaces and of the stroma of the lung. The bronchitis may be developed in an unusual degree, and involve not only the bronchi of the inflamed lung but also those of the other lung. The pleurisy may be unduly developed at any time in the course of the pneumonia, or after it has subsided. In the lobar pneumonia which accompanies epidemic influ- enza there is often an intense catarrhal bronchitis with a large production of muco-pus ; and in some cases an excessive conges- tion of the lung with comparatively little hepatization. The lymphatic vessels in the pulmonary pleura and in the septa between the lobules may be filled with pus cells, and the pleura and the septa infiltrated with fibrin and pus. It is often stated that lobar pneumonia can be changed into a tubercular pneumonia, or a chronic pneumonia, but I believe that the cases thus described are really examples of pneumonias which were of tubercular, or of productive character from the very outset. Symptoms. — Physical signs. During the stage of congestion the lung is more dense, but is not consolidated, the bronchi and some of the air-spaces contain inflammatory products, the pleura is not yet coated with fibrin. The percussion-note, therefore, remains unchanged, or its pitch becomes higher, its duration PNEUMONIA, 63 shorter, and its quality less distinctly pulmonary. The respiratory murmur is either rude, or diminished in intensity. The inflam- matory products in the small bronchi may give a subcrepitant rale. If the larger bronchi are also inflamed, there may be coarse rales and sibilant and sonorous breathing. As there is no fibrin yet on tlie pleura, there is no crepitant rale. It is evident, there- fore, that during this stage of a pneumonia we must expect that the physical signs will either not be very marked, or else absent altogether. During the stages of red and gray hepatization the air-spaces and small bronchi are filled with inflammatory products and im- pervious to air. The larger bronchi are coated with mucus or filled with fibrin. But although in all cases the lung is consol- idated there is a good deal of difference as to the quantity of in- flammatory products, the size of the consolidated lobe, the closeness with which its surface is applied to the chest-wall, and the degree of motion of which it is capable. The pulmonary pleura is coated with fibrin, occasionally there is serum in the pleural cavity. The percussion sound, therefore, is more or less dull or flat, or tympanitic, or of cracked-pot quality. Any considerable quantity of fluid in the pleural cavity gives flatness. A lobe of which the air-spaces are distended with exudation so that the lobe is increased in size, and its surface pressed closely against the wall of the chest gives either marked dulness ; or flatness ; or tympanitic resonance ; or, in young persons, the cracked-pot sound. The dulness on percussion is less marked, or is even absent altogether, if the inflamed lobe is very much congested but con- tains little exudation ; if the quantity of exudation is not suffi- cient to distend the air-spaces and increase the size of the lobe ; if the area of consolidation is small, or is situated in the central portions of the lung ; or if the ribs have undergone the senile changes which cause them to give increased resonance. It is especially in old persons that these reasons for the absence of dulness on percussion often exist. The vocal fremitus is regularly increased over the consolidated lung. There is no satisfactory reason why this should not always be the case, but as exceptional conditions we find the vocal frem- itus diminished, or absent. 64 PNEUMONIA. Bronchial voice and breathing should be heard over the con- solidated lung ; but we may get bronchial voice without bron- chial breathing, or we may get neither bronchial voice nor breathing. The absence of bronchial voice seems to be due sometimes to the incomplete consolidation, sometimes to the occlusion, of the large bronchi. The absence of bronchial breathing may be due to occlusion of the large bronchi, or to the absence of movements of the lung. As the crepitant rale is due to the friction of the fibrin on the surface of the pleura, the rale will not be produced unless fibrin is present, and tlie lung capable of movement. So we find in different cases a great difference as to the presence or absence of the crepitant rale. In some cases we only get it after coughing, or with a forced inspiration, in some cases it is only heard at the beginning of red hepatization while the lung still moves, in some cases it is heard throughout the stages of red and gray hepatization, in some cases it is absent altogetlier. In the stage of resolution the products of inflammation are softened and rapidly absorbed, the air re-enters the small bronchi and air spaces, the lung moves more and more freely. So with the increased motion of the lung we get the crepitant rale due to the friction of the pleura. With the softening of the inflamma- tory products we get the subcrepitant and coarse rales in the bronchi. The bronchial voice and breathing disappear, if they have been present. Normal vesicular breathing becomes more and more distinct. The percussion-note loses its dull, or flat, or tympanitic, or cracked-pot quality, and approaches nearer and nearer to the normal, but yet the changes in the percussion-note last the longest of all the physical signs, and even long after complete resolution some dulness is often present. It is always to be remembered that it is in old persons that the physical signs are the least constant and the least well marked. Rational Symptoms. — In from one-sixth to one-third of the ca^es there are prodromic symptoms. Chilliness, a little fever, general malaise and feelings of oppression about the chest continue for from one to four days. These symptoms probably correspond to a protracted period of congestion. In about ninety per cent, of the cases there are, during the first twenty-four hours, one or more decided chills, and it is from the time of the chill that we count the days of the disease. PNEUMONIA. 65 The temperature rises at once and reaches its maximum by the afternoon of the first, second, or third day, but very often the highest temperature of the disease will be reached during the twenty-four hours preceding defervescence. An afternoon tem- perature of 104° F. and a morning temperature of 102° or 103° are about the normal temperatures of a lobar pneumonia. A sudden rise of temperature during the course of the disease indi- cates the extension of the pneumonia, or the development of a complication. But the removal of the patient from one house to another is regularly followed by a rise of temperature, and in persons not suffering from malarial poisoning and not taking antipyretics there are quite often irregular rises and falls of sev- eral degrees of temperature which we cannot account for. Pneu- monias involving the upper lobes usually have high temperatures. The height of the temperature is usually in proportion to the severity of the disease, but patients may get worse with a falling temperature, or may die with temperatures below the normal, or, very rarely, have no rise of temperature throughout the disease. Defervescence may take place at any time from the second to the eighteenth day of the disease. It occurs most frequently on the seventh day, next on the fifth, eighth, sixth, and ninth days in order. The fall of temperature usually begins in the evening, and, within from six to forty-eight hours it reaches the normal, or for a time falls below it. Occasionally a rapid defervescence with a fall of temperature to 97° or 96° is attended with so much prostration and such a feeble heart-action that the condition of the patient is alarming. It is said that epistaxis, haematuria, or hemorrhage from the bowels may accompany defervescence. In the pneumonias which complicate epidemic influenza there may be no marked defervescence, but a gradual fall of tempera- ture extending over many days, and in some cases the fever per- sists after the pneumonia has resolved. A rise of temperature after several days of partial or com- plete defervescence usually means pleurisy or empyema, but it may indicate a fresh pneumonia, abscess of the lung, or gan- grene of the lung. The condition of the heart's action and of the pulse are of great importance. In a favorable case the pulse ought to be about 100 to the minute and fairly full. A pulse of over 120 is always cause for anxiety. The liability to failure of the heart's action, either gradual or sudden, constitutes one of the greatest 66 PNEUMONIA. dangers of a pneumonia. It is not certain what the cause of the heart failure is, but it seems probable that it it due to the effects of the poison produced by the pathogenic bacteria of the dis- ease. In persons already suffering from chronic endocarditis failure of the heart's action is exceedingly dangerous. The breathing during the invasion of the disease is rapid and oppressed. As the disease goes on the character of the breath- ing varies with the severity of the case. Rapid, labored, and insufficient breathing indicates either inflammation of a large part of the lung, excessive congestion of the lung, an intense general bronchitis, failure of the heart's action, or an intense pleurisy and pericarditis. Cough may be developed as one of the first symptoms, or come on at any time in the disease, or be deferred until resolu- tion has commenced. In old persons the cough is often slight, or absent altogether. The characteristic sputa of pneumonia are little rounded, viscid pellets of red, yellow, or brownisli color, mixed with thin fluid mucus, the so-called rusty sputa. In rare cases, with a severe invasion, the patients may cough up a little pure blood at the beginning of the disease. In the bad cases the sputa are changed and the patients cough up considerable quantities of a thin, dark-colored fluid. In some cases throughout the disease there will be nothing but a little white mucus coughed up from time to time. In cases with an excessive catarrhal bronchitis the quantity of expectoration may be very large and like that of an ordinary bronchitis. It is by no means unusual, especially in old people, for the expectoration to be absent altogether. Pain over the inflamed lung, referred to the region below the nipple, is developed within twelve hours after the initial chill in the majority of cases, and after three or four days gradually disappears. This pain is sometimes so intense as to be for a time the principal symptom. But in some persons there is no pain until resolution commences and the cough becomes troub- lesome. In old persons there is often not only an absence of pain, but there are no abnormal sensations whatever in the chest. The expression of the face is characteristic. There is a deep red flush at about the centre of each cheek, and the expression of the face is a curious mixture of anxiety and apathy. The skin may be either hot and dry, or bathed in pei-spiration throusfhout the disease. PNEUMONIA. 6^ The tongue is coated with a white fur, but in the favorable cases remains moist. A dry tongue indicates a severe form of the disease. Headache, restlessness, and sleeplessness are troublesome during the first days of the disease in many of the patients. Delirium and stupor belong to the severe cases. The alcoholic patients often have an active delirium, or delirium tremens. Old persons often become apathetic, or mildly delirious. The invasion of the disease is often attended with vomiting; less frequently with diarrhoea. The urine is diminished in quantity and high colored. It often contains a little albumin and a few casts, due to acute de- generation of the kidney. It is said that sodium chloride and some of the other inorganic salts are diminished in quantity. Complications. — At any time in the course of a pneumonia, or after defervescence, there may be developed pleurisy with effu- sion, or empyema on the same side as the pneumonia. The or- dinary course is for the patient to get to the sixth or seventh day of his pneumonia and behave as if he were about to get well, but yet without complete defervescence. After a few days the temperature rises a little with pleurisy with effusion, a good deal with empyema. The physical signs are those of fluid in the pleural cavity, but very often bronchial voice and breathing are heard below the level of the fluid. A catarrhal bronchitis involving the larger bronchi of both lungs is not infrequent, especially with the pneumonia of epi- demic influenza. The patients cough up large quantities of mucus, often mixed with blood. Coarse rales and sibilant and sonorous breathing can often be heard over both lungs. The dyspnoea is more troublesome, the temperature higher, and the tendency to heart failure and venous congestion more decided. Acute pericarditis is a serious complication. It may be that there will be nothing to call attention to the condition of the heart, and the case seems only to be a pneumonia of severe type. Or there may be decided precordial pain, a rapid and feeble pulse, a pericardial friction sound, rapid breathing, and cyanosis. It occasionally happens that the symptoms of the pericarditis are more marked than those of the pneumonia, so that it is even possible for the pneumonia to be overlooked. A previously existing chronic endocarditis adds much to the dangers of pneumonia. The heart's action is likely to be dis- 68 PNEUMONIA. turbed, and the condition of general venous congestion estab- lished. It must not be forgotten in such cases that a well-marked mitral or aortic stenosis may give no murmur at all. Acute meningitis is an infrequent complication, but a very fatal one. It may run its course without giving any distinctive symptoms ; or the delirium may be more active, with contrac- tions of groups of muscles, or general convulsions. Jaundice is seen both in mild and in severe cases. It seems to be a non-obstructive jaundice without symptom. Acute degeneration of tlie kidneys, of mild type, is of ordinary occurrence. It seems to do the patients no harm and to give no symptoms except the presence of albumin and casts in the urine. Acute exudative nephritis is of much less frequent occur- rence. It is not likely to prove fatal of itself, but it may add to the dangers of the pneumonia. Persons already suffering from chronic nephritis are very un- favorable subjects for an attack of pneumonia ; not many of them recover. Quite often the chronic nephritis is one which has given no symptoms until the time of the pneumonia. The Course of the Disease. — i. The regular cases. These cases may be mild or severe, they may terminate in recovery or in death, but they all have this in common, that the clinical picture is that of an inflammation of the lung with comparatively little evidence of general poisoning. The patients begin with the chills, rapid rise of temperature, sleeplessness and restlessness, vomiting, pain in the side, cough, expectoration, and dyspnoea. These symptoms continue either mildly or severely ; after the third day comes the liability to heart failure, and, finally, at the regular times come defervescence or death. The severity of the symptoms is directly in proportion to the extent of lung in- volved and to the intensity of the inflammation. 2. The infectious cases. In these cases the symptoms have no necessary relation with the extent of lung involved, in many of them only a part of one lobe is inflamed. The patients behave as if they were poisoned. The prostration is marked, the ema- ciation rapid. Tiie temperatures are high, the heart's action is rapid and feeble, the tongue is dr}^, the cerebral symptoms are marked, and the disease is very regularly fatal, 3. The rational symptoms run their regular course, but the physical signs are slow in developing, so that it may be as much as eight days before they are really well marked. PNEUMONIA. 69 4. The inflammation, instead of remaining confined to the lobe in whicli it began, may extend to other portions of the lungs. Each extension of the inflammation is attended witli an exacer- bation of the symptoms. 5. There are rare cases in which nearly the whole of both lungs becomes at once inflamed, tlie interference with breathing is overwiielming, and death results very soon. 6. Resolution instead of beginning within one or two days after defervescence, as it should, may be delayed for from one to ten weeks. And yet, even after these long periods, the inflam- matory products may be absorbed. 7. In some cases, not necessarily belonging to the infectious class, nor alcoholic, the delirium is an unusually marked symp- tom. In some of these patients the delirium continues for some days after defervescence, or even after resolution is completed. In a few cases the delirium is succeeded by permanent insanity. 8. Persons already suffering from chronic alcoholism, if they have an attack of lobar pneumonia, are likely to have high temperature, active delirium, or delirium tremens. 9. The pneumonia of old persons often runs an irregular course. The extent of lung inflamed may be small and the physical signs uncertain ; a little dulness on percussion, a few subcrepitant rales, a diminished intensity of breathing, or even no physical signs at all. The patients usually have chilliness, or a distinct chill, to mark the invasion of the disease, and more or less fever while it is running its course. The appetite is lost, and there maybe nausea and vomiting. The pulse is rapid and often feeble. Either stupor or a mild delirium are often present. The prostration is out of proportion to the extent of lung inflamed. The characteristic cough, expectoration, and pain in the chest are absent altogether, or imperfectly developed ; even the breathing may not be at all changed. But the disease is very fatal in old persons, and some of them die quite suddenly after seeming to be only moderately sick for a few days. ID. The pneumonia which accompanies epidemic influenza has, in New York, presented certain peculiarities. In many cases there was an intense catarrhal inflammation of the larger bronchi of both lungs, with profuse expectoration of mucus and more or less blood. Some of the fatal cases showed very marked conges- tion of the inflamed lung with com.paratively little consolidation, and this corresponded with an imperfect development of the 70 PNEUMONIA. physical signs of consolidation during the patient's life. Very often there was no regular defervescence, but a slow fall of tem- perature extending over a number of days, and sometimes not reacliing the normal until after resolution was completed. In some cases the whole duration of the disease was unusually long, and defervescence and resolution did not take place until after three or four weeks. Failure of the heart's action, with venous congestion of the lungs and other viscera was often present. The pneumonia was followed by empyema in an unusually large num- ber of cases. II. The course of the disease is changed by the complicating lesions in meningitis, bronchitis, pleurisy, pericarditis, endocar- ditis or nephritis. Modes of Death. — The patients die with heart failure just before defervescence ; from the extent of the inflammation ; from general poisoning; from one of the complications ; from throm- bosis of the coronary arteries. Duration. — In the cases which recover, defervescence takes place at any time from the second to the thirty-second day, most frequently on the seventh or fifth. Resolution is accomplished within a few days after this, but may be delayed up to ten weeks. In the fatal cases death may take place at any time from five hours to thiity days — most frequently on the seventh, eighth, and tenth days. In persons over seventy death is most common on the fifth, sixth, and seventh days. The mortality from pneumonia is a considerable one, ranging in hospitals from twelve to forty-four per cent. It seems to be the general impression that the disease is more fatal now than it was a number of years ago, but it is difficult to determine this accurately. A study of this subject has been made by Drs. Townsend and Coolidge, who have worked up the records of the Massachusetts General Hospital from 1822 to 1889. They ar- rived at the following conclusions : 1. In the one thousand cases of acute lobar pneumonia treated at the Massachusetts General Hospital from 1822 to 1889, there was a mortality of twenty-five per cent. 2. The mortality has gradually increased from ten per cent, in the first decade to twenty-eight per cent, in the present decade. PNEUMONIA. 71 3. This increase is deceptive, for the following reasons, all of which were shown to be a cause of a large mortality : {a) Tlie average age of the patients has been increasing from the first to the last decade. (d) The relative number of complicated and delicate cases has increased. (c) The relative number of intemperate cases has increased. (a) The relative number of foreigners has increased. 4. These causes are sufficient to explain the entire rise in the mortality. 5. Treatment, which was heroic before 1850, transitional be- tween 1850 and i860, and expectant and sustaining since i860, has not, therefore, influenced the mortality-rate. 6. Treatment has not influenced the duration of the disease or of its convalescence. Treatmetit. — Lobar pneumonia is a disease for whicli there is no routine treatment applicable to every case, on the contrary much judgment is required to decide what is the best way of managing each patient. In many of the simple cases the course of the disease is so regular and mild that we do not care to interfere with it at all. The patients are put to bed, are given a fluid diet and are al- lowed to go through the disease and get well. On the other hand, in some of these simple cases althougli the disease needs no treatment there are symptoms which re- quire our attention. The headache, restlessness, and sleepless- ness may be allayed by the bromides, sulfonal, or opium. Ex- cessive pain in the chest requires larger doses of opium, and in some patients the use of large poultices. My own belief con- cerning the value of poultices in pneumonia is that they are of no service except so far as they give comfort to the patients. Even in the simple cases there is often the danger of failure of the heart's action, and this danger, although it exists after the third day of the disease, seems to be at its greatest during the hours just preceding convalescence. Throughout the disease we watch the heart, the pulse, and the color of the skin and lips. As soon as the heart fails or there is venous congestion of the skin it is proper to use cardiac stimulants — whiskey, digitalis, strophanthus, or caffein. A very good combination is five grains of potassium iodide, one minim of fluid extract of digitalis and twenty minims of fluid extract of convallaria given togetlier 72 PNEUMONIA. every three hours. If the venous congestion is very marked a hypodermic injection of one-fiftieth grain of nitro-glycerine will often give great temporary relief. There are many cases in which, although the course of the disease is regular, the symptoms are severe. The temperature is over 104° F., the pulse is over 120, the breathing is insufficient, venous congestion is evident. So many of these patients die that it is not easy to resign one's self to a simply expectant treatment. The plans of treatment most frequently adopted for such cases are : Venesection employed once, or repeated several times, the quantity of blood taken to be considerable. This plan is not often employed at the present time. Large doses of calomel, 12 to 30 grains, placed dry on the tongue, from one to four such doses. This plan seems to answer well for some cases, to be of no use in others, and is attended with the risk of producing salivation. Small doses of calomel, one-fourth to one grain given every hour up to six doses. This seems to be of moderate efficacy. Drachm doses of magnesium sulphate given every hour up to eight doses. This again does not seem to be of much value. Either tr. aconite or veratrum viride in doses of froni two to five drops, at first every hour and later at longer intervals, have given good results in the hands of some physicians. Cold affusions to the chest, cold baths, blisters, the antipy- retic drugs, quinine, and carbonate of ammonia, have all been much used, but are all of doubtful efficacy. In the cases which behave as if the patients were poisoned, with high temperature, cerebral symptoms, dry tongue, rapid and feeble pulse, and rapid emaciation, we naturally use alcoholic and cardiac stimulants freely, but in spite of all most of these patients die. An excessive catarrhal bronchitis may be benefited by re- peated dry cupping over the entire chest, and by the administra- tion of small doses of ipecac every hour. For my own part, in the cases of pneumonia which require treatment, it has seemed to me, as I liave watched the disease in my own practice and in that of other physicians, that : 1. We have no plan of treatment which controls the inflam- mation of the lung except in so far as we can diminish the venous congestion of this organ. 2. We have as yet no means by which we can prevent or con- PNEUMONIA. 73 trol the poisoning from the chemical substances produced by the growth of the patliogenic bacteria. 3. Reduction of the temperature, while it may make the pa- tient more comfortable, has no effect on the course of the dis- ease. 4. The only thing that we can control with any certainty is the circulation of the blood, and, if we do control this in such a way that the proper relative quantity of blood is contained in the arteries and veins, the congestion of the lungs will be dimin- ished, the intensity of the inflammation made less, and the dan- ger of heart failure lessened. This means that we must keep throughout the disease, no matter how high the temperature, a pulse of between 90 to 100 to the minute, without increased ten- sion, soft, of good quality, and of good strength. To affect the circulation in this way we have at our com.mand a number of drugs which increase the force of the heart's action and which dilate the arteries. It is by a combination of such drugs that we can hope to regulate the circulation in the way in which we desire. The particular combination which has seemed to me to be the most reliable is that of aconitia, ^ milligr. ; digitalia, ^ milligr., and whiskey in doses of from one drachm to one ounce. The digi- talia and aconitia are given together at intervals of from one to three hours, the whiskey every three or four hours. The guide for the frequency of the use of these drugs is the effect on the circulation. We try to keep a pulse of between 90 and 100 and of good quality ; with this the breathing will be better and the disposition to general venous congestion diminished. The temperature, however, is not affected by this plan of treatment. Secondary Lobar Pneumonia. Definition. — An exudative inflammation involving one or more lobes of the lungs, occurring in persons already suffering from some disease, or injury. Etiology. — Persons who are confined to bed by an infectious disease, by injuries or inflammations of the brain and spinal cord, by surgical operations, or by severe injuries, are liable to have venous congestion of the dependent portions of the lung, and to inhale substances which can irritate the lung. In this way they often contract either a true broncho-pneumonia, or a pneumonia which somewhat resembles a lobar pneumonia. 74 PNEUMONIA. Morbid Anatomy. — The inflammatory process involves irregular areas of one or of both lungs. We find these areas after death in the condition of red or gray hepatization and surrounded by con- gested lung, but no complete consolidation of an entire lobe. The inflammation is of exudative type, with fibrin, pus, and epi- thelium in the air-spaces and small bronchi. Symptoms. — In many cases the pneumonia can hardly be said to give either rational symptoms or physical signs. We find the lesion after death but are not certain of its existence during life. But in some cases there are chills, fever, rapid breatliing, pain, cough, and expectoration, with the physical signs of bron- chitis, or of consolidation of small portions of the lung. The Treatment of such a pneumonia is unsatisfactory. Lobar Pneumonia with the Formation of Connective Tissue. It is well known that in some forms of inflammation of the lung there is a production of new connective tissue around the bronchi and blood-vessels, in the septa between the lobules, and in the walls of the air-spaces. It is not as well known that in these same forms of pneumonia there may be also a production of new connective tissue in the cavities of the air-spaces and of the small bronchi. This new tissue either grows directly from the walls of the air-spaces, or is formed out of plugs of coagu- lated matter and of cells which are formed within their cavities. Such a productive pneumonia has been recognized under a variety of names : gray induration, fibroid induration, cirrhosis, interstitial pneumonia, chronic pneumonia, desquamative pneu- monia, parenchymatous pneumonia, etc. If we look over all the different lungs in which such a productive pneumonia has been developed, we find that they can be classified as follows : 1. A productive pneumonia associated with the growth of tubercle bacilli. 2. A productive pneumonia associated with the growth of actinomyces. 3. A productive pneumonia due to the inhalation of particles of coal or of stone. 4. A productive pneumonia caused by constitutional syphilis. 5. A productive pneumonia secondary to changes in the pleura. 6. Broncho-pneumonia, 7. A special form of lobar pneumonia. PNEUMONIA. 75 It is concerning this last variety of productive pneumonia that our information is the least exact, and it is to this variety that I wish especially to call attention. The ordinary belief has been that it is possible for a regular exudative lobar pneumonia, instead of resolving, to be succeeded by a chronic productive in- flammation ; I believe, on the contrary, that a regular exudative lobar pneumonia terminates only in resolution or in death, and that lobar pneumonia with the production of new connective tis- sue is from the first a special form of inflammation of the lung. My reason for this belief is that I have seen a number of lungs which seem to show the different stages of the inflammatory process. The literature on the subject is not very abundant. Charcot^ describes this condition as following one or more attacks of or- dinary lobar pneumonia. Coupland * gives a very good descrip- tion with drawings, and believes that the new tissue is formed from the intra-alveolar exudation of ordinary lobar pneumonia. Kidd^ describes two cases with a subacute history, which he regards as cases of lobar pneumonia terminating in induration. Buhl^ considers the disease to be a primary one, which runs a subacute course and has nothing to do with ordinary pneumonia. Heitler * gives an account of the disease as observed in five cases. The development of the disease, he says, is more or less acute, with fever, dyspnoea, cough, prostration, sometimes rigors ; the constitutional depression is much less marked than in acute pneumonia. The fever is irregular, and not over 102°. The sputum is mucous, muco-purulent, or fetid. In two of the cases there was retraction of the wall of the thorax. The consolidation involved in three cases the right upper lobe, in one case the whole right lung, in one case the lower right lobe. The hepatization was smooth, with necrotic and cheesy areas and cavities. The course of the disease was subacute, but with an acute invasion, lasting from fifty days to nine months and nineteen days. Wag- ner ° has described six cases apparently belonging to this group, running a subacute course with retraction of the wall of the chest, but terminating in recovery. • Rev. Mens, de Med. et Chir., 1878, p. 776. 2 Transactions London Pathological Society, vol. xxx., p. 224. 3 Lancet, April 5, 1890. 4 Buhl : Briefe, p. 47. ^ Wiener med. Wochenschrift, 1884 and 1886. « Deutsch. Arch. f. klin. Med., vol. xxxiii. 76 PNEUMONIA. I have seen twelve cases which seem to belong to this group, and to demonstrate that there is a form of lobar pneumonia which is, from the outset, anatomically distinct from the ordinary- form. It is from the first an exudative inflammation with the production of new tissue, not a simple exudative inflammation. Such an inflammation naturally lasts longer, and is more likely to become chronic than is the case with a simple exudative in- flammation. I can see no reason to believe that in ordinary lobar pneumonia the pus and fibrin are ever replaced by connec- tive tissue. The development of the lesion seems to be as follows : 1. Congestion of the lung ; exudation of serum, fibrin, and pus into some of the air-spaces ; the formation in other air-spaces of irregular plugs with prolongations from one space into others, the plugs composed of a nearly homogeneous or finely fibril- lated material, none of them large enough to fill or distend the air-spaces ; a swelling and thickening of the walls of the air- spaces, with a very considerable increase. in the number of epi- thelial cells which cover them ; more or less general catarrhal bronchitis ; fibrin on the pulmonary pleura. 2. New cells, of the type of connective-tissue cells, are formed in the plugs ; the walls of the air-spaces are more swollen, and may be infiltrated with small round cells ; new blood-vessels are formed in the plugs, which can be artificially injected from the pulmonary vessels. The gross appearance of the lung at this time is usually characteristic. One or more lobes are consoli- dated, they are not large, as in ordinary pneumonia, their color is red or gray, the cut surface is smooth, not granular. 3. The growth of new connective tissue within the air-spaces, in their walls, and along the arteries and bronchi, is so extensive that many of the air-spaces are obliterated. The surface of the lung is now covered with connective-tissue adhesions ; the bron- chi contain muco-pus ; the lung is red, mottled wnth white, or gray, or black ; it is dense and hard ; portions of it may be ne- crotic, or cheesy, or broken down into cavities. Four of my cases illustrate the first period of the development of the lesion : Case I. — The duration of the disease was ten days. The en- tire left lung was consolidated, small, smooth, of gray color, with fibrin coating the pulmonary pleura. The right lower lobe was PNEUMONIA, 77 partly hepatized and red. The walls of the air-spaces were thickened and coated with epithelial cells. There was a growth of new connective tissue around the blood-vessels and bronchi. The air-spaces contained small, anastomosing plugs of a nearly homogeneous matter. Case II. — The duration of the disease was seventeen days The left lower lobe was consolidated, small, red, and smooth, its surface covered with old adhesions. The walls of the air-spaces were thickened, their cavities contained the plugs already de- scribed. Case III. — The duration of the disease was fourteen da3's. There was a general bronchitis. The right upper lobe was con- solidated, of reddish-gray color, its pleura coated with fibrin. The walls of the small bronchi were thickened and infiltrated with cells. The walls of the air-spaces were thickened and coated with epithelium. Some of the air spaces contained pus and fibrin, others the plugs already mentioned. Case IV. — The duration of the disease was seven days. The left lower lobe presented the regular picture of the red hepati- zation of ordinary pneumonia. The left upper lobe was consoli- dated, small, smooth, and red. The walls of the air spaces were thickened and coated with epithelium, their cavities contained pus and fibrin, or the plugs. Six of my cases illustrate the second period of the develop- ment of the lesion : Case V. — Duration nineteen days. The right upper lobe was consolidated, smooth, and red. There was a growth of new connective tissue around the arteries, in the septa, and in the walls of the air-spaces. Some of the air-spaces contained epithe- lium, others plugs of the same shape and appearance as seen in tlie preceding group of cases, but there were, in addition, con- nective-tissue cells imbedded in the basement substance compos- ing the plugs. Case VI. — Duration sixteen days. The right middle and lower and left lower lobes were consolidated, small, and smooth. The walls of the air spaces were thickened. Some of their cav- ities contained fibrin and pus, others plugs of connective tissue containing blood vessels. Case VII. — Duration twenty- three days. The left lower lobe 78 PNEUMONIA. was consolidated, small, and gray. The walls of the air spaces were thickened ; they contained plugs of connective tissue. Case VIII. — Duration twenty-eight days. The left upper lobe was consolidated, small, smooth, and black. The walls of the air-spaced were thickened ; they were covered with epithe- lium, and contained plugs of connective tissue. Case IX. — Duration six days. General bronchitis. The left upper lobe was consolidated, large, and red. The walls of the air-spaces were thickened Some contained pus and fibrin, others plugs of connective tissue. Case X. — Duration thirteen days. The left lower lobe was in the condition of ordinary red iiepatization. The right upper lobe looked like the resolution of an ordinary pneumonia, and some of the airspaces contained degenerated exudation, but in others there were plugs of connective tissue. Two cases illustrate the third period of development of the lesion : Case XL — Duration fifty two days. The left lung was cov- ered with old adhesions, consolidated, hard, smooth, mottled red and white, small. The growth of new connective tissue in the walls of the aii'-spaces and in their cavities had nearly obliterated the natural structure of the lung. Case XII. — Duration fifty-one days. The pleura was thick- ened and coated with fibrin. The left pleural cavity was half full of serum. The left upper lobe was consolidated, and of a pinkish-white color. It was almost entirely changed into con- nective tissue. Etiology. — In three of the case« there was a distinct history of prolonged exposure to cold and wet. In one case the symp- toms followed immediately after the patient having fallen into an excavation. In one case, for twenty days before the initial chill the patient was miserable, and had a troublesome cough. In one case, for twenty-one days before the initial chill, the pa- tient suffered from headache, loss of appetite, and prostration. In one case, under observation throughout, there was an attack of lobar pneumonia terminating in resolution after eleven days ; the patient was discharged from the hospital well, and after an interval of eighteen days came the beginning of the fatal attack PNEUMONIA. 79 in the other lobe of the same lung. In one case the patient stated that he had an attack of pneumonia five years before, and that for one year he had been troubled with cough and muco- purulent expectoration. Sympto7ns. — In ten of the cases the invasion of the disease was marked by chills and a rapid rise of temperature. There was cough in all the cases, the sputa rusty in five cases, muco- purulent in two cases, bloody in one case. The temperature was rarely over 104° F., and in some of the cases not over 100° F. In seven of the cases delirium is noted as a prominent symptom. One case was supposed to be acute phthisis, one acute menin- gitis, and one acute general tuberculosis. Three of the patients passed fairly into the typhoid condition. The physical signs of the consolidation of the lung were well marked, except in one case. The duration of the disease was for 6, 7, 10, 13, 14, 16, 17, 19, 23, 28, 51, and 52 days ; in most of the cases longer than that of an ordinary lobar pneumonia. There seems to be, therefore, a form of lobar pneumonia which is anatomically different from the regular form. Its phys- ical signs are, of course, the same, but its clinical symptoms are somewhat different. Although the patients have the same chill, fever, cough, expectoration, and pain as in the regular cases, yet there is something about the course of the disease which makes its diagnosis possible, even during its early days. The tempera- tures do not run high, but the tendency to cerebral symptoms and the typhoid state is very marked, and most of the cases run a protracted and subacute course. Concerning the. prognosis, it is not possible to speak certainly, but there seems no reason why recovery should not be possible. Broncho-pneumonia. Definition. — An infectious inflammation with exudation from the blood-vessels, a formation of new connective tissue and the growth of pathogenic bacteria, which involves principally the walls of the bronchi and the air-spaces which surround the in- flamed bronchi. Synonyins. — Capillary bronchitis, lobular pneumonia, catarrhal pneumonia. There seems to be no form of pneumonia which does not have associated with it more or less bronchitis, so that every pneumonia is in one sense a broncho-pneumonia. But it has 8o PNEUMONIA. long been recognized that there is one form of inflammation of the lung which is different from others and in which the share of the bronchi is especially important. For several reasons, how- ever, the popular notions concerning the disease have become somewhat confused. It was seen that in some cases, while there was a bronchitis extending down to the small bronchi, there was no consolidation of the lung, and so these were called cases of capillary bronchitis. It was seen that there were cases of gen- eral bronchitis with consolidation of circumscribed portions of the lung, and it was inferred that the inflammation extended from the bronchi to the air-spaces which empty into them, so these were called cases of lobular pneumonia. This, however, was an error in observation. Areas of atelectasis do correspond to bronchi, but the areas of consolidation do not so correspond. It was seen that in some cases the symptoms and lesions could not be distinguished from those of phthisis, and it was not under- stood that the only real difference between the two was the presence or absence of the tubercle bacilli. A number of curi- ous ideas were connected with the term "catarrhal inflammation" and it was not realized that a catarrhal inflammation is nothing but an exudative inflammation occurring in a mucous membrane. It is to be regretted that the erroneous idea still exists that a broncho-pneumonia is simply an inflammation of tlie bronchi w^hich extends to the air-spaces opening into these bronchi. Etiology. — Broncho-pneumonia is the ordinary pneumonia of children, it is frequently seen in young persons, and occasion- ally in adults and old persons. It occurs as a primary inflammation, is often secondary to measles, whooping-cough, and diphtheria, less frequently to the other infectious diseases. Persons confined to bed by injury or disease, and persons with emphysema are liable to subacute forms of broncho-pneumonia. The disease is most frequent during the cold and wet months of the year ; in some cases there is a history of exposure to cold, in others no exciting cause is discoverable. Children crowded together in asylums are especially liable to the disease. The same patient not infrequently suffers from several attacks of broncho-pneumonia. The pathogenic bacteria are either the pneumococci of lobar pneumonia, or the bacteria of suppuration. PNEUMONIA. 8 1 Morbid Anatomy. — In persons who die from broncho pneumonia the lungs after death present considerable variety in their gross appearance. The mucous membrane of the trachea and large bronchi may appear to be normal, or is congested and coated with mucus, or the small bronchi may contain pus. The walls of the small bronchi are thickened so that a section of the lung looks studded with little nodules. In some cases most of the small bronchi of both lungs have their walls thickened in this way, more frequently it is only the bronchi of one lung or of one lobe. Around the bronchi whose walls are thickened are zones of consolidated lung from the size of a pin-head to that of a pea. Scattered through one or both lungs are irregular areas of consolidation, having no definite relation with the bronchi. They may be so large and numerous that an entire lobe or an entire lung is completely consolidated. The pulmonary pleura may be coated with fibrin. In the lungs of very young chil- dren there may be consolidated shrunken portions due to col- lapse of the air-vesicles, the so-called areas of atelectasis. The same condition is found with bronchitis, and in children who die so soon after birth that the whole of the lungs have not become aerated. The bronchial glands are usually swollen and inflamed. The smaller bronchi may be dilated. In the portions of lung which are not consolidated the air-spaces may be somewhat di- lated. Occasionally some of the air-spaces are ruptured, and the septa between the lobules are infiltrated with air. In order to understand the true anatomical characters of broncho-pneumonia, it is necessary to determine which of these different changes is essential and constant and which are acces- sory and inconstant. The essential and constant lesion is a productive inflammation of the walls (not the mucous membrane) of the bronchi, and of the air-spaces immediately surrounding the inflamed bronchi. The walls of the bronchi are thickened and infiltrated by a growth of new cells ; the walls of the air-spaces are thickened, their cavi- ties are filled with new connective tissue, or with fibrin, pus, and epithelium. The inflammation is from the first not exudative, but productive, that is, with the formation of new tissue. It in- volves the medium-sized and smaller bronchi of both lungs, but is not everywhere equally severe ; in some parts of the lungs the lesions are much more marked than in others. 82 PNEUMONIA. The accessory lesions, some of which are present in one case and some in others, are : 1. A catarrhal inflammation of the mucous membrane of the bronchi. 2. An exudative inflammation of the air-spaces, which fills their cavities with fibrin, pus, and epithelium, and produces con- solidation of larger or smaller portions of the lungs. In young children the epithelial cells which line the air-spaces are much more numerous than they are in adults, so when children's lungs are inflamed the epithelial cells form a larger part of the inflam- matory product than they do in the lungs of adults. 3. An exudative inflammation of the pleura, which coats it with fibrin. 4. Dilatation of the bronchi, of which the walls are the seat of productive inflammation. 5. Areas of atelectasis. 6. Simple, or tubercular inflammation of the bronchial glands. As the inflammation of the walls of the bronchi and of the air-spaces surrounding them is from the first a productive inflam- mation it follows the law which governs that form of inflamma- tion. It is apt to last for a longer time than does an exudative inflammation, and it is liable to change into a chronic productive inflammation. It is not uncommon, therefore, for a broncho-pneumonia to continue for several weeks, or to be followed by permanent changes in the lungs. If the broncho-pneumonia becomes chronic the inflammation of the walls of the bronchi and of the air spaces w^hich surround them continues, we then find that the bronchi are dilated, their walls are thickened, tliey are surrounded by zones of connective tissue ; or part of a lobe, or an entire lobe, is entirely changed into connective tissue. The pulmonary pleura may also be very much thickened. Symptoms. — In very young infants the only symptoms are : Fever, prostration, and rapid breathing. There is no cough ; there are no physical signs. The disease is almost certainly fatal within a very few days. In older children the broncho-pneumonia may be preceded by the symptoms of measles, of whooping-cough, of coryza, of pharyngitis, or of a catarrhal bronchitis of the larger tubes ; or PNEUMONIA. 83 it may begin without having been preceded by any other morbid conditions. Tliere is a good deal of difference in the different cases as to the severity of the invasion. The more severe cases are ushered in by one or more general convulsions ; or by a rapid rise of temperature, vomiting, oppressed breathing, and delirium. The milder cases begin with lower temperatures, moderate prostra- tion, and increased frequency of breathing. After the disease is established the patients continue to have a febrile movement. Tlie temperature in most cases is irregular, but on many days up to 105° F. Very often the temperature is of distinctly remittent type, a morning temperature of 99° to 100° F., and an evening temperature of 104° to 105° F. It is to be noticed, however, that in children both bronchitis and lobar pneumonia are also often accompanied by fever of a remittent type. It may very well be that this disposition to remission be- longs rather to the age of the patient than to the character of the disease. The height of the temperature varies from day to day, sometimes with the progress or extension of the inflamma- tion, sometimes without discoverable cause. In the cases which recover it requires several days for the temperature to fall to the normal. The height of the temperature is regularly in propor- tion to the severity of the broncho- pneumonia ; with tempera- tures of over 105° F. the mortality of the disease is considerable. There are, however, patients in whom the temperature runs be- tween 99° and 100° F. who do very badly. In children the pulse is more rapid than it is in adults, and is also more easily rendered rapid by disease. So in broncho- pneumopias pulses of from 140 to 170 to the minute are not un- common, and in bad cases the pulse can hardly be counted. An increase in the frequency of the breathing is almost con- stantly present, as much as 40 to the minute even in mild cases, up to 60, 70, or 80 in the bad cases. It is of importance to no- tice not only the frequency of the breathing, but also how much air enters into the lungs. The breathing may be made worse for a time by distention of the stomach. Sleeplessness, restlessness, and delirium are often present, and sometimes very troublesome. They seem to depend partly on the fever, partly on the interference with breathing, partly on the temperament of the child. The face is flushed, the tongue is coated and sometimes dry. 84 PNEUMONIA. there may be vomiting or diarrhoea ; sometimes there is pain over the chest. Cough is often present, dependent on the catarrhal bronchitis rather than on the broncho-pneumonia. The sputa are swal- lowed rather than coughed up. They may collect in the stomach and be vomited up. The urine may contain a little albumin and a few casts, the kidneys being the seat of acute degeneration. The physical signs vary with the condition of tlie lung. If the inflammation is limited to the walls of the bronchi and to the air-spaces immediately surrounding them there are no phys- ical signs. If a catarrhal bronchitis is present there are coarse and subcrepitant rales. If there is a diffuse pneumonia, with consolidation of a considerable portion of the lung, there are dulness on percussion and bronchial voice and breathing. If there is fibrin on the pleura, there are crepitant or subcrepitant rales. The signs of tlie consolidation and of the pleurisy are usually developed between the second and fifth days, but it is not uncommon for them to be delayed until a much later period. The duration of broncho-pneumonia in children varies very much in different cases. Of the fatal cases the larger number die within two weeks, but some prove fatal within two da3'-s, and some are protracted for seven or eight weeks. In the cases which recover the constitutional symptoms continue for from one to three weeks in the majority of patients, but it is bv no means unusual for the active symptoms to continue for six or eight weeks, and yet the patients make a perfectly good recov- ery. Resolution requires a longer time than in lobar pneumonia, from seven to fourteen days in most of the cases. The Cereb7'al Cases. — In many of the cases of broncho-pneu- monia there are cerebral symptoms — convulsions, restlessness, and delirium — but in some patients these symptoms are devel- oped to such a degree, and are so out of proportion to the pul- monary symptoms, that the cases require a separate description. The symptoms resemble those of an acute or a tubercular meningitis. They may begin and go on acutely, with high fever, prostration, one or more convulsions, alternating delirium and stupor. Or the course is more subacute, loss of appetite, vomit- ing, moderate prostration, not very higli fever, alternating stupor and delirium. These symptoms may continue for from two to ten days before there are any pulmonary symptoms. Then, as PNEUMONIA. 85 the pulmonary symptoms are developed, the cerebral symptoms subside. Persistent Cases. — If, after the subsidence of the acute bron- cho-pneumonia a chronic inflammation persists, the children begin to improve, but yet do not get well. In some the cough and the physical signs continue, the appe- tite is poor, the children do not gain flesh and strength, but yet they are not sick in bed — often not confined to the house. In others the same symptoms exist, there is also an irregular fever, and the patients are sick in bed. Of these protracted cases some recover entirely ; some re- cover with permanent consolidation of a portion of the lungs ; some die exhausted by the disease ; some go on to have a chronic interstitial pneumonia which lasts for many years. In some cases of acute broncho-pneumonia, the accompany- ing inflammation of the bronchial glands may be of tubercular character, and this may serve at a later period as the focus of infection which causes an acute general tuberculosis. Treatment. — If the inflammation is confined to the walls of ^ the bronchi and the air-spaces around them, counter-irritation of the wall of the chest and antiphlogistic remedies are not likely to be of service. If, on the other hand, catarrhal bronchitis and general congestion of the lungs are present, with rapid and la- bored breathing, it may be well to use cups, or irritating lini- ments, or poultices over the chest, and to give repeated small doses of calomel or the sulphate of magnesia. Throughout the disease good results may be obtained from the continued use of ipecac in small doses. The sleeplessness, restlessness, and delirium are best relieved by opium ; in children who cannot take opium we may use the bromides or asafoetida. The disposition to convulsions seems to be lessened by the use of the bromides. If the pulse is too full, with high temperatures, the children are made more comfortable by the tincture of aconite. Alcoholic stimulants are not to be used unless there is decided failure of the heart's action. The feeding and nursing of the child are of the greatest importance. If resolution is delayed, or if the broncho-pneumonia persists, we employ iron, quinine, mineral acids, oxygen, cod-liver oil, and above all, change of air. In adolescence the clinical picture of broncho-pneumonia is the same as it is in children, but the cerebral symptoms are not 86 PNEUMONIA. developed to the same extent, and they are more likely to cough up blood. In adults the disease presents itself to us under several differ- ent forms : T. The patient has an ordinary attack of catarrhal bronchitis lasting for several days. Instead of getting well promptly, how- ever, the patients continue to cough and to feel sick, and, on examining the chest, we find a circumscribed area where there is dulness on percussion and loud, high-pitched voice. This con- solidation of the lung does not, however, last very long, and the patients make a good recovery. 2. The patients are suddenly attacked with a very severe and general broncho-pneumonia. There are chills, a rapid rise of temperature, headache, pains in the back and chest, vomiting, great prostration, a rapid pulse which soon becomes feeble, very bad breathing — rapid, labored, and insufficient — venous conges- tion of the skin and of the viscera, cough, at first dry, then with profuse mucous and blood-stained sputa, sleeplessness, restless- ness, and delirium, and albumin in the urine. There are coarse, subcrepitant and crepitant rales over both lungs, sibilant and sonorous breathing ; the percussion-note is normal, or exagger- ated, or dull. The disease lasts for from seven to fourteen days ; it is very apt to prove fatal. Treatment. — The most efficient remedies are the energetic use of wet or dry cups over the entire chest, the administration of calomel or the sulphate of magnesia in small and repeated doses, ipecac, the inhalation of oxygen gas, and stimulants, 3. There is a form of broncho-pneumonia in adults which resembles lobar pneumonia. There is a general catarrhal bron- chitis, with broncho-pneumonia and consolidation of one or more lobes. The symptoms and physical signs are like those of lobar pneumonia, but with some difference. The invasion of the dis- ease is not as sudden, and the pulse is more rapid, the cerebral symptoms are more constant, the expectoration is like that of bronchitis, the physical signs are more slowly developed, the duration of the disease is rather longer and resolution is slower. 4. There is a form of broncho-pneumonia which resembles tubercular broncho-pneurnonia. The invasion of the symptoms is gradual and the disease is protracted over a number of weeks. The patients have more or less cough and expectoration, at first mucous, later muco-purulent, but not containing tubercle bacilli. PNEUMONIA. 87 There is a moderate fever, with evening exacerbation and sweat- ing at night. The physical signs are those of bronchitis and of consolidation of circumscribed portions of the lung. The pa- tients have no appetite and lose flesh and strength. Often the diagnosis depends upon the examination of the sputa. After a number of weeks in some of tlie patients the inflammation sub- sides and a complete recovery is made, but in others it continues and proves fatal. Treatment. — The patients are to be kept in bed and as well fed as possible. The most efficacious treatment seems to be the continued inhalation of the vapor of creosote. 5. Persons suffering from emphysema sometimes get up a subacute broncho- pneumonia, which may prove fatal. 6. Broncho-pneumonia, especially of the lower lobes, is sec- ondary to the infectious diseases, to injuries, to surgical opera- tions and to any conditions which are likely to cause congestion of the lungs and the inhalation of streptococci. The Pneumonia of Heart Disease. Definition. — A chronic productive inflammation of the lungs caused by chronic congestion, and resulting in thickening of the walls of the air-spaces, filling of their cavities with epithelial ceils and a deposition of pigment. Synonyms. — Brown, or pigment, induration of the lungs. Etiology. — Any long-continued mechanical obstruction to the escape of the blood from the lungs into the left cavities of the heart can produce this form of pneumonia. The most frequent and effectual obstruction is furnished by a stenosis of the mitral valves ; but any valvular lesion of the heart, dilatation of the ventricles, or aneurism of the arch of the aorta may act in the same way. Morbid Anatomy. — The first effect of the obstruction to the circulation seems to be a change in the capillary vessels in the walls of the air-spaces. These vessels become dilated, tortuous, and have their walls thickened. Then there is a gradual thick- ening and pigmentation of the walls of the air-spaces ; an in- crease in the size and number of the epithelial cells, until they partly or completely fill the cavities of the air-spaces ; an escape of the red blood-cells into the air-spaces. Finally, when the in- flammation has reached its full development, there is a smooth. 88 PNEUMONIA. red hepatization of portions of both lungs, an hepatization due principally to the filling of the air-spaces with epithelial cells. The lungs are diminished in size, sometimes covered with old adhesions, but seldom with fibrin. There may be more or less serum of dropsical character in the pleural cavities. The texture of the lungs is leathery and dense, or that of a smooth hepatiza- tion. They are dry, of a salmon-pink color mottled with brown or black. There may be large or small areas where the air- spaces are filled with extravasated blood. Symptoms. — The principal symptoms exhibited by the patients are those due to the lesions of the heart or aorta. The changes in the lungs do not give as marked symptoms as might be ex- pected. The physical signs are obscure — more or less dulness and diminished breathing. The rational symptoms are — -dysp- noea, cough, mucous and bloody sputa, the continued expec- toration of pure blood. Treatment. — It is evident that this condition of the lungs is one which cannot be influenced by treatment. We simply attend as well as we can to the disturbances of circulation which have caused the lung trouble. ■' Interstitial Pneumonia. Definition. — A chronic productive inflammation, which in- volves the connective-tissue framework of the lung and the walls of the air-spaces, and results in the formation of new connective tissue and obliteration of the air-spaces. Etiology. — The well-marked examples of interstitial pneu- monia follow acute lobar pneumonia with the production of new connective tissue ; broncho-pneumonia; chronic pleurisy with adhesions ; chronic bronchitis, and the inhalation of the dust of coal, or of stone. Morbid Anatomy. — The condition of the lungs varies with the cause of the interstitial pneumonia. (i.) If it follows acute lobar pneumonia with the production of new connective tissue, one lobe, or an entire lung, is covered with pleuritic adhesions, it is small, smooth, and dense ; the air- spaces and small bronchi are obliterated by the new connective tissue. (2) If it follows broncho-pneumonia, one or more lobes are studded with fibrous nodules, or are converted into dense fibrous PNEUMONIA. 89 tissue. The pleura is thickened, tiie bronchi are inflamed and often dilated. (3) If it follows thickening of the pleura, bands of connective tissue extend from the pleura into the lung, the bronchi are in- fiamed and often dilated, (4) If it follows chronic bronchitis there are fibrous nodules around the bronchi, with more or less diffuse connective tissue. (5) If it is due to the inhalation of the dust of coal or stone, we find in both lungs fibrous peribronchitic nodules and diffuse connective tissue. In most of the cases the portions of lung exempt from the in- terstitial pneumonia are em.physematous. Syrnpioms. — The patients have a cough with mucous expecto- ration. The cough becomes more constant and troublesome as the disease progresses. The expectoration becomes muco-puru- lent, sometimes fetid. If the bronchi become dilated, the muco- pus accumulates in them and is coughed up at intervals in large quantities. There may be occasional haemoptyses. There is dyspnoea on exertion, at first slight, later more marked. There may be uncomfortable feelings or actual pain over the affected side of the chest. There is gradual loss of flesh and of strength. Neither laryngitis nor diarrhoea belong to the disease. There is no fever except with exacerbations of the bronchitis. The affected side of the chest is retracted, the other side is enlarged, the heart is displaced, the vertebral column is curved laterally. There is, on percussion, dulness, or flatness, or tym- panitic resonance. The vocal fremitus is increased. The breath- ing is sonorous, sibilant, bronchial, cavernous, or amphoric, ac- cording to the condition of the bronchi and the degree of con- solidation of the lung. There are pleuritic creaking sounds, subcrepitant, coarse, or gurgling rales. The disease is one which lasts for many years, and the pa- tients usually die with some acute inflammation of the other healthy lung. Treatment. — The most efficient treatment is that the patient should reside permanently in a climate where he is able to live out of doors, and where his bronchitis does well. If this cannot be done, we attend to the bronchitis and the nu- trition of the patient as well as we can. 90 MILIARY TUBERCULOSIS. Tubercular Pneumonia. Defifiition. — Under this name we include all the inflamma- tions of the lung which are accompanied with the growth of tubercle bacilli. Of such inflammations there are a number which differ from each other widely in their morbid anatomy and clinical symptoms. We are not at the present time provided with satisfactory names to designate these different forms of tubercular pneumonia, so that we still have to use the old arbi- trary terms to which there are so many objections. We distinguish, therefore : Acute miliary tuberculosis of the lungs. Chronic miliary tuberculosis of the lungs. Acute pulmonary phthisis. Chronic pulmonary phthisis. Acute Miliary Tuberculosis of the Lungs. Definition. — A tubercular inflammation of the lungs character- ized by the presence of a number of small foci of inflammation, of which the inflammatory products form very small nodules, called miliary tubercles. The tubercular inflammation may be confined to the lungs, or it may be part of a general tuber- culosis. Etiology. — For the development of tubercular inflammation in any part of the body there are necessary : the proper predispo- sition of the individual, a local cause of inflammation, and the growth of tubercle bacilli. In the lungs the tubercle bacilli seem to be either inhaled or brought to the lungs by the blood. It is possible that the bacilli may be first inhaled, then collected in the bronchial glands, and from the glands find their way into the pulmonary circulation. Certainly, we see cases in which tuber- cular inflammation of the bronchial glands precedes miliary tuberculosis of the lungs. The bacilli which are inhaled must be derived to some extent from the dried sputa of persons who have tubercular pneumonia. The bacilli a;re much more abun- dant in the air of some localities than of others, and at high alti- tudes and on the ocean the air contains none of these organisms. The bacilli which are conveyed to the lungs by the blood are derived from a focus of tubercular inflammation in some other parts of the body. In man tuberculosis is conveyed by inocula- MILIARY TUBERCULOSIS. 91 tion from one person to another only in rare cases. In some animals tuberculosis can be inoculated at will, and miliary tuber- cles of the lungs easily produced. Trudeau, however, has shown that the success of such an inoculation can be influenced by en- vironment, and that it is possible to keep rabbits under such conditions of good health that they cease to offer a good soil for the growth of tubercle bacilli. The most perfect miliary tuber- cles in the lungs of animals which I have ever seen, are those produced by injections of dead tubercle bacilli into the trachea of rabbits (Prudden). Morbid Anatomy. — The miliary tubercles may be confined to part of a lung, or be distributed through both lungs. They are close together, or separated by considerable intervals, or aggre- gated together into larger masses. They are of gray, white, or yellow color. They all contain tubercle bacilli, but these bodies are much more numerous in some tubercles than they are in others. They are composed of : 1. Groups of air-passages and air-vesicles filled with granular matter, pus-cells, and epithelium. 2. Groups of air-passages and air-vesicles of which the walls are infiltrated with tubercle tissue, while their cavities are filled either with tubercle tissue or with epithelium, pus, and fibrin. 3. Infiltrations of the walls of small bronchi with tubercle tissue, or round-celled tissue, the infiltration extending to the walls of the adjacent air-spaces. 4. Nodules of tubercle tissue situated in the pulmonary pleura, the septa between the lobules, the walls of the bronchi, and the walls of the veins. In addition to the presence of the miliary tubercles the bron^ chi are congested and coated with mucus, the walls of the air- spaces are congested, the epithelial cells which line them are in- creased in size and number, some of the air-spaces are filled with epithelium, fibrin, and pus ; there may be fibrin on the pul- monary pleura. Symptoms. — i. The method of infection may be such that an enormous number of miliary tubercles are at once formed in the lungs and in other parts of the body, the poisonous effects of the chemical substances produced by the growth of the tubercle bacilli are very marked, and the patients behave as if they had a general disease rather than an inflammation of the lungs. Although the lungs are congested and thickly studded with 92 MILIARY TUBERCULOSIS. miliary tubercles the physical signs are not as constant or as plain as one would wish them to be. The changes in the percus- sion-note are not well marked. There may or may not be some dulness. Crepitant or subcrepitant or coarse rales, bronchial voice and breathing, or rude breathing are sometimes present, sometimes absent. Moreover the physical signs may be modified by the existence of old tubercular lesions in the lungs. The rational pulmonary symptoms also are not constant. Cough and mucous sputa, rapid and oppressed breathing, and pain over the chest are present in some cases, absent in others. The temperature rises rapidly and is between ioo° and 107° F. throughout the disease. The pulse and heart action become more rapid and feeble as the disease progresses. The tongue is coated and soon becomes brown and dry. There is loss of appe- tite, nausea, and sometimes vomiting. The bowels remain regu- lar, or are constipated, or loose. Sooner or later alternating stupor and delirium, extreme emaciation and the typhoid state are developed. The disease m.ay last for only a few days, or for three or four weeks. So far as I know it always terminates fatally. 2. The method of infection is such that miliary tubercles are formed only in part of a lobe, or are distributed through an en- tire lobe, or the whole of one lung, or a large part of both lungs. But there are no tubercles outside of the lungs, it is a localized tubercular inflammation. Etiology. — This condition may be developed at any time in a person who has the tubercular disposition, and we are seldom certain in such cases as to the exciting cause of the inflamma- tion or the exact method of the infection. It is also of frequent occurrence in persons who already have a chronic tubercular in- flammation of some part of the lung. In such cases it is proba- ble that the infection comes from the old tubercular lesion. Morbid Anatomy. — As the disease runs rather a subacute than an acute course the tubercles are firmer and more regularly com- posed of tubercle tissue than is the case in acute general tuber- losis. The most frequent position of the tubercles is at the apex of one lung, but they may be localized at any part of the lungs. It is not often that the whole of both lungs is involved. The cases vary greatly as to the extent of the associated bronchitis, pleurisy, and exudative pneumonia. The bronchitis may be con- fined to the portion of the lung which contains the miliary tuber- MILIARY TUBERCULOSIS. 93 cles, or it may be a general bronchitis involving the larger tubes in both lungs. The pleurisy is either with j5brin alone, or with large quantities of serum in the pleural cavity. The exudative pneumonia may involve only small portions of the lung, or an entire lobe may be consolidated. Syfnptoms. — These are in proportion to the extent of lung in- volved. If only a part of one lung is involved the other symp- toms are often preceded by one or more haemoptyses. When the disease is established the patients suffer from : 1. A febrile movement which is regularly higher in the after- noon and followed by sweating at night. The fever may be con- fined to the afternoon, with normal morning temperatures. The height of the temperature varies with the extent of lung involved, the severity of the associated bronchitis, pleurisy, or pneumo- nia, the character of the patient, and, probably, the quantity of poisonous products which are evolved by the growth of the bacteria. 2. An increased frequency of the heart action. This is a very constant symptom, so constant that whenever we find a patient with a rapid pulse for which there is no evident cause we must always think of the possibility of a tubercular inflammation of the lungs. 3. The breathing is often increased in frequency and some- times labored even with lesions of small extent. It is made worse by an extension of the tuberculosis, or by the development of bronchitis, pleurisy, or pneumonia. 4. Most of the patients have more or less cough. They may only cough in the morning, or throughout the day, or in severe attacks, which may provoke vomiting. In some patients the cough is hardly noticeable, in others it is the most distressing feature of the disease. The immediate cause of the cough is not always the same. It may be principally due to a catarrhal pharyn- gitis, or to the bronchitis, or to the pleurisy. How far the pres- ence of the tubercles in the lungs causes cough is difficult to say. In some persons the cough is evidently largely hysterical, out of all proportion to any real reason for it. The expectoration, if there is any, is mucous, or muco-purulent in character. It often, but not always, contains tubercle bacilli. There may be small haemoptyses throughout the course of the disease. 5. Loss of appetite with more or less nausea. This is present in a great many of the patients. It is a serious matter, for it is 94 MILIARY TUBERCULOSIS. one reason for their loss of flesh and strength. Actual vomiting usually occurs only after fits of coughing. 6. Loss of flesh and strength are characteristic symptoms, but they are not always in proportion to the extent of lung involved. We must judge of the real condition of the patient rather by the pulmonary lesions than by the general condition. It is questionable whether the miliary tubercles alone give any physical signs. And as a matter of fact many patients who have acute miliary tuberculosis give no physical signs at all. But the associated bronchitis, pleurisy, and pneumonia do give physical signs. The bronchitis gives coarse and subcrepitant rales ; the pleurisy, dulness, friction sounds, crepitant and subcrepitant rales ; the pneumonia, dulness, increased vocal resonance, bron- chial voice, and bronchial breathing. (i) When the disease is once established it may continue for a number of months, the inflammation then subsides, and the pa- tients recover altogether. (2) Or, the inflammation may remain localized but will become chronic, and the patients go on with the history of chronic miliary tuberculosis. (3) Instead of this the tubercular inflammation, after remain- ing for months circumscribed, will either continuously, or at intervals, extend and involve more and more of the lungs. When this is the case the patients get worse either continuously, or with intervals of improvement. (4) In some cases there are one or several intercurrent attacks of bronchitis, pleurisy, or pneumonia so severe as to modify the course of the disease. With each attack of this kind the temper- ature runs up, the physical signs change, and the patient is evi- dently more seriously ill. (5) If both lungs are at the first involved by the tubercular inflammation, the patients have the same symptoms but in a more severe form. They lose flesh and strength rapidly, develop alter- nating delirium and stupor, pass into the typhoid condition, and die within a few weeks. Treatment. — If both lungs are involved in the morbid process treatment is of no avail. But if only a part of one lung is dis- eased, the patients can be much benefited by proper management — the two essential points in the treatment being that the patients should eat enough food, and live in a proper climate. As regards the feeding, it is important that the patients should MILIARY TUBERCULOSIS. 95 take fat in some form in addition to the other articles of diet. In some patients a proper climate alone will improve the appetite ; in others, it may be necessary to use bitters, alkalies, or mineral acids, to relieve constipation, to wash out the stomach, or to feed through tlie stomach-tube. Generally speaking, all the prepared and peptonized foods and extracts are to be avoided. The pa- tients do best with milk, cream, meats, vegetables, fruits, and breadstuffs. As regards climate, I doubt if there is any one place suitable for all the patients. The idiosyncracy of each person must be considered, and we find that some do best on the sea- shore, some in the interior, some in a warm climate, some in a cold climate, while some do best if they travel from place to place. Chronic Miliar\ Tuberculosis. Definitioti. — A chronic tubercular inflammation of the lungs characterized by the formation of miliary tubercles, to which may be added bronchitis, dilatation of the bronchi, pleurisy, in- terstitial pneumonia, and emphysema. Etiology. — It seems to be necessary to suppose in these cases : a predisposition, an exciting cause for inflammation, and the growth of tubercle bacilli. It is evident, however, that the mode and character of the infection must differ from those of acute miliary tuberculosis. The structure of the tubercles is differ- ent, they contain very few tubercle bacilli, and the other morbid changes in the lungs may be of more importance than are the tubercles. Mo7'bid Anatomy. — The morbid process begins regularly at the apex of one of the lungs, and then slowly extends either progres- sively or in attacks, until a larger portion of the lungs is in- volved. In the simplest form of the disease the only change in the lungs is the formation of miliary tubercles. These tubercles are harder and denser than are those which are found with acute tuberculosis. They are composed of tubercle tissue, or round- celled tissue, or connective tissue, or are in the condition of cheesy degeneration. They contain but few tubercle bacilli. Another simple form of the disease is when miliary tubercles alone are formed in lungs which are already the seat of vesicular emphysema. 96 MILIARY TUBERCULOSIS. Usuall}', however, in addition to the miliary tubercles there are other changes in the lungs. These additional lesions begin in the same part of the lung where the tubercles are formed, and accompany the development of the tubercles in fresh parts of the lungs. (i) There may be a localized catarrhal bronchitis. {2) There may be an inflammation of the walls of the bronchi with partial destruction of these walls, and the formation of cyl- indrical or sacculated bronchiectasiae. The walls of the cavities thus formed may be converted into connective tissue, or they may remain suppurating and necrotic. (3) There may be an interstitial pneumonia with the produc- tion of new connective tissue, the obliteration of the air-spaces, and tlie consolidation of portions of the lung. (4) There may be dilatation of the air-spaces of the portions of the lungs which are not consolidated. (5) There may be thickening of the pulmonary and costal pleura, with connective-tissue adhesions. (6) While the morbid process begins as a localized tubercular inflammation of the lung, and often retains throughout this local character, yet it may also happen that from this local lesion other parts of the body may be infected. Tubercular laryngitis, and tubercular inflammation of the solitary and agminated glands of the small intestine, often complicate the pulmonary lesion, and sometimes even acute general tuberculosis is produced. Sympto7ns. — The disease may follow an acute pulmonary tuber- culosis, or it may be chronic from the outset. There is such a very great difference in the behavior of the disease in different per- sons, that it is necessary to arrange the cases into a number of groups according to the character of the lesions and the symp- toms. 1. There seems good reason to believe that a small tubercular inflammation of one apex often runs its course and terminates in recovery, without ever giving symptoms of sufficient severity to attract the attention of the patient, or lead him to consult a physician, 2. There are patients who suffer for some time fi'om pulmo- nary emphysema with its attendant symptoms. In them miliary tubercles are formed in the lungs and slowly increase in number, but are not accompanied with the growth of much connective tis- sue, and are scattered at some distance from each other through MILIARY TUBERCULOSIS. 97 the lungs. The formation of the tubercles does not change the physical signs belonging to the emphysema which the patient already has. The ordinary rational symptoms of emphysema continue unchanged, but the patients lose flesh and strength rapidly, and finally die very much emaciated. It is very difficult to distinguish these cases from the bad cases of emphysema with- out tuberculosis. 3. A very common form of the disease is that in which the inflammation is confined to one or both apices, continues for some time, subsides, and the patient recovers. In these cases the first symptom may be one or more small or large hsemoptyses. Before the bleeding the patients have had no pulmonary symptoms, but after the bleeding these symptoms are gradually developed. Or the first symptom may be a troublesome cough with little or no expectoration. This cough at first does not seem of much consequence, but it continues in spite of all remedies. Or the patients simply lose flesh and strength without any evident reason for this loss of nutrition. The pulse is also in- creased in frequency, but for a time there are no pulmonary symptoms. At this early stage of the disease there may be no physical signs. As the disease goes on the patients have more or less cough, which troubles them only in the morning, or occurs in attacks, or is persistent and troublesome through the whole day. There may be no expectoration. When present the sputa are mucous or muco-purulent, not abundant, and often contain tubercle ba- cilli. There is some dyspnoea on exertion. Some of the patients complain of a great deal of pain over the inflamed lung, others have no pain at all. Haemoptyses may be repeated at any time, and are apt to be followed by an increase in the severity of the s\'mptoms. The frequency of the pulse is increased in nearly all the patients. A febrile movement is not a prominent symptom, there may be afternoon temperatures of 100° F. followed by sweat- ing, but often during much of the time there is no fever at all. The appetite is poor, nausea and vomiting are often troublesome. The patients lose flesh and strength. In some cases the svmp- toms are not at any time severe ; in others the constitutional dis- turbances are so out of proportion to the lesion as to indicate systemic infection. 98 MILIARY TUBERCULOSIS. The physical signs become more marked with the further development of the thickening of the pleura, the formation of miliary tubercles, the growth of interstitial connective tissue, the localized bronchitis, and the dilatation of the bronchi. So we find : retraction of the chest-wall above and below the clavicle, the percussion sound of higher pitch and of shorter duration above and below the clavicle, subcrepitant rales, friction sounds, a higher pitched and louder voice, the breathing diminished, or of altered quality, or with prolonged expiration. Such a circumscribed tubercular inflammation usually con- tinues for a year, sometimes longer, then it subsides and the patients recover. The portion of lung which has been inflamed is left permanently changed into connective tissue. As the patient has had one attack of tubercular inflammation, so, although he has entirely recovered from this attack, he may have subsequent attacks of tlie same kind. In some of the pa- tients, after the subsidence of the inflammation, tubercle bacilli are left in the portion of lung which has been inflamed. These may at any time later serve as a source of infection for a new local or general tuberculosis. 4. The tubercular inflammation, beginning at the apex of one lung, gradually extends and involves a large part of both lungs. The pleuritic adhesions become more extensive, a larger number of bronchi are involved in tlie catarrhal bronchitis, miliary tuber- cles and new connective tissue replace more and more of the lung tissue. The changes in the walls of the bronchi and of the lung surrounding them result in the formation of bronchiectatic cavities, which constantly increase in size, and the walls of which are necrotic or suppurating. As the disease progresses, therefore, the patients suffer, not only from the infection due to the tuber- cular inflammation, but also from that due to the necrosis and suppuration of the walls of cavities, while in addition more and more of the lungs is rendered unfit for breathing. The physical signs of consolidation and of pleuritic adhesions become more marked, and as the cavities are formed and increase in size their physical signs are added. The cough, which depends at first upon the bronchitis or the pleurisy, is made worse by the formation of bronchiectasife. The expectoration becomes more profuse, more purulent and contains portions of dead lung. Bacilli are present, in the sputum in larger numbers. The difficulty in breathing becomes MILIARY TUBERCULOSIS. 99 more troublesome. The patients differ very much as to the presence or absence of pain in the cliest. Either large or small haemoptyses may be repeated at any time. At first the blood comes from the mucous membrane of tlie bronchi, but after cavities have been formed there may be bleeding from eroded vessels in their walls. This bleeding is apt to be profuse, con- tinuous, and often fatal. The pulse continues to be rapid through the greater part of the disease. The fever becomes higher and more continuous as the disease progresses, especially after the formation of cavities. The appetite is poor and nausea and vomiting are often troublesome. In women menstruation becomes irregular or ceases altogether. The patients get worse from year to year, but often with periods of improvement, and the whole duration of the disease is apt to be very considerable. After a time in many of the patients a tubercular inflamma- tion of the larynx or of the agminated glands of the small intes- tines is added and then the loss of flesh and strength are much more rapid. 5. There are cases in which the tubercular inflammation gradually extends until the whole of both lungs are thickly studded with miliary tubercules and in addition there are exten- sive pleuritic adhesions, but there is little diffuse fibrous tissue, little or no bronchitis, and no dilatation of the bronchi. The clinical history of these patients is very misleading. They have no cough, no haemoptysis, no pulmonary symptoms, no fever. There are no physical signs except those belonging to the pleuritic adhesions. But very often the functions of the stomach and intestine are much disordered. The most striking symptom of these patients is their emaciation. This goes on steadily until the patients are mere skeletons, looking as if they were starving to death with a cancer of the stomach. And yet they may really be taking and retaining a considerable quantity of food. But in spite of the food they continue to lose flesh as if the}'- had a malignant disease. The diagnosis of these cases is often extremely difficult. 6. There are cases in which a tubercular laryngitis is respon- sible for most of the symptoms, the lesions in the lungs being inconsiderable. The upper part of the larynx and the epiglottis are the portions usually involved. There is first a formation of tubercle granula here and there in the stroma of the mucous membrane witli more or less catarrhal inflammation. After a lOO MILIARY TUBERCULOSIS. time the tubercle granula and the mucous membrane over them become necrotic, soften, slough, and form ulcers. These ulcers do not heal, but rather increase in size, their floors and walls being- formed partly of tubercle, partly of round-celled tissue. The mucous membrane left between the ulcers is thickened and the seat of chronic catarrhal inflammation. With such a tubercidar laryngitis the patients have a cough with muco-purulent expectoration, a changed voice, and some- times laryngeal dyspnoea. But the thing whicli troubles them the most is the pain in the throat, which is made worse by swal- lowing. This may interfere seriously with the feeding of the patient. The patients lose flesh and strength, but are not confined to bed. Indeed, many years may pass before the pulmonary tuber- culosis gives much trouble. 7. In a few cases a very small miliary tuberculosis of the lung is complicated with an extensive tubercular inflammation of the small intestine. These patients have a little cough, and perhaps the physical signs of a small consolidation at one apex. It is important to remember that they do not necessarily have diarrhoea. But they lose flesh and strength with a rapidity which the pulmonary con- ditions do not account for. P7'ognosis. — In the early periods of the disease, with little evidence of systemic infection, we may often expect the complete recovery of the patient. As more of the lungs is involved, as cavities are formed, as the complicating laryngitis and enteritis are developed and the evidences of systemic infection become manifest, the prognosis is worse and worse. Treatment. — The curative treatment of chronic miliary tuber- culosis is embraced in two principal things — climate and feeding. The selection of a proper climate is to be made with reference to the individual rather than to the condition of the lungs. It should be a climate where he feels well, eats well, sleeps well, and gains flesh and strength. If no one climate answers this pur- pose, the patient should travel from place to place. The climatic treatment should be continued, if possible, for two full years, and for some persons it is necessary that they should pass the rest of their lives in a favorable climate. The feeding consists in enabling the patient to eat and digest considerable quantities of wliolesome food and of fats. To do tins MILIARY TUBERCULOSIS. lOI the most minute attention is necessary to the functions of the stomach, the liver, and the intestines. Great care should be taken to avoid the use of all medicines which interfere with the patient's ability to eat and digest food. Wines and spirits will with some persons increase the appetite and the nutrition, with other per- sons they interfere with digestion and do harm. Often we are much lielped by the use of the stomach-tube. Not only can we in this way cure a complicating chronic gastritis, but we can intro- duce into the stomach much larger quantities of fluid food than the patients are willing to swallow. It may also be necessary to alleviate symptoms. The cough is not only annoying, but it often interferes witli eating and sleep- ing. It is, therefore, important in each case to determine the principal cause of the cough. It may be due to a catarrhal inflammation of the nose and throat, or to either a catarrhal or tubercular inflammation of the larynx. These conditions are best treated by local applications made with the spray or with the brush. It may be due to the pleuritic adhesions. If this is the case counter-irritation by blisters or iodine may be of service, but some of these pleuritic coughs can only be controlled by opium. For the cough which is due to the bronchitis and to the cavi- ties a great many remedies have been employed. In selecting from these remedies .it is well to prefer those which do not dis- order the stomach. Creosote seems to be capable of exerting a real effect on the bronchitis, but, unfortunately, it is apt to dis- order the stomach. I prefer to use it by inhalation, or by enema. For inhalation a mixture is made of equal parts of creosote, chloroform, and alcohol. The sponge of a Robinson's inhaler is moistened with a few drops of this mixture, and the patient wears the inhaler all the time except when sleeping or eating. An enema is easily made up of five to twenty drops of creosote with some white of egg and a little water, and this can be used once a day. The different preparations of tar and of turpentine, terebene and terpine hydrate, seem to be of service in some cases. The methodical inhalation of compressed air is highly thought of by some physicians. All sorts of combinations of opium, ipecac, squills, sanguinaria, hydrocyanic acid, chloroform, senega, etc., are given as cough mixtures. The mineral acids, nux vom- ica or strychnia and potassium iodide may somewhat control the bronchitis. 102 PHTHISIS. If the patients are anaemic they may be benefited by one of the preparations of iron. The hemorrhages from the bronchi may be small or large, but even if large and continued for several days they are very seldom fatal. They do, however, weaken the patient very much, and are often followed by an extension of the tubercular pneu- monia. To check such hemorrhages it is customary to use hypo- dermic injections of morphine or of ergotine, or to give by the mouth five grains of gallic acid every two hours, twenty drops of fluid extract of hydrastis every three hours, or one grain of ipecac every hour. The hemorrhages which come from eroded vessels in the walls of cavities cannot be controlled. The fever and night-sweats rnay be made less severe by the use of antifebrin or phenacetine alone, or combined with arsenic or quinine ; by the mineral acids, belladonna, or the oxide of zinc ; by sponging off the body with hot water at night. For the diarrhoea we employ a restricted diet, and a number of drugs. The drugs most frequently employed are : the prepa- rations of mercury, ipecac, iron, arsenic, camphor, acetate of lead, bismuth, castor-oil, opium, and naphthalin. These drugs are used singly or combined in different ways. Acute Tubercular Phthisis. Synonyms, — Acute catarrhal phthisis. Acute consumption. Definition. — An acute affection of the lungs characterized by the association of tubercular inflammation with other forms of inflammation — either exudative or productive, or both. The name is an arbitrary one, and is used for convenience to group together a set of clinical cases. Etiology. — An attack of acute phthisis may follow some pre- vious tubercular inflammation of the lung, or it may be a prim- ary inflammation. A person who has the tubercular predispo- sition, when exposed to the ordinary causes of inflammation of the lung, and at the same time infected with tubercle bacilli, in- stead of having a simple exudative or productive pneumonia, has an inflammation of the lung, partly tubercular, partly exuda- tive, partly productive. Morbid Anatomy. — The inflammation of the lungs may follow one of several types, all of which have much the same clinical his- tory, but vary in their physical signs. PHTHISIS. 103 1. One or more lobes are completely consolidated. The con- solidation is effected by the filling of the air-spaces and small bronchi with epithelium, fibrin, and pus. Scattered through the consolidation are miliary tubercles. The pleura is coated with fibrin. 2. Tliere is a general catarrhal bronchitis and a tubercular in- flammation of the walls of some of the bronchi and of small zones of air-spaces immediately surrounding them. The lung is not consolidated, but a section of it appears to be studded with little nodules, each nodule is the section of a bronchus with thickened wall and surrounded by a zone of filled air-spaces. 3. There is a general catarrhal bronchitis, a tubercular inflam- mation of the walls of some of the bronchi and of the air-spaces which surround them, but in addition there are small or large areas of diffuse consolidation due to the filling of air-spaces with epithelium, pus, and fibrin. The pulmonary pleura is often coated with fibrin. 4. Besides the tubercular broncho-pneumonia, the diffuse con- solidation, and the pleurisy, small or large portions of the in- flamed lung die. These dead portions of lung first pass into the condition of coagulation necrosis, and then undergo cheesy de- generation. They may remain in the condition of cheesy de- generation for a long time and become surrounded by zones of tubercle tissue or of round-celled tissue ; or they often break down and form ragged cavities which communicate with the bronchi. 5. In addition to the lesions already mentioned, the walls of the bronchi are so changed by the tubercular inflammation that cylindrical or sacculated bronchiectasiae are formed. Symptoms. — The invasion may be acute or subacute, I. The acute cases. The patients are suddenly attacked with chills, fever, pain in the side, cough with mucous expectoration, and marked prostration. The appearance of the patient is like that of a person attacked with lobar or broncho-pneumonia, and we are often in doubt at first as to the true nature of the disease. One symptom of the invasion, however, is not often seen except with phthisis and that is the bleeding from the bronchi. For a day, or for several days, many of the patients cough up very con- siderable quantities of blood. Within a few days we begin to get the physical signs, which will be found to vary according to the anatomical condition of the lung. If there is complete consoli- dation of one or more lobes with fibrin on the pleura we get dul- 104 PHTHISIS. ness oil percussion, bronchial voice and breathing, and subcrepi- tant and crepitant rales. If there is only broncho-pneumonia without consolidation, we get sibilant and sonorous breathing and coarse and subcrepitant rales. If there is broncho-pneumonia with areas of diffuse consolidation, we get sibilant and sonorous breathing, coarse and subcrepitant rales, and small areas over which there are dulness on percussion, increased voice, and a crepitant rale are found. The patients continue seriously ill and with high temperatures for one or two weeks. Then there is a partial subsidence of the symptoms. After this the patients may : {a) Continue to get worse. The fever continues, the cough is very troublesome and accompanied with muco-purulent expec- toration, there is rapid loss of flesh and strength, the patients pass into the typhoid state with alternating delirium and stupor. The physical signs which existed earlier in the disease continue and there are added the coarse and gurgling rales which accompany the dilatation of the bronchi and the softening of the dead areas of consolidation. These patients die at the end of a few weeks or months. (d) Improve very considerably. The temperature falls, the expectoration diminishes, the cough is less frequent, the appetite returns. The patients gain flesh and strength, they are able to leave the bed, and later the house, but yet they are not well. A considerable portion of the lung remains diseased and the patients go on to the condition of chronic phthisis. (c) Recover. Of the lesions of acute phthisis, the tubercular changes, the death of portions of lung, and the dilatation of the bronchi are necessarily permanent. On the other hand, the catarrhal bronchitis may subside, the epithelium, pus, and fibrin within the air-spaces may degenerate and be absorbed. It is possible, therefore, for the patients who have only catarrhal bronchitis, exudative pneumonia, and comparatively little tuber- cular pneumonia to recover. We see this in two sets of cases. First, the patients who have consolidation of an entire lobe due to the filling of the air-spaces with epithelium, pus, and fibrin, and to the presence of miliary tubercles. The epithelium, pus, and fibrin can be absorbed, the tubercles are converted into fibrous tissue, and the patients get well with a lung which is nor- mal except for the presence of fibrous nodules. Second, the patients who have tubercular broncho-pneumonia without de- PHTHISIS. 105 struction or dilatation of the bronclii, and without areas of diffuse consolidation. The patients can get well with lungs which are normal except for the presence of a number of peri-bronchitic fibrous nodules. 2. The subacute cases. The extent of lung at first involved is small, but gradually increases in size. The patients usually have cough with mucous or muco-purulent sputa which contain bacilli, but sometimes there is very little either of cough or of expectoration, and that even while cavities are being formed. The difficulty in breathing increases with the extent of lung in- volved, pain over the chest is present in some cases, absent in others. There is regularly a rise of temperature in the afternoon with sweating at night, and the temperature is higher and more con- tinuous after cavities with suppurating walls are formed. But we have to become accustomed to very great discrepancies be- tween the lung lesion and the height of the temperature, and even to find no fever with an advancing consolidation of the lung. There may be bleeding from the bronchi or from eroded ves- sels in the walls of cavities. A large hemorrhage from the bronchi is apt to precede the inflammation of a fresh portion of the lung. The patients, as a rule, have no appetite and gradually lose flesh and strength. But in some persons the changes in the lung for some time produce very little effect on the general health. And it is sometimes very curious, and of importance in judging of treatment, to see patients eating well and gaining flesh with con- solidation of an entire lung and without any real improvement in their tubercular pneumonia. The physical signs are those of the pleurisy, the consolida- tion, the bronchitis, and the cavities. The patients are for the most part not sick in bed, and the disease progresses either continuously or in attacks. Some of the patients go on to have chronic phthisis. Some of them recover, but with lungs more or less permanently dam- aged. Often these patients can only escape fresh attacks by remaining permanently in a favorable climate. The Prognosis of acute phthisis is unfavorable. Complete re- coveries are rare, but the number of patients who go on living with damaged lungs for many years is considerable. Treatment. — While the inflammation of the lungs is active the I06 PHTHISIS. patients are to be kept in bed, on a fluid diet, tlie liaemoptysis controlled by ergot, hydrastin or ipecac, the patients made more comfortable by opium or the bromides. As the acuteness of the inflammation subsides, the patients return to solid food, they get out of bed, and tlie question of a suitable climate for them has to be determined. In some cases it is evident that the changes in the lungs are so extensive and profound that no improvement can be ex- pected ; these patients are best kept at home. In some cases the extent of lung involved is comparatively small, so that we may hope for complete or incomplete recovery. The proper climate for these patients is a dr\', inland one, where they are not likely to have fresh attacks of inflammation of tlie lung. Whether this climate should be a warm or a cold one, must be determined by the character of the individual. In the cases of tubercular broncho-pneumonia without consolidation a cold, dry, inland climate seems to be the best. The symptomatic treatment is the same as tliat used in the cases of acute miliary tuberculosis. Chronic Tubercular Phthisis. Definition. — A chronic affection of the lungs characterized by tubercular inflammation associated with productive and exu- dative inflammation. Etiology. — Clironic phthisis regularly succeeds acute or sub- acute phthisis, but it may also follow acute or chronic miliary tuberculosis of the lungs, or a tubercular inflammation of some other part of the body. Morbid Anato77iy. — The changes in the lungs are of the same nature as those found in acute phthisis, but modified by the long duration of the inflammation. The pleura is coated with suc- cessive layers of fibrin, or thickened by the growth of new con- nective tissue, or covered with adhesions. More or less of the lung is consolidated. This consolidation is effected partly by the filling of the cavities of the air-spaces with inflammatory products, partly by a growth of new tissue in the walls of the air-spaces and between them. When the hepatization is effected only by changes within the cavities of the air-spaces, the affected portions of lung are solid, increased in size of red, gray, white, or yellow color. When the PHTHISIS. 107 hepatization is due to interstitial inflammation tlie affected por- tion of lung is dense, but may still be partly aerated ; it is dimin- ished in size and looks like fibrous tissue or granulation tissue, it is often changed in color by the deposition of black pigment. The combination of intra-alveolar and interstitial pneumonia with dilatation of the bronchi and the formation of cavities gives a great variety of pictures. We find some of the air-spaces filled vvitli large epithelial cells either well formed or fatty ; some witli an amorphous granular matter, or a peculiar translucent coagulated sub- stance ; some with fibrin, pus, and epithelium either fresh or in the condition of cheesy degeneration ; some with new connective tissue. The walls of these air-spaces remain unchanged, or they are compressed and the blood-vessels obliterated, or they are thickened. The interstitial inflammation affects the walls of the air- spaces, the bronchi, the blood-vessels and the septa between the lobules. It results in the production of new connective tissue, of round-celled tissue and of tubercle tissue, either separately or together. By this growth the air-spaces are compressed, de- formed, and obliterated in a variety of ways. The walls of some of the bronchi are infiltrated with round cells or with tubercle tissue. This infiltration is not symmetrical, but affects a bronchus in some particular portion of its length, and in this portion some parts of the circumference of the bron- chus are affected more than others. As a result of this irregu- lar infiltration the wall of the bronchus yields here and there, and small sacculated dilatations are formed. In some cases, espe- cially in chronic miliary tuberculosis, the cavities thus formed simply became larger and larger, compressing the surrounding lung. More frequently, however, the process extends from the wall of the bronchus to the surrounding air-vesicle, so that the bronchus is surrounded with tubercle tissue, round-celled tissue, and air-vesicles filled with inflammatory products. Then necro- sis sets in, with softening of the walls of the bronchus and of the surrounding inflamed lung. So cavities are formed partly by de- struction of tissue, partly by dilatation of bronchi of which the walls are either necrotic or suppurating. Some of the cavities in chronic phthisis seem to be formed simply by the softening of areas of coagulation necrosis, but the larger number are bronchiectasise such as have just been described. I08 PHTHISIS. The cavities which are formed by dilatation without necrosis of their walls may be developed with hardly any cough or expec- toration. As we examine the patients from time to time, the change in the percussion and the breathing show the increasing size of a cavity which remains nearly dry and empty. The cavities formed botli by dilatation and necrosis, on the contrary, are regularly accompanied by an harassing cough and profuse expectoration. They contain pus, mucus, fragments of dead tissue, and great numbers of tubercle bacilli. Their walls are ragged and irregular, partly necrotic, partly suppurating. In this active condition the cavities may remain up to the time of the patient's death. Or, instead of this, the active processes may subside, the production of pus and the death of tissue cease, the cavity become dry and its walls changed into fibrous tissue. The natural tendency of all these cavities is to increase in size and open into each other. Miliary tubercles are scattered through the inflamed lung in varying numbers. The "tubercle bacilli are found principally in the walls of the cavities and in the inflammatory products which have undergone cheesy degeneration. Symptoms. — The cough depends principally upon the bronchi- tis and the morbid processes going on in the walls of cavities. The expectoration consists of mucus, pus, and fragments of dead lung tissue, with many tubercle bacilli. But in patients with consolidation of the lung without bronchitis, and with cavities of which the walls are comparatively healthy, the cough and expec- toration amount to very little. Generally speaking, however, the quantity of the sputa and the number of the bacilli are a fair test of the activity of the morbid process. Haemoptysis occurs in a large proportion of the cases, and at any time in the course of the disease. After some of these bleed- ings the patients feel more comfortable, but after others there is a rapid extension of the disease. Hemorrhages from eroded ves- sels in the walls of cavities are very dangerous. In some of the patients the pleurisy from time to time gives pain. In others there is a considerable exudation of serum in one of the pleural cavities, which increases the difficulty in breathing. The softening of a dead portion of lung or the rupt- ure of the wall of a cavity just beneath the pleura may cause perforation, pneumothorax, and then either a pleurisy with effu- PHTHISIS. 109 sion, or an empyema. At the time of the perforation the patients feel as if something had given way, and at once suffer from the most urgent dyspncea. The heart's action becomes rapid and feeble, and the veins throughout the body congested. Tlie char- acteristic physical signs are soon evident. Such a perforation usually proves fatal within a few days or weeks. The dyspnoea on exertion increases with the extension of the disease and the consequent diminution in the extent of lung available for breathing. Tubercular laryngitis occurs later in the disease with chronic phthisis than with chronic miliary tuberculosis. It gives rise to cough, hoarseness, and pain. The fever and the sweating at night seem to be related to the severity of the bronchitis, and of the necrosis and suppuration of the cavities. The temperature rises and falls according to the activity of these conditions. The consolidation of the lung alone can extend with little or no fever. The functions of the stomach and liver are sooner or later affected, either with or without chronic catarrhal gastritis and fatty infiltration of the liver. Loss of appetite, repugnance to food, nausea. Vomiting, and gastric pain may seriously annoy the patient. Toward the close of the disease a severe diarrhoea often sets in, and the patients lose flesh and strength very rapidly. In these patients after death we may find tubercular ulcers of the small intestine or only a catarrhal colitis. It may also happen that extensive tubercular ulcers of the small intestine exist with- out any diarrhoea at all. Tubercular meningitis, or peritonitis, or nephritis may occur as complicating inflammations. Chronic degeneration of the kidney, or chronic nephritis with or without exudation, are often developed after the phthisis has lasted for some time. In women menstruation is either irregular, or stops alto- gether. The physical signs with only a small area of lung consolidated are : dulness on percussion, broncho-vesicular or feeble breath- ing, increased vocal resonance, increased bronchial whisper, and in addition, subcrepitant rales and friction sounds. As more of the lung is consolidated the dulness on percussion becomes more marked, the voice and breathing approach more nearly to the no PHTHISIS. bronchial character, and an increasing broncliitis gives coarse and subcrepitant rales. After cavities have been formed the percussion sound changes to flatness, tympanitic resonance, or the cracked-pot sound. The breathing and voice remain of bron chial quality, or become cavernous. There may be gurgling rales. Tlie patients regularly lose flesh and strength in proportion to the extent of lung diseased. But it is not rare to see persons who are well nourished and comparatively strong with extensive changes in the lungs. If we compare chronic miliary tuberculosis with chronic phthisis, we may say that in the former there are but few tuber- cle bacilli in the sputa or in the lungs, but little necrosis or sup- puration, and less consolidation of the lung, but a loss of health and nutrition much greater than would be expected from the extent of the pulmonary lesion. In chronic phthisis, on the other hand, the number of tuber- cle bacilli in the sputa and in the lungs is large, necrosis and suppuration are regularly present, the patients seem to suffer rather from septic than from tubercular infection, the severity of the symptoms is usually in direct relation with the extent of lung inflamed. Prognosis. — It is possible for the inflammatory and necrotic processes which belong to chronic phthisis at any time to cease. When this happens, all symptoms of pulmonary disease may also cease and the patients are apparently cured. The portions of lung, however, which have been destroyed or converted into fibrous tissue are never replaced by lung tissue, so that the in- jury inflicted on the lungs is a permanent one. The fibrous tis- sue and cheesy masses left behind after the subsidence of active changes are liable to act as foci, from which fresh attacks of inflammation and fresh infection may proceed. The prognosis is, therefore, unfavorable, although life may be prolonged in comparative comfort for many years. Treatment. — Cases of chronic phthisis are to be managed in the same way as are the cases of chronic miliary tuberculosis. In a work of this kind it is not necessary to describe the plans of treatment by such agents as sulphuretted hydrogen, tuber- culin, chloride of gold, etc. None of them have as yet proved satisfactory. SYPHILITIC PNEUMONIA. Ill Syphilitic Pneumomia. In children wlio have inherited syphilis, a number of inflam- mations of different parts of the body are liable to be developed soon after birth. The lungs are not exempt. They may be studded with gummy tumors of different sizes, or they may be the seat of interstitial, or of intra-alveolar pneumonia. The interstitial pneumonia may cause the consolidation of one or more lobes. The section of such a consolidated lobe is smooth and of grayish or white color. The consolidation is effected by a growth of new tissue in the walls of the air-spaces, the bronclii, and the blood-vessels, together with the filling of some of the air- spaces with epithelium. The intra-alveolar pneumonia also produces a whitish hepa- tization of considerable portions of the lung. But the consolida- tion is effected entirely by the filling of the air-spaces with fatty epithelium. The clinical symptoms in these children are obscure. They often have other syphilitic lesions besides those in the lungs, and become weaker and more emaciated from day to dav, without any pulmonary symptoms except the physical signs of the consoli- dation. In adults, syphilitic inflammations of the lung are rare. The best collection of cases that I have seen is that given by Hiller in the Charite Annalen for 1884. He gives 58 cases of unmistakable syphilitic pneumonia. Morbid Anatomy. — The inflammation is of productive charac- ter with the formation of round-celled tissue, of gummv tumors, and of new connective tissue. There may also be some exudation into the air-spaces and a formation of epithelial cells in the air- spaces. The new tissue is formed in the walls of the bronchi, the walls'of the air-spaces, the walls of the blood-vessels, the septa between the lobules and the pleura. The new tissue is of low vitality and may become necrotic. There results from such an inflammation, therefore : stenosis, ulceration or dilatation of the bronchi, consolidation of parts of the lung, obliteration of the blood-vessels, lobulation of the lung, and thickening of the pleura. The gross appearance of the lungs will accordingly vary in different cases. 112 SYPHILITIC PNEUMONIA. 1. There is an interstitial inflammation beginning at the root of the lung around the large bronchi and blood-vessels. This causes stenosis of the bronchi, consolidation of the lung, or masses of fibrous tissue along the lines of the bronchi. The cases vary as to whether the stenosis of the bronchi or the con- solidation of the lung is the principal feature. 2. The inflammation follows the type of a broncho-pneu- monia, with thickening of the walls of the bronchi and small zones of peri-bronchitic pneumonia. 3. There are large or small irregular masses, or bands, of dense fibrous tissue in any part of the lung. These replace the lung tissue, and in them may be cavities formed by the dilatation of the bronchi. 4. With the interstitial pneumonia there may be associated the formation of gummy tumors, or an obliterating endarteritis with areas of necrosis. 5. With more or less interstitial pneumonia at the roots of the lungs there is a syphilitic inflammation of the walls of the large bronchi, the trachea, and the larynx. These walls are thickened in some places, ulcerated in others, so that in some places there is stenosis, in others dilatation. 6. We also occasionally meet with pneumonia of the anatom- ical type of ordinary lobar or broncho-pneumonia. But the clinical history although acute is irregular, and it is probable, although not at all certain, that they are caused or modified by the syphilitic poison. Symptoms. — Syphilitic pneumonia is one of the later manifes- tations of syphilis, in most of the cases coming on several years after the initial lesion. A great many of the patients have other syphilitic lesions, a fact of much assistance in making a diag- nosis which is always difficult. Of the pulmonary symptoms perhaps the most constant is dyspnoea. This is like any dyspnoea due to narrowing of the trachea or large bronchi. First a dyspnoea on exertion, then a constant dyspnoea made worse by the least bodily or mental ex- ertion, and becoming more and more distressing up to the time of the patient's death. Cough is present at some time in most of the cases, a dry cough, a laryngeal cough, or a cough with mucus or muco-puru- lent expectoration. Small haemoptyses occur from time to time in some cases. SYPHILITIC PNEUMONIA. II 3 Pain referred to some part of the chest is present in some cases, absent in others. A febrile movement seems to be the exception rather than the rule. If a syphilitic laryngitis exists the symptoms belonging to this will be added to those of the pneumonia. The physical signs vary with the exact condition of the lungs and are often obscure. They depend upon the pleurisy, the bronchitis, the stenosis or dilatation of the bronchi, and the con- solidation of the lung. So in the different cases we may get tubular breathing over one or both lungs, absence of breathing over one lung or part of a lung, subcrepitant, coarse, or gurgling rales, usually local- ized, dulness on percussion, and increase in vocal resonance ac- cording to the extent of the consolidation. The fact that the inflammation involves the roots of the lungs rather than their apices causes the physical signs to be heard largely over the central portions of the lungs, while in tubercular inflammations of the lungs it is over the upper lobes that the physical signs are usually heard. The symptoms continue for weeks or months, the patients gradually lose flesh and strength, and finally die from the inter- ference with breathing or worn out with the disease. The Diagnosis is apt to be difficult. The symptoms resemble those of chronic tuberculosis, of aneurism of the aorta, of intra- thoracic tumors, and of actinomycosis of the lung. We are very dependent upon the history of the patient and the presence of other syphilitic lesions. Treatment — -It is natural in these patients to adopt an energetic treatment with mercury and the iodide of potash, although the rule seems to be that the disease is fatal. Gangrene of the Lung. Definition. — Death accompanied by putrefaction of a portion of the lung. Etiology. — Whenever the vitality of a portion of the lung is im- paired and at the same time the bacteria of putrefaction are pres- .ent, there may be gangrene. It is found, therefore, with lobar pneumonia, haemorrhagic infarctions, compression or embolism of the pulmonary or bronchial vessels, wounds of the lung^ con- 114 GANGRENE OF THE LUNG. tusions of tlie chest, cavities in the lung, foreign bodies in the bronchi, cancer of the oesophagus, and in persons whose health has been enfeebled by disease or privation. But it also occurs without discoverable cause in persons who have been in good health. Morbid Anatomy. — Gangrene of the lung is either circum- scribed or diffuse. Circumscribed gangrene occurs in the form of one or more foci of small size where tlie lung is of blackish or greenish color, soft, or broken down into ragged cavities. These foci have a most offensive odor. Tlie lung around them is inflamed and the air-spaces contain epithelium, fibrin, and pus. Such gangrenous foci when once formed may increase in size ; as they do so the adjoining veins may become filled with infectious thrombi, or eroded. From tlie thrombi infectious emboli can be carried into the circulation and set up inflammatory foci in different parts of the body. From the eroded vessels there are considerable haem- orrhages. If the spot of gangrene is near the pleura it may set up either a simple or a gangrenous pleurisy. Or the pulmonary pleura may be perforated and pyopneumothorax result. In- tense bronchitis, either catarrhal or croupous, may be excited by the irritation of the gangrenous matter. If the patients recover the gangrenous portion of lung is entirely removed, a cavity is formed of which the walls are changed into connective tissue. Such a cavity may remain for a long time, or it may become con- tracted. Diffuse gangrene may be secondary to the circumscribed form, or it may be diffuse from the first. The greater portion of a lobe, a whole lobe, or even a whole lung, may be involved. The por- tion of lung involved is changed into a soft, foul-smelling, black- ish or greenish mass. Symptoms. — The patients have a cough with more or less fetid expectoration and a fetid breath. There is much variety as to the quantity of the expectoration, it may be scanty or abundant. When it is abundant and is allowed to stand for a time in a glass dish it separates into three layers: The upper, frothy, opaque, and of a dirty gray or yellowish color; the middle, clear and watery ; the lower, greenisli and purulent, or mixed witli blood. It consists of serum, mucus, pus, and shreds of lung tissue. There may be, however, only a very fetid breath without any ex- pectoration. If the pulmonary vessels are eroded large quantities of blood are coughed up. ASTHMA. 115 The patients have an irregular fever, they lose flesh and strength and pass into the septic condition. But some of the pa- tients, who apparently have gangrene of the lung and recover, are not at any time so sick as one would expect. The physical signs are sometimes obscure, sometimes well marked. They are most commonly found over the middle of the chest behind. At this point we mwy get dulness or flatness on percussion ; absence of breathing, bronchial breathing, or cavern- ous breathing; exaggerated or bronchial voice, and coarse rales. If the pleura is inflamed or perforated, producing pneumo- thorax, the symptoms belonging to these conditions are added. The diagnosis is often difficult. It may be evident that the patient has a serious disease and yet impossible for some time to determine its character. Even when it is certain that there is a pulmonary lesion we cannot always tell whether this is gangrene, abscess, or fetid bronchitis. The Prognosis is always serious, but recovery is by no means impossible. Treatment. — Besides the employment of such measures as add to the comfort of the patients and contribute to their nutrition, it is customary to give creosote or carbolic acid either by inha- lation or by the mouth. Perhaps the simplest plan is to use a Robinson's inhaler moistened with equal parts of creosote, alco- hol, and chloroform. In a moderate number of cases gangrenous cavities in the lungs have been opened and drained. Asthma. Definition. — An affection characterized by paroxysmal dysp- noea, recurring at intervals, generally in the night, the dyspnoea due to a contraction of the bronchi. The same name of asthma is also frequently employed to designate the paroxysmal dvspnoea caused by disease of the heart, and by contraction of the arteries. Etiology. — Bronchial asthma occurs most frequently in per- sons who have pulmonary emphysema, but it is by no means rare in persons whose lungs are normal except for the condition of the bronchi. The causes which produce an attack of asthma may act directly on the mucous membrane of the bronchi, or indirectly Il6 ASTHMA. on the bronchi tlirough the blood, or the nervous system. So we find some persons who never have an attack of asthma except when exposed to a directly exciting cause ; while other persons have constantly recurring attacks for long periods of time with- out any direct cause for each attack. Among the direct causes we reckon bronchitis, inflammations, and obstructions of the nose, climatic influences, dust, vegeta- ble irritants, chemical vapors, and animal emanations. The ordinary dust floating in the air, the odor or pollen of many plants and grasses ; the vapors of pitch, sulphur, or phos- phorus ; the peculiar smell of dogs, cats, or horses are familiar examples of direct causes. The efifect of climate in causing asthma is very marked in some persons. This effect does not follow any definite law, but only the idiosyncrasy of the individual. It does not matter whether the locality is warm or cold, wet or dry, low or elevated. For nearly ever}-^ asthmatic person we can find some one place where he will have little or no asthma. Of all the causes of asthma, however, bronchitis is the most frequent. In the patients who belong to this class the bronchitis constitutes the important part of the case, for if the attacks of bronchitis can be prevented there is no more asthma. Of late years much attention has been called to diseases of the nasal passages as a cause of asthma. I think there is no question that they do constitute one of the causes. But it is go- ing a great deal too far to say that they are the only cause. Among the indirect causes of asthma we enumerate mental emotions, indigestion, hysteria, gout, heredity, and some of the skin diseases. But it must be confessed that we are often unable to say why a previously healthy person should at some particular time, without any exciting cause, begin to have attacks of asthma. Morbid Anatomy. — As asthma is a functional disease it has no lesions. But in the bodies of old asthmatics we commonly find the morbid changes belonging to pulmonary emphysema and bronchitis. Symptoms. — -A paroxysm of asthma begins with a feeling of oppression or suffocation about the upper part of the chest which obliges the patient to sit up in order to breatlie. Tlie feeling of suffocation continues, and the patients bring into play all the muscles of respiration in order to satisfy the hunger for air. The skin becomes livid, the pulse feeble^ and the patient's face shows ASTHMA. 117 his suffering. If we listen to the cliest, we henr over both lungs the sibilant and sonorous breathing caused by the contraction of the bronchi. Such an attack lasts for hours or days. During the most severe attack the patients look as if they might die at any minute, but yet after a time the attack always subsides. As attacks of asthma are due to a variety of causes, so they present themselves to us under a variety of clinical aspects. 1. There are the persons who never have astlima unless they have an attack of acute bronchitis. In such persons we liave to look at the bronchitis as the real disease, while the asthma is only a complication. 2. There are the persons who only have asthma at certain times of year and in certain localities, the attacks being caused by the inhalation of the pollen or odor of plants. These persons are said to suffer from "hay fever," "rose cold," "autumnal catarrh," etc. 3. There are persons in whom the asthma only constitutes one of the symptoms of pulmonary emphysema. These cases Avill be described with emphvsema. 4. There are other cases in which the asthma occurs by itself as a pure neurosis. In these persons the disease is apt to be very tenacious, the paroxysms recurring again and again even after considerable intervals of improvement. In the more severe cases the bronchi are somewhat contracted and the breathing labored nearly all the time, while tlie spasmodic dyspnoea recurs at reg- ular intervals. The patients become worn out by the constant dyspnoea, the face is one of suffering, the chest is bent forward and stooping, the nutrition is impaired, the whole condition is one of chronic invalidism, but yet life is prolonged and death is usually due to some other disease. Treatment. — The objects of treatment are : to cut short the attacks of asthma, and to prevent the recurrence of subsequent attacks. To cut short an attack of spasmodic asthma we employ sucii means as will relax the spasmodic contraction of the walls of the bronchi. Tliis can be done in a variety of ways : inhalation of the fumes of stramonium, nitrate of potash, chloroform, ether, or the nitrite of amyl ; hypodermic injections of morphine, or chloral hydrate given by the mouth or the rectum ; the use of the drugs which increase the production of mucus from the bron- chi, such as lobelia and grindelia robusta. Il8 HAEMOPTYSIS. To prevent the recurrence of the attacks we examine into the condition of the nasal passages to see whether there is disease there which may cause the asthma. We inquire into the liistory to determine whether the asthma is not caused by bronchitis, or by the pollen or odor of plants. If the astlima is a pure neurosis a considerable number of patients can find a climate in which they cease to suffer. But the selection of this climate has to be made experimentally by each patient. There is no rule to guide us. Each person has to travel from place to place until they find the particular spot where they cease to have asthma. For the patients who cannot travel the most efficient treat- ment seems to be the long-continued administration of the iodide of potash, the systematic inhalation of compressed air, attention to the feeding, disorders of digestion, and to any conditions which impair the general health. HEMOPTYSIS. Blood which is coughed up comes for the most part from the bronchi ; less frequently from the pharynx, from eroded vessels in the walls of cavities, or from aneurisms of the pulmonary artery or of the aorta. Haemoptyses occur so frequently with the tubercular inflam- mations of the lungs and so much less frequently with other morbid conditions, that any haemoptysis is regarded with a good deal of suspicion. In tubercular inflammations of the lungs the bleeding is from the mucous membrane of the bronchi. The quantity of blood coughed up may be large or small. The bleeding may last only a few minutes, or continue a number of days. The same patient may have only a single haemoptysis, or several. There seems to be no period in the course of tubercular inflammation of the lungs which is exempt from the liability to bleeding from the mucous membrane of the bronchi. Especially is it to be re- membered that either large or small haemoptyses may precede bv a considerable interval of time any rational symptoms oi physical signs of pulmonary disease. In the older cases of pulmonary tuberculosis in which cavities have been formed, the vessels in the walls of these cavities ma} be eroded, with an escape of blood which is large and dangerous H/EMOPTYSIS. 119 The very frequency of the association of haemoptysis with pulmonary tuberculosis makes it important to enumerate the other conditions under which haemoptysis may occur. Tlie fol- lowing are the forms of haemoptysis wliich occiu- without pul- monary tuberculosis : 1. A person has an attack of haemoptysis only lasting for a short time, but during which he raises a considerable quantity of blood. He has no other attacks and does not develop any pul- monary lesions. The bleeding may follow severe muscular ex- ertion, great mental excitenient, or occur without discoverable cause. 2. In women haemoptysis may take the place of menstruation. Flint says that lie lias seen haemoptysis occurring at regular in- tervals for four years after the suspension of the menses. But these cases must be looked on with suspicion. A woman may cough up blood on several occasions instead of menstruating and then go on to have lung disease. 3. Chronic naso-pharyngeal catarrh is sometimes attended with occasional small haemoptyses. 4. Tliere are a set of women who are hysterical, anaemic, al- ways suffering from some real or fancied ailment, who from time to time cough up a little blood. 5. It is said that pregnant and nursing women sometimes have haemoptysis. 6. With disease of the aortic and mitral valves, especially with mitral stenosis, bleeding from the bronchi is of frequent occur- rence. In the course of the heart disease tlie patients from time to time, during periods of several days, cough up clear blood in considerable quantities. 7. Aneurisms of the branches of the pulmonary artery within the lungs, when they rupture, cause fatal hemorrhage, a large part of the blood being coughed up. Aneurisms of the arch of the aorta which erode the trachea or main bronchi may rupture into the trachea or bronchi by small or large openings. With the small openings the patients cough up a little blood from time to time, while part of the escaped blood is inspired into the lungs and sets up a peculiar form of pneu- monia. With the large openings the blood escapes through the trachea in enormous quantities, and the patients bleed to death within a few minutes. 8. Patients wlio suffer from emphysema and chronic bron- I20 HEMOPTYSIS. chitis not infrequently from time to time cough up small quan- tities of blood. Much less often such patients have at some time a large bleeding from the bronchi. Part of this blood is coughed up at once, part is coagulated in the large bronchi and is after- ward coughed up in the form of casts of these tubes. 9. Sir Andrew Clark [Lancet, 1889, p. 841) describes a form of bleeding which he calls "arthritic haemoptysis," of which he says that he has seen some twenty cases. He lays down the following propositions : There occurs in elderly persons, free from ordinary diseases of the heart and lungs, a form of haemoptysis arising out of minute structural alterations in the terminal blood-vessels of the lung. These vascular alterations occur in persons of the arthritic diathesis, resemble the vascular alterations found in osteo-ar- thritic articulations, and are themselves of an arthritic nature. Although sometimes leading to a fatal issue, this variety of haemoptysis usually subsides without the supervention of any coarse anatomical lesion of either the heart or the lungs. This variety of hemorrhage is aggravated or maintained by the frequent administration of large doses of strong astringents, and by an unrestricted indulgence in liquids to allay the thirst which the liquids themselves create. The treatment which appears to be the most successful in this variety of haemoptysis consists in diet and quiet, in the restricted use of liquids, and the stilling of cough ; in calomel and salines, in the use of alkalies, with iodide of potassium, and in frequently renewed counter-irritation. ID. Dr. Flint ("Practice of Medicine," p. 265) says that he has met with a few cases of persistent bronchial hemorrhage. In two of these cases, after expectoration daily more or less of a sero- sanguinolent liquid during several months, recovery took place under the use of tonics and hygienic measures. In the third case the hemorrhagic expectoration continued for six years, dur- ing which time repeated examinations of the chest failed to dis- cover any positive signs of pulmonary disease. II. Severe injuries inflicted upon the wall of the thorax may be followed by the expectoration of blood for hours, or days. Treatment. — In managing cases of bleeding from the mucous mem'^rane of the bronchi it is important to bear in mind that even tlie most profuse hemorrhages are seldom fatal. The methods of treatment commonly employed are : the appli- H.1iM0PTYSIS. 121 cation of cold to the chest, the temporary ligation of one of the arms or legs, the internal use of opium, ergot, hydrastis, kramaria, tannic acid, gallic acid, acetate of lead, persulphate or pernitrate of iron, or of calomel or of the saline cathartics. It is also custo- mary to keep the patients very quiet while the bleeding is going on. I doubt if it be wise to be too anxious and energetic in the treatment of bleeding from the mucous membrane of the bronchi. The bleeding will regularly stop, no matter what is done. The frequent use of astringents disorders the stomach, the insistence of absolute quiet demoralizes the patient, the keeping the patients on a low diet unnecessarily reduces their strength. EMPHYSEMA. Interlobular Emphysema. Definition. — An accumulation of air in the connective tissue septa between the lobules of the lung. Etiology. — Interlobular emphysema is, I think, most fre- quently seen with the broncho-pneumonia of young children. It may be caused by any violent efforts which require the abrupt introduction of a large quantity of air into the lungs, and its forcible retention therein by closure of the glottis. The efforts in parturition, defecation, raising weights, coughing, paroxysms of rage, excessive laughter, and hysterical convulsions have all been occasionally followed by rupture of the air-cells and inter- lobular emphysema. Morbid Anatomy. — We find after death the interlobular septa infiltrated with air, with more or less compression of the paren- chyma of the lung. The air may find its way from the lung into the mediastinum and thence into the connective tissue of the neck and the wall of the thorax. Symptoms. — There seem to be no distinctive rational or physi- cal symptoms belonging to interlobular emphysema. But in extreme cases it is said to have caused sudden death. Vesicular Emphysema. It is customary to speak of three forms of vesicular emphy- sema : Compensating emphysema, senile emphysema, and sub- stantive emphysema. I. Compensating Emphysema. — If one lung, or a part of one lung, is so changed by disease that it can only partially perform its functions, the other lung becomes increased in size and its air- spaces are dilated. This change in the lung is a healthy, rather than a morbid one, and gives no symptoms of disease. EMPHYSEMA. 123 2. Senile Emphysema. — This condition is often described as something different from substantive emphysema. It is said that, instead of there being an abnormal accumulation of air in the lungs, these organs are smaller and contain less air than normal. In consequence of atrophy of the alveolar walls the air-cells coalesce and form larger air-spaces. These, however, do not re- sult from a dilatation of the alveoli, but from a gradual shrinkage and disappearance of the lung tissue. I must confess that such descriptions of senile emphysema do not correspond with the lungs which I have seen. I believe that the anatomical conditions are the same in senile as in substantive emphysema, although the causation and clinical history are different. 3. Substantive Emphysema. — The definition of substantive emphysema usually given is that it is a morbid condition of the lungs, characterized by enlarged capacity of the air-cells, with atrophy of their walls, and obliteration of their capillaries. I should define the disease, on the contrary, as a chronic interstitial inflammation of the lungs, with which more or less dilatation of the air-spaces is associated. Etiology. — Laennec, who was the first to describe this lesion, gives the causation of emphysema as follows : chronic catarrh, plugging by mucus of small bronchi, consequent obstruction to the passage of air, conveyance by inspiration of air past the ob- struction, failure of expiration to expel this air, accumulation of air in the air-spaces, dilatation of the air-spaces — the foundation of the disease, therefore, is bronchitis. Louis denies this mechanism, because the symptoms of dilated air-cells are not preceded by catarrh, because habitual dyspnoea does not undergo permanent increase after acute catarrh, and be- cause normal inspiration is not more powerful than expiration. Dr. Williams maintains the catarrhal basis of Laennec, but supposes that while the air-cells communicating with plugged bronchi escape distention, those adjoining, and possessed of free communication with the trachea, dilate in consequence of the extra work and pressure thrown upon them. Walshe says : The vesicular dilatation may be a primary or a secondary phenomenon ; that is, it may occur independently of any acknowledged form of statical change within the chest, or it may supervene on some actual organic mischief. The dilatation may be the resultant of primary nutritive changes in the actual 124 EMPHYSEMA. walls of the enlarged vesicles, affecting both their statical and dynamic properties. Or these cells, being in their own nature healthy, may dilate through the extra strain thrown on them in consequence of the inaction of neighboring portions of lung. It is frequently stated that playing on wind instruments or glass-blowing causes emphysema. If, on the other hand, we believe that emphysema is a chronic interstitial inflammation of the lung, and that the dilatation of the air-spaces is not the primary or essential part of the morbid process, then we class emphysema with chronic endocarditis, en- darteritis, and nephritis, and ascribe it to the same cause. It is generally agreed that the disease is of more common occurrence in some families than in others. The tradition has been handed down from one text-book to another that persons who have emphysema are less liable than are others to have tuberculosis of the lungs, or lobar pneumonia. This tradition seems to have no foundation in fact, tuberculosis and emphysema of the lung are frequently associated. Morbid Anatomy. — Both lungs are regularly increased in size. The dilatation of the air-spaces may be so great as to be evident to the naked eye, or so moderate as not to be appreciable. When we examine minutely the lungs of a large number of persons who have, during life, suffered from the symptoms of emphysema, we find a very great variety. In some both the air-passages and air- vesicles are largely dilated ; in some the air-passages alone are dilated, the air-vesicles remaining of normal size ; in some neither the air-passages nor vesicles are appreciably dilated. We find also when we compare the lungs with the clinical histories which belong to them, that the most marked symptoms are often asso- ciated with very slight degrees of dilatation of the air-spaces, and it is evident that the severity of an emphysema is not to be meas- ured by the degree of dilatation of the air-spaces. The walls of the air-spaces are thickened in some parts of the lung, thinned in others. The epithelial cells which line the walls of the air-spaces are often increased in size and number. In the walls of the air-spaces are holes with sharp-cut edges. These holes are formed in the spaces between the capillaries, some are very minute, others are of large size. It is evident that these holes are not formed by the stretching of the air-spaces, for they are found in small air-spaces as well as in large ones. They con- stitute a curious and important part of the lesion. The septa EMPHYSEMA. 12$ between the lobules, the connective tissue around the bronchi and blood-vessels, and the pulmonary pleura are often consider- ably thickened. Very frequently there are adhesions between the pulmonary and costal pleura. The mucous membrane of the larger bronchi is often thickened. The blood-vessels of these lungs can be readily filled with an artificial injection. Neither arteries, capillaries, nor veins are obstructed or obliterated. But in the walls of dilated air-spaces, and in the walls of those in which there are holes the meshes of the capillary plexus are larger and the capillaries are farther apart from each other. During life, however, in some cases of emphysema there is an obstruction to the passage of blood through the lungs, and consequently dilatation and hypertrophy of the right ventricle of the heart and venous congestion of the pia mater, stomach, small intestine, liver, spleen, and kidneys. These evidences of venous congestion often exist in cases in which the air-spaces are but very little dilated. It is not often that we see a case of advanced emphysema after death without finding at the same time chronic endarteritis, endocarditis, or nephritis. Symiptoyns. — Physical Signs. In the lesser degrees of emphy- sema there is no change in the shape of the thorax. In the more advanced cases there is a prominence of the upper part of the sternum and of the costal cartilages. In patients who have suffered much from dyspnoea the hypertrophy of the muscles which move the thorax contrasts with the general emaciation of the patients. In the cases in which there is great dilatation of the air-spaces the chest assumes the so-called barrel shape. The percussion sound may remain unchanged for a consider- able length of time. When it is changed the change is either to a rather dull note of wooden quality, or to exaggerated reso- nance of either vesicular, or vesiculo-tympanitic quality. The respiratory murmur is feeble ; or there is feeble inspira- tion with longer, louder, low-pitched expiration ; or both inspira- tion and expiration may be exaggerated, loud, and high-pitched. The pleuritic adhesions give more or less dulness on percus- sion. When the bronchi are contracted there is sibilant and sonorous breathing. Rational Symptoms. There are many persons in whom sub- stantive emphysema is developed and continues for many years 126 EMPHYSEMA. without giving rise to any symptoms, and yet, even in. sucli per- sons, it is often possible to be pretty sure of the presence of the disease, because they are persons whose general condition and age are such as are usually associated with emphysema. There are many persons in whom the associated chronic endocarditis or endarteritis, or nephritis, gives such marked symptoms that the emphysema passes unnoticed. In some persons tlie emphysema gives after a time dyspnoea on exertion, but without bronchitis, or disturbance of the gen- eral healtli. These are persons past middle age, who do not consider themselves invalids, who, on the contrar}', are often strong and robust, and in whom the emphysema is only an in- convenience. In some persons the principal symptoms are those belonging to the associated acute and chronic bronchitis. The attacks of acute bronchitis may be mild, lasting for a few days or a few weeks, with cough, mucous expectoration, sometimes haemopty- sis, asthmatic breathing, and a febrile movement. Or they may be severe and last for several months, with continued cough, asthmatic breathing, fever, venous congestion, dropsy, and loss of flesh and strength. The chronic bronchitis continues year after year, better every summer and worse every winter. The patients have a cough with mucous, or muco-purulent expectora- tion, sometimes with small haemoptyses. They are always a lit- tle sliort of breath when they exert themselves. After a time they have attacks of spasmodic asthma. In the unfavorable cases the dyspnoea on exertion becomes more constant and more decided, venous congestion and dropsy are established, and the patients lose flesh and strength. In some persons the prominent feature in the disease is the liability to attacks of spasmodic asthma, which often are fre- quently repeated and of long duration. These attacks are some- times due to contraction of the bronchi, and then we get sibilant and sonorous breathing ; or they are due to contraction of the arteries belonging to the aortic system and there is a radial pulse of increased tension ; or they are due to contraction of the branches of the pulmonary artery and then there is neither sibil- ant and sonorous breathing, nor a pulse of high tension. In some persons the principal symptom is the constant dysp- noea. The difficult breathing is at first only developed by exer- tion, later it becomes more constant and is made worse bv slight EMPHYSEMA. 12/ exertion, bv indigestion, and by broncliitis. Finully, in the bad cases, the dyspnoea is constant and distressing. Tlie patients constantly feel the need of air and are always overusing the muscles of respiration in order to satisfy this need. General venous congestion is gradually established as well as cyanosis of the skin, clubbing of the fingers, congestion of the stomach, small intestine, liver, and kidneys ; dilatation and liypertrophy of the right ventricle of the heart and general dropsy. The nu- trition of the patients suffers and they become emaciated, feeble, and anaemic. It is not easy to tell how much of this dyspnoea depends upon the anatomical changes in the lungs, how much upon contraction of the branches of the pulmonary artery, and how much upon contraction of the arteries belonging to the aortic system. There are rare and fatal cases in which there are no pulmonary symptoms. The patients lose flesli and strength and become aneemic without any evident cause for tlieir ill- health. After going on in this way for some time they begin to have attacks of contraction of the arteries with headache, sleep- lessness, delirium, stupor, muscular twitchings, and vomiting, or a dyspnoea like that seen in chronic nephritis. They die within a few months after they have begun to have the attacks of con- traction of the arteries. In some persons, after emphysema has existed for some time with more or less marked symptoms, chronic miliary tubercu- losis is slowly established. Emphysema by itself proves fatal only in a moderate num- ber of cases. Death is usually due to some complicating or intercurrent disease. Treatment.— "YX^Q conditions which call for treatment are : The morbid condition of the lung, the loss of nutrition, the bron- chitis, the constant dyspnoea and the spasmodic dyspnoea ; the contraction of the arteries, and the venous congestion. The emphysema is favorably affected by an out-of-door life in a suitable climate ; by abstinence from alcohol, tobacco, sugars, and starches ; by the use of fats and by overfeeding with the stomach-tube ; and by methodical inhalations of com- pressed air. All of these measure*; are also of service in improv- ing the nutrition of the patients and in helping them to get rid ")f chronic bronchitis. The constant dyspnoea is due to the changes in the lungs, and 5 then to be treated by the same means which are used to con- 128 THE LUNGS. trol the emphysema ; or it is due to the complicating contrac- tion of the arteries, and is then to be treated by the drugs which dilate the arteries — nitro- glycerine, potassium iodide, or chloral hydrate. The attacks of spasmodic dyspnoea are due to : (a) Spasmodic contraction of the muscular coat of the bron- chi. This can be relieved by the inhalation of the fumes of stra- monium, nitrate of potash, chloroform, or ether ; by the admin- istration of chloral hydrate, potassium iodide, belladonna, or opium. (d) Congestion of the walls of the bronchi. This can be re- lieved by drugs which increase the production of mucus, such as lobelia and grindelia robusta ; by drugs which stimulate the heart, such as caffeine, convallaria, and digitalis ; or by the ap- plication of dry cups to the walls of the chest, (c) Contraction of the small arteries. This can be relieved by the drugs which dilate the arteries, such as nitrite of amyl, nitro-glycerine, chloral hydrate, potassium iodide, or opium. (d) Inflammation of the nasal passages. This is to be treated by local applications. Actinomycosis of the Lung. The following account of actinomycosis of the lung is taken from a compilation of thirty-four cases made by Dr. Hodenpyl. My own experience is limited to two cases. Definition. — Pulmonary actinomycosis is a chronic infectious disease of the lungs dependent upon the presence of actino- myces. Etiology. — Information concerning the characters and causa- tion of actinomycosis in general are given in the article on that disease. So far as the lungs are concerned the living germ seems to be inhaled into the bronchi. The majority of the cases were in young adults ; the youngest patient was nine years old, the oldest sixty-three. Morbid Anatomy. — The lesions are unilateral in about the pro- portion of three to one. They may be classified into two groups. I. There are cases with the symptoms of chronic general bronchitis with the germ present in the sputum, but in which no autopsy is made. Whether in these cases there is no lesion but that of chronic bronchitis we cannot certainly tell. THE LUNGS. 1 29 2. There is a broncho-pneumonia of a peculiar type, which involves part of a lobe, or an entire lung. The large bronchi are coated with muco-pus. The small bronchi contain pus, their walls are thickened, they are surrounded by zones of peri-bron- chitic pneumonia. In some of the small bronchi there are growths of new connective tissue partly filling them. In the peri-bronchitic zones of pneumonia the walls of the air-spaces are thickened and their cavities filled with new connective tissue. Between these zones is a diffuse hepatization of ordinary exuda- tive type. There are adhesions between the pulmonary and costal pleura. There are often, in addition, sacculated collections of pus in the pleural cavity, which may perforate through the skin, or through the diaphragm. The ribs, sternum, or vertebrae may be eroded. The opposite lung, the pericardium, or the heart may become involved. There may be secondary inflammations of the abdominal organs, or of the brain. In one case the in- flammation penetrated the portal vein and there were metastases all over the body. Sytnptoins. — A febrile movement is present in nearly all the cases. Usually it is one of the first symptoms, but sometimes it does not come on until later in the course of the disease. Cough is regularly the first symptom, and continues through- out the disease. It is accompanied with an abundant muco- purulent, often fetid, expectoration, and sometimes contains actinomyces. Haemoptyses were not observed, although the sputa were sometimes stained with blood. The patients lose flesh and strength, at first slowly, later, as abscesses are formed and septic poisoning established, they run down more rap- idly. The physical signs are those of bronchitis, of broncho-pneu- monia, of phthisis, or of empyema. The average duration of the disease is ten months ; the short- est case lasted four months, and the longest was still living after a duration of several years. Of the thirty-four cases all died except two. Diagnosis. — The disease is liable to be confounded with fetid bronchitis, gangrene of the lung, broncho-pneumonia, or pul- monary phthisis. The only positive diagnostic symptom seems to be the presence of the actinomyces in the sputa or in the pus from the pleura. .,::,, 130 THE LUNGS. Treatment. — There seems to be no way of directly improving" this disease of the lunes. Malignant Growths in the Lungs. We include under this head the primary and secondary tumors formed in the lungs which belong to the classes of carcinoma, sarcoma, and lymphoma. Morbid Anatomy. — The carcinomata of the lung are either sec- ondary or primary. The secondary tumors follow the anatomical type of the primary tumor. The primary tumors consist of a stroma enclosing spaces lined with cylindrical epithelium, the growth apparently beginning in tlie small bronchi. Whether the tumors are primarv or secondary we find that they may be de- veloped in such a way as to compress the bronchi, or be asso- ciated with exudative and productive inflammation in such a way as to consolidate large portions of the lung ; or be associated with suppurative and destructive inflammation in such a way that ab- scesses are formed ; or involve the pleura so that large collections of serum are formed in the pleural cavities. The sarcomata of the lung are secondary tumors. Tliey usu- ally are in the form of nodules scattered through the lung, or of tumors which compress the bronchi, or of tumors in the pleura with serum in the pleural cavities. The lymphomata begin in the bronchial glands and infiltrate the lungs from the root outward, following the track of the bronchi or of the interlobular septa. Symptoms. — While in some cases the symptoms are obscure, in others they are well defined. They are apt to follow one of three types : 1. The most marked symptom is dyspnoea due to pressure on the bronclii. The dyspnoea is developed slowly and is brought on by exertion. It becomes more and more distressing until finally the patient can hardly move at all without bringing on the bad breathing. The physical signs are either tubular breathing, or diminished breathing over the lung corresponding to the compressed bronchi. The patients lose flesh and strength, at first slowly, later very rapidly. 2. The symptoms are those of a chronic inflammation of the lung. The patients have cough, dyspnoea, muco-purulent or THE LUNGS. 131 bloody expectoration, a febrile movement, pains in the chest, the physical signs of bronchitis and of consolidation of the lung, and gradual loss of flesh and strength. 3. The symptoms are those of a pleurisy with effusion, but it is a pleurisy which does not improve under treatment. The serum is apt to be blood stained, but is not always so, it reaccumulates after it has been drawn off, the patients steadilv lose flesh and strength, or there may be a combination of the signs of consoli- dation of tlie lung with that of fluid in the pleura. THE HEART. In examining any person who is suspected of having a dis- ease of tlie heart we follow a certain routine in the physical examination. We determine the size of the heart, the character of its impulse, the rhythm of its contractions and dilatations, the character of the heart-sounds, and tlie presence or absence of murmurs. The size of tlie heart is made out by simple, or by ausculta- tory percussion, and by locating the apex-beat. We determine the upper, the left, and tlie right edges, and the apex-beat. The upper border of the heart should be at the third left cos- tal cartilage. Tiie left border is at the left nipple. The right border is one inch to the right of the sternum. The apex-beat is in the fifth interspace, midway between the left edge of the sternum and the nipple, three and one-fourth inches from the middle of the sternum. A small portion of the anterior surface of the pericardium, usually corresponding to the fourth left interspace and the fifth left cartilage, is uncovered by the lungs, and gives more decided dulness on percussion than the rest of the precordial area. It is comparatively easy in this way to make out any increase in the size of the heart, but a diminution in its size is much more difficult to determine. The apex-beat can usually be felt by the hand, but in many healthy persons does not communicate a perceptible shock to the chest-wall. Its position must then be determined by the stethoscope. The force of the impulse is temporarily increased by muscular exertion, by rapid respiration, by digestion, and by mental emotions. It is decreased by any disease which impairs nutrition. Myocarditis, degeneration of the wall of the heart, an excess of fat about the heart, and fluid in the pericardial sac diminish 134 THE HEART. the force of the impulse. There are often cases of abnormally feeble impulse for which it is diflficult to account. The force of the impulse is increased in some of the cardiac neuroses, with hypertrophy of the ventricles, with contraction of the arteries, and with some of the acute inflammations of the pericardium and endocardium. Dilatation of the ventricles changes the character of the im- pulse ; instead of a circumscribed apex-beat there is a diffuse, heaving impulse over the whole precordial region. The rhythm of the alternate contractions and dilatations of the heart should be perfectly regular. In some healthy persons, however, there is a regular intermission of the ventricular sys- tole. The same thing may occur in the tubercular meningitis of children. In some persons the heart-sounds are reduplicated ; either the systolic, or the diastolic sound, or both, may be redu- plicated ; this is said to be due to a want of synchronism between the action of the two sides of the heart. The heart's action becomes irregular with valvular disease, dilatation and hypertrophy of the ventricles, fatty degeneration of the wall of the heart, myocarditis, pericarditis, and the cardiac neuroses. The Normal Heart-sounds. — -The contraction and dilatation of the cavities of the heart are accompanied with certain sounds. The first sound is synchronous with the systole of the ventricles, the apex-beat, and the closure of the auriculo-ventricular valves ; it is loudest at the apex. After the first sound is a short interval of silence, the post-systolic silence. The second sound is syn- chronous with the closure of the aorta and pulmonary valves ; it is most distinct over the third cartilage and the middle of the sternum. After the second sound is another interval of silence, the post-diastolic silence. If the period of an entire revolution of the heart from the beginning of one first sound to the begin- ning of the next first sound be divided into ten equal parts, the duration of the several periods of sound and silence will be as follows: First sound, 4; first silence, i ; second sound, 2 ; second silence, 3. When we listen to the heart-sounds we notice the loudness, the distinctness, and the quality. Murmurs are pericardial or endocardial. Pericardial murmurs are produced by the rubbing of opposed surfaces of the pericardium coated with fibrin or with adhesions. THE HEART. 135 The sound may be of a rubbing, grating, creaking, squeaking, or whistling character ; or it maybe soft and blowing like an endo- cardial murmur. The sound may be very loud, or so faint as to be hardly audible. Such murmurs are heard with the first or second sounds, or with both : less frequently they are pre-sys- tolic ; but they are not always exactly synchronous with the heart-sounds. There is no fixed point of intensity for pericardial murmurs, but they are most frequently heard over the base. Usually the sound seems to be superficial. Such murmurs are distinguished from endocardial murmurs by their quality, their superficial character, their limitation to a small area, their changeableness in position and intensity from hour to hour, their greater inten- sity when the patient leans forward or fills the lung, their greater intensity if we press on the chest-wall, their want of synchronism with the heart-sounds. But in some cases it is hardly possible to distinguish between pericardial and endocardial murmurs. Endocardial murmurs are produced by : (a) Change in the valves, by which they are rendered rough, stenosed, or insufficient. ((^) Ventricular lesions. Inflammation of the endocardium or of tlie chordae tendinse, abnormal tendinous cords extending across the ventricles, or thrombi in the ventricles. Ventricular murmurs are systolic, their point of maximum intensity is at the apex ; they are not transmitted. (id heart action, a cold skin, and sometimes marked prostration. Finally it vomits the food in nearly the same con- dition as when it was taken into the stomach, and is at once re- lieved of all symptoms. The same thing can be seen in adults. A large meal is eaten, little or no gastric digestion takes place, the pylorus remains closed, the stomach is distended with undigested food. After a number of hours the patient has the feeling of vertigo or of faint- ness, or he may fall to the ground unconscious. Then there is a profuse vomiting of the contents of the stomach. In adults habitual over-eating may cause chronic gastritis and dilatation of the stomach, but it is much more apt to cause symp- toms referable to disturbances of the functions of the liver — feel- ings of lassitude and depression, headache, constipation, diarrhoea, flatulence, an excess of urates in the urine. The habitual eating of improper food results in an impair- ment of nutrition, for not only is the improper food bad in itself, but it takes the place of wholesome food. The treatment of these cases consists in a regulation of the THE STOMACH. 1/5 diet. In the bad cases the patients must be put for a time on the exclusive use of milic, or of scraped beef, but neither of tiiese exclusive diets can be continued uitli advantage for any great length of time. The use of all sorts of heakli-foods, peptonized foods, pepsin and pancreatine, is to be avoided. The patients must be educated to eat meat, starches, fats, vegetables, and fruits in proper quantities. In doing this the use of the stomach- tube, about four hours after one of the meals, is of much service as a guide to the particular articles of food which are best di- gested and remain the shortest time in the stomach. 2. Changes in the gastric juice. The two most marked changes in the gastric juices are : such a change in its composition as renders it unable to perform stomach digestion, or increased quantity and hyperacidity. (a) Changes in the composition of the gastric juice of such a character that stomach digestion is imperfectly performed. This condition is seen in persons who have had chronic gas- tritis for a long time, with changes in the glandular coat of the stomach. It is also seen in young persons in whom there is no evidence of disease of the glandular coat. The patients have no appetite, or even a distaste for food. In some there is occasional nausea, vomiting, and pain after eating. Tlie bowels are usually constipated. The nutrition suffers not:iceably, the patients lose flesh and strength. Besides the gastric symptoms there are often a variety of accessory symp- toms of nervous and hysterical character. It is not uncommon to find persons belonging to this class who do not complain of any gastric symptoms, but only of the loss of nutrition and some disturbance of sensation. On the other hand we must not confound with this class the persons who complain of gastric pain and oppression, loss of ap- petite and nausea, but in whom gastric digestion is well per- formed. The diagnosis is made with the help of the stomach-tube. There will be found a considerable number of persons in whom more or less partly digested food is always present in the stomach. The problem in these persons is to improve gastric di- gestion. It would seem as if this could be done by the use of pepsin, or hydrochloric acid, or partly digested foods, but it will be found that no permanent improvement can be effected in this way. There is no one rule for the management of all these 17^ THE STOMACH. patients, but the general plan is to improve the general health by massage, baths, exercise, and travel, and to feed the patients as well as can be done. The method of feeding has to be found out for each person with the stomach-tube. We try the simple articles of food — milk, eggs, kumyss, meat, beef-juice, gruels, etc. — and see which ones leave the cleanest stomach in the short- est time. In this way we get a guide as to the best kind of food and the proper intervals between taking food. As the patients improve we gradually add other kinds of food. It requires a number of months to get these persons back to a natural condi- tion of health. {l>) The gastric juice may contain an excessive quantity of hydrochloric acid, and be itself produced in too large quantities. The most marked symptoms of this condition are epigastric pains and vomiting. To determine this condition accurately the stomach should be washed out in the evening and its contents aspirated the next morning before the ingestion of food or fluid. The milder cases are benefited by the use of alkalies, but the only satisfactory treatment is the systematic washing out of the stomach. Temporary insufficiency of the gastric juice may be caused by a variety of nervous and mental conditions. 3. The muscular coat of the stomach may cease to perform properly its function of moving and expelling the food. This condition is apt to be slowly developed, so that it is not until after several years that it becomes a serious evil. The insuffi- cient action of the muscular coat of the stomach allows food to remain in the stomach from one meal to another, so that the organ is never empty. This constant presence of food may event- ually cause chronic gastritis or dilatation of the stomach. The symptoms at first come on in attacks which last for several days ; between the attacks the patient is well. As time goes on the attacks become more frequent and of longer duration, and finally the symptoms are continuous. The principal symptom is pain of greater or less severity referred to the region of the stomach. To the pain are regularly added after a time constipation, nausea, vomiting, and finally loss of flesh and strength. During the earlier periods of their trouble the patients im- prove under an absolute diet of milk or of meat, but the only really satisfactory treatment is the washing out of the stomach, with a regulated diet. THE STOMACH. 1 77 4. Disorders of the colon — constipation, chronic inflamma- tion, or carcinoma — may be accompanied by gastric symptoms — pain, nausea, and vomiting. In elderly persons, whenever nau- sea and vomiting are present it is always necessary to think of an accumulation of faeces in the colon as the probable cause. 5. Diseases of the uterus, ovaries, and tubes are rather fre- quently accompanied by loss of appetite, nausea, and vomiting. These symptoms are continuous, or come on in attacks. There may really be chronic gastritis, or inefficient gastric juice, or retention of food in the stomach in addition. But it will be found that the treatment of the stomach is unsatisfactory unless the disease of the laterus, ovaries, or tubes, can first be cured. 6. In the simple anaemia of young women gastric symptoms are usually present, and in some of the patients are especially severe. Loss of appetite, nausea, and vomiting are often present, haematemesis is not rare. The gastric symptoms may be so marked as to make it easy to overlook the anaemia, but this error is readily avoided by the examination of the blood. In these anaemic patients the gastric symptoms promptly dis- appear with the cure of the anaemia. 7. Hysterical patients are capable of developing a great variety of gastric symptoms — loss of appetite, perverted appetite, distaste for food, nausea, vomiting, pain, and flatulence. As a rule these patients are best treated if we disregard the gastric symptoms and employ the regular management for hys- terical cases. 8. The habitual use of tobacco and of alcohol will, in some persons, even before chronic gastritis is produced, cause loss of appetite, nausea, and vomiting. 9. Neurasthenia. Of the patients w^ho suffer from the condi- tion of neurasthenia a considerable number have decided gastric symptoms. Generally speaking it is better not to pay too much attention to the stomach, but to rely on baths, massage, exercise, climate, etc. I see neurasthenics, however, who are entirely re- lieved by lavage of the stomach. This seems to be a simple faith cure. Gastralgia. Pain in the stomach accompanies an excessive production of hyperacid gastric juice, regurgitation of bile into the stomach, in- sufficient action of the muscular coat, diseases of the colon, anae- 178 THE STOMACH. mia, hysteria, acute gastritis, chronic gastritis, ulcer of the stomach and cancer of the stomach, and locomotor ataxia. It is closely simulated by the pain of intestinal colic, by the pain due to cal- culi in the gall-bladder and bile-ducts, and by ulcers of the duodenum. In some cases of movable kidney the patients complain of gastric pain, nausea, and vomiting. Whether, in addition, gastralgia occurs as a pure neurosis, it is difficult to say. Probably with greater accuracy in diagnosis the apparent number of such cases diminishes. In those cases in which we do have to make the diagnosis of gastralgia as an independent condition, the drugs which seem to be of ilie most service are arsenic or quinine. Acute Dilatation of the Stomach. This is a very rare condition. I copy the account of it from Quain's " Dictionary of Medicine." The earliest case on record is that of a lady mentioned in the fourth volume of the " Pathological Transactions," by Dr. Miller and Dr. Humby. She had been under treatment for piles shortly before her illness, and the abdomen had been observed to have increased in size. She was attacked with vomiting of immense quantities of fluid. The vomiting ceased four days afterward, and the abdomen was found to be greatly enlarged. After death the cause of the abdominal distention proved to be the stomach, which was so much dilated that it was capable of holding ten pints of liquid. Dr. H. Bennett, of Edinburgh, relates a similar case, and attributes the dilatation to a large quantity of efferves- cing liquid the patient had swallowed to allay his thirst. Dr. Hilton Fagge, in the "Guy's Hospital Reports" (vol. xviii., Third Series), describes two cases that had fallen under his notice, and also mentions that two similar cases had been ob- served at Guy's Hospital during fourteen years. Diagnosis. — The signs of the dilatation, according to Dr. Fagge, are : i. A rapidly increasing distention of the abdomen, which is unsymmetrical, the left hypochondrium being full, while the right hypochondrium is comparatively flattened. 2. Tlie exist- ence of a surface-marking descending obliquely toward the umbilicus from the left hypochondrium, and corresponding with the dragged-down lesser curvature of the stomach, this line ap- THE STOMACH. 1 79 pearing to descend with each inspiration. 3. Tlic presence of fluctuation in the lower part of the abdomen. 4. The occurrence of splasliing wlien the distended part of the abdomen is manipu- lated. 5. The presence of a uniformly tympanitic note over a large part of the distended region when the patient lies flat on his back. Above the pubes, on the other hand, there may be dulness on percussion simulating that of a distended bladder. The treatment is to empty the stomach by the stomach-tube and feed the patient with nutrient enemata. Chronic Dilatation of the Stomach. For clinical purposes it is convenient to describe three forms of dilatation of the stomach. 1. There is a form of moderate dilatation of the stomach, with- out stenosis of the p3dorus, without chronic gastritis, without failure of stomach digestion. If not relieved by treatment the condition continues for years, although there are often periods of improvement. The two prominent symptoms are pain in the upper part of the abdominal cavity and loss of nutrition. The pain comes on at intervals, which become shorter and shorter until there is pain every day. The loss of flesh and strength are progressive until the patients can hardly walk. With these two cardinal symptoms are often associated a variety of accessory symptoms. Some patients complain of dyspnoea, apparently diaphragmatic in character. In some the heart's action is increased in frequency. In women there may be a variety of nervous and hysterical symptoms. The loss of nutrition seems to depend partly on insufficient food, for the pa- tients are apt to leave off one article of food after another with the idea of preventing the pain. Temporary relief may be obtained by travelling, by an ex- clusive diet of milk or of meat, by pepsine, bismuth, nux vomica, etc. But tlie symptoms soon return and grow worse. The only curative treatment is the daily lavage of the stomach. This is very effectual, even in patients who have suffered for a number of years. 2. There is a form of dilatation of the stomach without stenosis of the pylorus, but with chronic gastritis. In these cases the stomach is larger and articles of food are retained in it for a longer time, sometimes for several days. There are pains l80 THE STOMACH." in the upper part of the abdominal cavity and a loss of flesh and strength which is carried very far. Nausea and vomiting are regularly developed after a time. When the stomach is first washed out, even after twelve hours' abstinence from food, it will be found to contain a large quantity of undigested material. These patients get well with lavage, but it has to be kept up for a long time. 3. There is a form of dilatation with stenosis of the pylorus. The stenosis is caused by carcinoma, b}'' ulcers, and by inflam- matory thickenings. The dilatations produced in this way are very large and much food is retained. Tlie patients have pain, loss of nutrition, nausea, and vomiting. The patients are made more comfortable and life is prolonged by lavage, but after a time they do badly, lose flesh and strength and die. The surgical procedures usually adopted for the relief of the stenosis are : resection of the pylorus, dilatation of the pylorus, and intestinal anastomosis. Acute Catarrhal Gastritis. Lesions. — Tlie changes are tlie same as in all acute catarrhal in- flammations — congestion, swelling, at first dryness, later an in- creased production of mucus, exudation of serum, emigration of white blood-cells. The inflammation may involve the whole of the glandular coat of the stomach, or only its pyloric portion ; it may extend to the duodenum. Causes. — The disease occurs at all ages and in both sexes. It may occur at any time of the year, but is especially common in summer. It is apparently sometimes caused by atmospheric conditions. It frequently complicates the exanthemata, typhoid fever, and epidemic influenza. It may be produced by unwhole- some and irritating food. It is of frequent occurrence in per- sons who have fatty degeneration of the liver. It occurs very often as a primary inflammation. Some persons show a marked predisposition to the disease, and suffer from repeated attacks. This is especially the case in some young children. They will have one or more attacks of acute gastritis every year for several years. As they grow older the attacks are less fre- quent and less severe. Symptoms. — The symptoms of an acute gastritis may come on THE STOMACH. l8l suddenly or they may be preceded by symptoms of gastric indi- gestion, of subacute gastritis, or by a diminution of the quan- tity of bile in the stools. Pain is often complained of. It may be a severe pain, or only a feeling of soreness or of discomfort. Vomiting is regularly present. It is in proportion to the severity of the gastritis, and is most troublesome during the first days of the inflammation. The patients vomit whatever they take into the stomach, and more or less mucus and serum. In se- vere cases large numbers of pus-cells and some red blood-cells are found in the vomited mucus and serum. The irritability of the stomach may be so great that neither food nor medicine can be retained. A rise of temperature accompanies the first days of the inflam- mation in some patients, but in many there is not at any time a febrile movement. As a rule, the bowels are constipated. But in some patients an acute colitis is developed at the same time as the gastritis, and then there is diarrhoea. There is a good deal of variety as to the length and severity of the attacks, the frequency of the vomiting, the height of the temperature, and the degree of the prostration. Attacks of acute gastritis are not infrequently followed by subacute and chronic gastritis. Course of the Disease. — (i) In infants and young children the vomiting is incessant, and excited by everything which is taken into the stomach ; the rise of temperature is often well marked, and the prostration is considerable. The gastritis may be ac- companied with or followed by diarrhoea. The S3'mptoms may last only for a few days, or for several weeks. Such a gastritis may not at any time be serious, or it may produce a prostration which lasts for weeks, or it may be fatal. (2) Mild cases in adults. The patients are not at any time very sick, nor is there a rise of temperature. There are loss of appetite, nausea and vomiting, with a feeling of discomfort or of actual pain referred to the stomach. The tongue is coated, the bowels may be constipated. The attack usually runs its course within a week and terminates in recovery, but the inflammation may pass into the subacute or chronic condition. (3) Severe gastritis in adults is attended with the same symp- toms, but they are more marked. The patients are sick enough to stay in bed, in some the prostration and feeble heart action are alarming, in some the 1 82 THE STOMACH. loss of flesh and strength are extreme. A febrile movement may be present or absent. The feeling of nausea is constant, the vomiting frequent, the pain and discomfort most distressing. Even a severe attack may run its course within a week, but tlie attacks often last much longer, and may be succeeded by sub- acute or chronic gastritis. (4) The inflammation involves either the whole stomach, or the pyloric end of the stomach, the duodenum, and the common bile-duct. The patients then have the symptoms described under the name of simple jaundice. (5) The inflammation is confined to the pyloric end of the stomach and the duodenum. The symptoms are the same as those of an attack of simple jaundice, but without the jaundice. The patients suffer from general malaise, headache, dulness, drowsiness, vertigo. The tongue is coated, loss of appetite, nausea, occasional vomiting, pain in the epigastric region and sometimes fever are present. The bowels are constipated and the faeces light colored. Treatment. — There can be no doubt that in some persons acute gastritis is caused by hot weather. It is important for such per- sons to pass their summers in a cool climate. In infants gastritis is often caused by the food. Not that the food is irritating but that it contains pathogenic bacteria and the products of their growth. This is an additional reason for tlie most scrupulous cleanliness in preparing and sterilizing the food of children. In any case of acute gastritis it is well to keep the patient in bed. For the first twenty-four or forty-eight hours the irritabil- ity of the stomach maybe so great that it will retain nothing. When this is the case it is wise to desist altogether from giving food or medicine by the mouth. After this tlie food is given at first by the teaspoonful and then the quantity gradually in- creased. The best foods are usually cream and water, koumyss, milk, beef-tea, beef-juice, and scraped beef. Rectal enemata help but very little in nourishing these patients. The external application of heat over the upper portion of the abdomen by fomentations, hot-water bags, or poultices is grateful to the patient. Of drugs the sulphate of morphia and codeia are the most valuable. They are to be given in small doses, -^-^ to \ grain of morphia, -^^ to i grain of codeia, at intervals of from one to three THE STOMACH. 183 hours. They are to be used in the form of tablets, wliich dis- solve in the mouth, or given hypodermically. The hydrochlorate of cocaine is sometimes of use for aduks, one-tenth grain in tablet form at intervals of from one to four hours. Ipecac in tablets of one-tentl. grain given every hour may exert a specific effect on the gastritis. The oxalate of cerium and bicarbonate of soda are useful drugs, they are best given in milk or in cream and water. A good formula is to mix together in a half-pint measure equal parts of cream, milk, and water, add to tliis ten grains of oxalate of cerium and twenty grains of bi- carbonate of soda ; give a teaspoonful every half hour. When the gastritis involves the pyloric end of the stomach, rectal enemata of very hot or very cold water, and purgation by calomel may be of much service. Chronic Catarrhal Gastritis. It is customary to include several different lesions of the stomach under this name. Lesions. — i. The only evident change in the stomach is an increased production of mucus. This can be washed out of the stomach during life, it is found adherent to the wall of the stom- ach after death. 2. Besides the increased production of mucus there is also degeneration of the cells of the peptic glands. 3. There is a growth of connective tissue betw^een the gastric tubules, with deformity and atrophy of the tubules. In some cases the new connective tissue forms little polypoid tumors which project inward. 4. With cardiac disease and with cirrhosis of the liver there may be a well-marked chronic congestion of the mucous mem- brane. 5. There may be hypertrophy of the muscular and connective coats at the pylorus producing stenosis, and with this there is often dilatation of the stomach. 6. There may be a more diffuse hypertrophy of the muscular and connective-tissue coats with marked diminution in the size of the stomach. 7. The stomach may be considerably dilated without stenosis of the pylorus. I 84 THE STOMACH. When we say that a patient has chronic catarrhal gastritis we mean that either : The mucous glands are constantly producing too much mu- cus. Or that in addition the functions of the peptic glands are dis- turbed. Or that the structure of the glandular coat is so impaired by disease that gastric digestion is seriously interfered with. Or that the mucous membrane is constantly in the condition of chronic congestion. Or that from stenosis of the pylorus or relaxation of the mus- cular coat, food is retained in the stomach. Or that the stomach is dilated or contracted. Etiology. — A considerable number of cases of chronic gastritis follow acute or subacute gastritis. This is especially true of the gastritis which complicates epidemic infiuenza, typhoid fever, and so many of the infectious diseases. Cardiac disease, pulmonary emphysema, and cirrhosis of the liver produce, first, chronic congestion and then chronic gastritis. Pulmonary phthisis, chronic nephritis, and gout are often ac- companied by chronic gastritis. The habitual use of improper food, of alcohol, and of drugs are ordinary causes. The same climatic conditions which predispose to chronic naso-pharyngeal catarrh and to chronic bronchitis have the like effect as regards chronic gastritis. Symptoms. — First among the symptoms comes pain, varying from a mere feeling of oppression and discomfort to the most severe and agonizing pain. The pain is in some cases due to the presence of food in the stomach. It comes on at first only with a considerable quantity of food, but later even small frag- ments of solid food or spoonfuls of liquid food will excite it. Very often patients learn to vomit of their own accord in order to relieve the pain. In some persons the pain seems to accompany gastric diges- tion and to cease when this is finished. In some cases the pain seems to depend on hyperacidity and hypersecretion of the gastric juice. With alcoholic gastritis there may be a peculiar feeling of soreness in the stomach, which is commonly called heartburn. Then there are many cases in which we can only say that so THE STOMACH. 1 85 long as the patients have gastritis they Imve pain, and as the gastritis improves so does the pain. As a rule the pain is at first not constant, but comes on in at- tacks, which become more frequent and of longer duration as the gastritis progresses. It is often difficult to distinguish the pain of chronic gastritis from that belonging to ulcer of the stomach, ulcer of the duode- num, biliary calculi, intestinal colic, movable kidney, disease of the uterus, tubes, and ovaries, anaemia, liysteria, and neurasthenia. Nausea and vomiting are also regular symptoms. The nausea belongs to the early morning hours, but may persist throughout the day. It may show itself as a disgust for food, or as a feeling of anxiety and depression of spirits, or as the actual sensation of impending vomiting. The vomiting is most frequently a vomiting of food, either in considerable quantities, or vomiting kept up so long as the smallest particle of food is left in the stomach. In some cases of alcoholic gastritis the stomach empties itself about an hour after nearly every meal. In other cases large quantities of brownish fluid, mixed with mucus and food, accumulate in the stomach and are vomited from time to time. This is especially the case when the stomach is dilated. Regurgitation of an acid fluid before breakfast in the morning is especially common with alcoholic gastritis. In a few cases the patients will vomit nearly every day as much as half a pint of pure mucus. There are rare cases in whicli vomiting is kept up as a habit long after the real reasons for it have stopped. Vomiting of blood may occur in the course of any chronic gastritis, but is much more likely to occur if cirrhosis of the liver, or fatty liver, exist at the same time. Usually the hemor- rhages are small, but with cirrhosis of the liver large quantities of blood are coughed up. The vomiting may occur in attacks with intervals of days or weeks, or it comes every dav. I have known a man to vomit every day for twenty years. Vomiting is also caused by diseases of the uterus, tubes, and ovaries, by an accumulation of faeces in the colon, by anaemia and by hysteria. Retention of food in the stomach is especially a feature when there is stenosis of the pylorus or dilatation of the stomach, but 1 86 THE STOMACH. it is also found with chronic gastritis. A considerable retention of food is regularly attended with vomiting. Constipation is often present. It seems to depend on a variety of causes and may have nothing to do with the condition of the stomach, but in some cases as the gastritis improves the bowels become regular. Headache is often a symptom. It follows a variety of types, but perhaps the most common is that which comes on at inter- vals. In some cases it is found that whenever there is headache bile can be washed out of the stomach. A general loss of health, of which emaciation and loss of muscular strength are the most prominent features, is found with the more severe cases of gastritis. This depends largely upon the gastritis and the interference with digestion, but in some cases it is simply due to starvation. Of their own accord, or by the advice of a physician, they give up one article of food after another until they do not get enough to eat. The exclusive diet of meat and hot water, if kept up for too long a time, has a particularly bad effect. A considerable number of nervous and hysterical symptoms, and disturbances of sensation in the mouth, throat, and other parts of the body are often present. It is difficult to tell how far these symptoms are to be attributed to the gastritis. Course of the Disease. — Chronic gastritis seems to have a natu- ral disposition to continue and to grow worse from year to year, but with periods of remission and exacerbation. The histories, therefore, may extend over many years, and the symptoms come on in attacks. Between the attacks the patients seem to be well, but the attacks become more severe, of longer duration, and oc- cur at shorter intervals, as the disease goes on, I do not know of any satisfactory way of classifying the varie- ties of chronic gastritis. We can, however, for practical pur- poses, put the patients together in rather rough groups. I. The cases in which pain referred to the region of the stom- ach is the principal symptom. (a.) Pain without vomiting occurs witli chronic gastritis by itself, or with retention of food, or with dilatation of the stomach, or with failure of gastric digestion. The patients do not distin- guish between these conditions, they only complain of the pain, they often do not think that they have any stomach disease. The diao-nosis has to be made with the stomach-tube. THE STOMACH. I 8; (b.) Pain with vomiting occurs with hypcracidily, with dilata- tion, and with abnormal sensitiveness of the gastric mucous mem- brane to the contact of food. The last condition seems to give the most intense gastric pain there is, a pain that can only be re- lieved by the removal of the food from the stomach. 2. Nausea and vomiting are ordinary symptoms in all the forms of chronic gastritis, but there are some patients in whom they are particularly prominent. There are persons in whom for many years nausea, with the accompanying depression (;f spirits, in the early morning, is the only symptom for many years. There are persons in whom vomiting, with or without nausea, continues for years, and yet there are no other gastric symp- toms. 3. There are patients who for 3'ears suffer from attacks of sick-headache, witii or without vomiting. Later, instead of the sick-headaches, there are attacks of gastric pain and vomiting. In some of the cases bile can be washed out of the stomach during every attack, in others no bile is present. 4. There are patients who suffer from retention of food in the stomach, or from dilatation without stenosis in addition to the chronic gastritis. Pain and loss of nutrition are the prominent symptoms. Treatment is often very satisfactory. 5. In the patients with dilatation and stenosis of the pylorus the pain, vomiting, and loss of nutrition get steadily worse. Treatment only relieves the pain and vomiting, the loss of nutri- tion continues. The question of a surgical operation regularly comes up. 6. Tliere are patients in whom depression of spirits going on to actual melancholia is the most niarked symptom. In these cases as the gastritis improves the melancholia disappears. Of course a great many of the cases of melancholia do not have gastritis at all. 7. There are patients in whom the loss of nutrition is out ol proportion to the gastric symptoms. They really have a chronic gastritis, but it may be difficult to tell how far this is the cause of the loss of nutrition, and how far it is the thing to be treated. Some of these cases are very difficult to manage. Treatment. — In attempting to establish a satisfactory treatment for chronic gastritis, it is important to state as clearly as possible the problem which is to be solved. First, then, we must remember that all the patients who suf- 1 88 THE STOMACH. fer from gastric symptoms do not necessarily have chronic gas- tritis. Besides those wlio have functional disturbance of the stomach, or cancer or ulcer of the stomach, we find many others in whom gastric symptoms are due to diseases of other parts of the body. Anaemia, uterine disease, the neurotic and hysterical condition, and constipation, often behave in this way. In old people the function of gastric digestion is often impaired simply as the re- sult of old age. To each one of these conditions belongs its ap- propriate treatment, but it is not the treatment of chronic gastritis. Still further, we must remember that in many cases of gas- tritis palliation of the symptoms is all that we can hope for. This is true with the gastritis associated with heart disease, em- physema, phthisis, cirrhosis, Bright's disease, gout, rheumatism, and alcoholism. It is also true of the cases in which the inflam- mation has gone on to the destruction of the peptic and mucous glands. After excluding all these, there remains a large and im- portant group of cases of chronic catarrhal gastritis, in which we may hope not only to alleviate the symptoms, but to cure the disease. It is evident, from the nature of the disease, that any treat- ment intended not merely to palliate, but to cure, must be of long duration, and that it must be repeated from time to time, when the inevitable relapses occur. The different plans of treatment, then, which maybe adopted are: The curative effects of climate and mode of life. The regulation of the diet. The administration of drugs. The use of local applications directly to the inflamed mem- brane. It is unnecessary to lay down rules as to the sort of climate, that can be regulated by the tastes of the patient. The two points of importance are : First, the locality selected must be one where the patient can lead an out-door life. Second, the patient must live in this climate either for several years, or for a considerable part of each year. Excellent as this method of treatment is, it is evident that it can be carried out only by a limited number of persons. The reo-ulation of the diet is a matter which demands consid- THE STOMACH. ' 189 eration in every case of chronic gastritis. In trying to ascertain the best way of feeding tiiese patients, I liave found only one sat- isfactory method, and that is to feed tlieni experimentally with different articles of food, and then after an interval of several hours wash out the stomach and see how thoroughly these arti- cles of food have been digested and removed from the stomach. After pursuing tliis course for a number of years I have arrived at the following conclusions : It is necessary that the patient should be well fed, a starva- tion diet never answers. The stomach does not require any rest from the performance of stomach digestion ; on the contrary, it is all the better for being called on to perform its natural functions. The patients' own ideas as to what food agrees with them are usually erroneous. They are apt either to starve themselves or to select the least nutritious articles of food. The use of artificially digested foods, or of substances, such as pepsine, to assist stomach digestion is unnecessary. The starches, oatmeal, corn-m.eal, bread, the cereals, the health foods are, as a rule, bad. Portions of them remain undi- gested in the stomach for many hours. Milk in adults is an uncertain article. It answers very well for some persons, not at all for others. Meat is usually readily and well digested, but there are oc- casional exceptions to this rule. Vegetables and fruits can be eaten, but the particular varie- ties must be selected experimentally for each patient. I do not believe that any case of chronic gastritis is to be cured by diet alone. Even the exclusive milk diet, while it often relieves symptoms, is, as a rule, only temporary in its effects, so that the patient simply loses a certain amount of time by em- ploying this instead of more efficacious plans of treatment. The advantageous use of drugs belongs to the earlier stages of chronic gastritis. At that time they often palliate symptoms and sometimes even seem to cure the inflammation. In the later stages of the disease their use becomes more and more unavail- ing. The reliable drugs for this purpose are not numerous : the preparations of soda, potash, and bismuth, the mineral acids, glycerine, sometimes carbolic acid, sometimes iodoform, some- times the bitter infusions. If none of these answer, it is hardly worth while to look any further. If we can combine, with the IQO THE STOMACH. administration of di ugs, tlie regulation of the diet, and of the mode of life of the patient, then of course, our chances of suc- cess are much greater. THE USE OF LOCAL APPLICATIONS DIRECTLY TO THE GLANDULAR COAT OF THE STOMACH. This I regard as the most efficacious plan of treatment for those patients who are not able to leave home and seek a proper climate, but ask to be relieved without interruption to tiieir or- dinary pursuits. The local applications are readily made by the introduction of a soft rubber-tube through the oesophagus into the stomach. Liquid applications are the best. They should be made in such quantities as to come thoroughly into contact with the en- tire surface of the mucous membrane, although the pyloric end of the stomach is the region where the inflammation is principally situated. They should be made at a time long enough after eat- ing for the stomach to be as nearly empty as possible. For many cases warm water alone in considerable quantities is the only local application needed. In some, however, there is an advantage in medicating the water, and for this purpose I employ a variety of substances. The alkalies, the mineral acids, bismuth, carbolic acid, the salicylates, iodoform, belladonna, ipecac, gelseminum, may each one be employed according to the particular case. For the first week it is often necessary to put the patient on a milk diet, and this can be done even with those patients who under ordinary circumstances cannot take milk at all. Then, after a time, to the milk we add one solid meal com- posed of meat alone. Next, this single meal is increased by the gradual addition of fruits, vegetables, and bread. Then comes the giving of two solid meals a day, instead of one, then three solid meals, and now we get rid of the milk in part or altogether. For the first week of this treatment it is wise not to expect any special improvement. Indeed, even a longer time than this may try the perseverance of the physician and the confidence of the patient. Sooner or later, however, the expected improvement begins : the nausea and vomiting cease, the constipation or diarrhoea is improved ; the flatulence is no longer troublesome ; the head- THE STOMACH. I9I ache becomes less frequent ; and, of more real value tlian these, the improvement in the general condition of tlie patient becomes evident. The color, the weight, the appetite, the sleep, the spirits of the patient, all show a change for the better. Of all the symptoms, the pain is tlie one which is apt to persist the longest. For two or three months the patient has to be kept under observation, and tlie applications to the stomach made by the physician. After tliis the patient is dismissed, but continues the treatment himself, first every other day, then twice a week, then once a week for several months. The regular relapses of the dis- ease are managed in the same way, but are much more quickly relieved. Suppurative Gastritis. Lesions. — There is a suppurative inflammation beginning in the connective-tissue coat of the stomach, and extending to the other coats. This inflammation may be circumscribed, with the formation of an abscess ; or diffuse, with a purulent infiltration of the entire connective-tissue coat. The abscesses may rupture into the cavity of the stomach. The inflammation of the perito- neal coat may give ris.e to a general peritonitis. Causes. — The disease belongs to adult life. It is more com- mon in males than in females. There is, in some cases, a history of the over-eating of indigestible food. It evidently belongs to the class of infectious inflammations. Symptoms. — The formation of the abscesses in the wall of the stomach is attended with pain in the epigastric region, vomiting, a febrile movement, and the formation of a tumor. If the ab- scess ruptures into the stomach, the pus may be vomited. The peritonitis often remains localized. The disease may run an acute or a chronic course. The diffuse suppurative inflammation of the wall of the stomach runs an acute course, terminating fatally in from three to eighteen days. The patient is suddenly attacked with vomiting, pain, and tenderness over the stomach, fever, and great prostra- tion. The symptoms of general peritonitis are soon added, and the patients rapidly get worse. Treatment. — The best that we can do seems to be to alleviate the patient's symptoms by the liberal use of opium. 192 THE STOMACH. Ulcer of the Stomach. Lesions. — Ulcers of the stomach are usually single, but two or more ulcers may be formed at the same time, or successively. Welch, from a collection of 793 cases, gives the position of such ulcers as follows : On the lesser curvature, 288. On the posterior wall, 235. At the pylorus, 95. On the anterior wall, 69. At the oesophageal end, 50. At the fundus, 29. On the greater curvature, 27. The ordinary diameter of these ulcers is from half an inch to two inches, but some are very small, and some are much larger. Two or more ulcers may become joined, and so form a large ul- cerated area. The ulcers are round or oval, largest in the glandular coat. They may destroy only the glandular coat, or the entire thick- ness of the wall of the stomach. The edges of the ulcers are clean cut, and their floors smooth ; but sometimes the edges are ■much thickened, and the floor may be formed by tissues whicii have become adherent. The edges and the floor are formed of amorphous granular matter, or of connective tissue. If the patients recover, the ulcers cicatrize either with or without deformity of the stomach. If the ulcers perforate the wall of the stomach, this perfora- tion may be large and sudden, with the escape of the contents of the stomach into the abdominal cavity ; or the perforation may be small, and set up a localized peritonitis ; or the opening may be entirely closed by adhesions. The ulcer may erode either the arteries or the veins of the stomach. With an ulcer there is more or less chronic gastritis. Causes. — These ulcers are said to be twice as common in wom- en as in men. Tliey have been observed at nearly every age, but seven tenths of them are in people between twenty and forty years of age. The ordinary explanation of the way in which these ulcers are formed is, that by embolism, thrombosis, or chronic endar- teritis one of the branches of the gastric artery is occluded. The THE STOMACH. I93 corresponding portion of the wall of the stomacli dies and is destroj^ed by the action of the gastric juice. Symptoms. — Of all t!ic symptoms pain is the most constant, it is absent only in exceptional cases, it varies in its quality, its in- tensity, its situation, and its duration. The most characteristic pain is severe paroxysmal pain local- ized in a circumscribed spot in the epigastrium, coming on soon after eating and disappearing when the stomach is emptied. Of more common occurrence are paroxysms of severe pain dif- fused over the epigastrium and radiating in different directions. In many cases both these forms of pain exist. In the intervals between the paroxysms of pain there is often a more or less con- stant dull pain or feeling of discomfort at the epigastrium. The position of the pain is usually at or a little below the ensiform cartilage. It may, however, be felt as low as the umbilicus, or on either side in the hypochrondriac regions. The pain usually comes on within half an hour of taking food and continues until the stomach is emptied by vomiting or by the passage of food into the duodenum. The pain is regularly increased by pressure over the stomach, by fatigue, and by exposure. It is diminished by rest and the recumbent position. The pain may recur at regular intervals, it may stop altogether for days or weeks. Besides the pain belonging to the gastric ulcer the patients may also have pain due to chronic gastritis, to hyperacidity, to retention of food, to dilatation of the stomach, or to localized peritonitis. Next to pain, vomiting is the most frequent symptom of gastric ulcer. It is apt to occur soon after taking food, or after an attack of gastric pain. The patients may only vomit occasion- ally, or every day, or very frequently. In some cases the irrita- bility of the stomach is so great that no food can be retained, and the effort at vomiting will be made even when the stomach is entirely empty. The vomiting seems to be due partly to the ulcer, partl}^ to the accompanying chronic gastritis. It is estimated that vomiting of blood occurs in about one- third of the cases of gastric ulcer. This estimation is not of much value, on account of the occurrence of vomiting of blood, with chronic gastritis and simple anaemia. The bleeding may be preceded by pain, vomiting, and dis- turbances of digestion, or it may come on suddenly without any 194 THE STOMACH. other gastric symptoms. The quantity of blood lost may be small, or large, the larger hemorrhages are those which are most characteristic of gastric ulcer. The most important bleedings are those which are due to the erosion of a blood-vessel in the floor of the ulcer. The blood may be entirely vomited, or some of it may pass into the intestine and be discharged with the stools. With small bleedings all the blood may pass into the intestine, none of it being vomited. Rarely the patients die sud- denly without any vomiting, and at the autopsy the stomach is found to be full of blood. It is not generally understood that patients with either per- nicious or simple anaemia may vomit large quantities of blood, and even bleed to death without any ulcer or erosion of the stomach. Such large bleedings, due to anaemia, and not to ulcer of the stomach, are of frequent occurrence and yet are recognized by few physicians. The importance of a correct diagnosis is very great. If the bleeding is due to anaemia and the patients are treated for ulcer of the stomach they are very apt to die. If, on the other hand, it is appreciated that they have no stomach lesion, and they are treated for anaemia they usually recover. It is to be remembered in this connection that many anaemic patients have pain after eating, nausea, and vomiting without any disease of the stomach. Any of the symptoms which have been described under the heads of functional disorders of the stomach and chronic gastritis may occur in cases of gastric ulcer. The frequency of perforation of the ulcers is variously stated by different authors. Welch gives it as six and one-half per cent, of all cases of gastric ulcer. It is said that perforation occurs two or three times oftener in the female than in the male, and that in the female the liabil- ity is greatest between fourteen and thirty years of age. In the male there seems to be no greater liability to perforation at one age than at another. Ulcers of the anterior wall of the stomach perforate more frequently than those in other situations. The perforation may be preceded by the characteristic pain and vomiting of gastric ulcer, or only by indefinite gastric symptoms, or it may occur suddenly in a person who is apparently perfectly well. If the perforation is such that the contents of the stomach THE STOMACH. 195 escape into the peritoneal cavity there is at once a severe pain and the patients pass into the condition of collapse. If they survive the slioclv of tlie perforation an acute general peritonitis is developed wliich is regularly fatal. The perforation may be small and limited by adhesions. Tlien a localized peritonitis with collections of pus is set up around the perforation. In this way are formed the subphrenic abscesses which perforate the diaphragm and simulate empyema or pyopneumothorax. The Course of the Disease.— T\\&xq may be no symptoms during life, and the ulcer, or its cicatrix, is found after death from some other disease. There are cases which last for weeks, months, or years. The symptoms are marked, but more or less severe. Some of tlie patients recover, others die of starvation. There are cases in which one or more large hemorrhages form the prominent, and sometimes the only, symptom. Tliere are cases in which the large or small perforation of the wall of the stomach forms the prominent feature. There are cases in which the deformity of the stomach, pro- duced by the cicatrization of the ulcer, gives S3miptoms for the rest of the patient's life. Terminations. — In the majority of cases gastric ulcer termi- nates in recovery, and such a recovery may be complete. But it may happen that chronic gastritis or deformities will be left be- hind which give troublesome symptoms for many years. In the fatal cases death is due to perforation, to hemorrhage, or to starvation from the inability of the stomach to retain any food. Treatment. — The first point is to determine whether the pa- tients can be fed by the stomach or by the rectum. If they can be fed by the mouth we give, in moderate quan- tities and at regular intervals, milk, peptonized milk, a mixture of equal parts of milk, cream, and water, beef-juice, or Leube's or Rudisch's prepared beef. If they have to be fed by the rectum, this is washed out once a day witli warm water, and the nutrient enemata are given once in four hours. The quantity of each enema should be four ounces. They may be composed of peptonized milk, defibri- nated blood, Leube's beef solution, the yolk of eggs, cream, cod-liver oil, or beef-juice. There may be an advantage in add- ing brandy or opium to the enema. 196 THE STOMACH. The drugs ordinarily employed are : The alkalies, the arti- ficial Carlsbad salt (sodium sulphate, 5 parts; sodium bicarbo- nate, 2 parts ; sodium chloride, i part ; a teaspoonful in half a pint of hot water every morning), bismuth, cocaine, oxalate of cerium, nitrate of silver, iodoform, hydrocyanic acid, and opium. In any case of suspected ulcer of the stomach with vomiting of blood, if the haemoglobim is less than fifty per cent., and the red blood-cells less than 2,000,000 to the cubic millimetre, it is better to treat the anaemia than the ulcer of the stomach. Cancer of the Stomach. Lesions. — The new growth follows the anatomical types of colloid cancer, of cancer with cylindrical epithelial cells, and of cancer with small polygonal cells. The growth seems to origi- nate in the glandular coat. The most common shape for the new growth to take is that of a flattened tumor with necrotic and ulcerating centre which projects inward into the cavity of the stomach. Instead of this, however, the tumor may be quite large and of polypoid shape. In still other cases there is no tumor, but a flat infiltration which occupies more or less of the wall of the stomach. There is usually more or less chronic catarrhal inflammation of the glan- dular coat. The peritoneal coat is often thickened and adherent to the surrounding viscera. The process of ulceration may in- volve not only the new growth, but also the wall of the stomach and even extend into the adherent viscera. While the great majority of cancers of the stomach are primary, yet secondary tumors have also been observed. Welch has col- lected 37 such cases, 17 secondary to cancer of the breast, 8 to cancer of the oesophagus, 3 to cancer of the mouth or nose, and the remainder to cancer of other parts of the body. Cancer of the stomach is very often attended with the growth of metastatic tumors in other parts of the body. Welch gives the foUovving table, based on 1,574 cases : Lymphatic Glands. Liver. Peritoneum, Omentum, Intestine. Pancreas. Pleura and Lung. Spleen. Brain. Other parts of the body. SSI 35 P.c. 475 30.2 p.c. 357 22.7 p.c. 122 7.8 p.c. 98 6.2 p.c. 26 1.7 p.c. 9 0.6 p.c. 92 S.8 p.c. THE STOMACH. 1 97 Causes. — The disease is equally common in males and females. The maximum liability to the disease is between the ages of 60 and 70 years, but gastric cancer is common enough after the age of forty, and is even occasionally seen in persons not over 20 years old. Symptoms. — The appetite as a rule is poor, either because the ingestion of food causes pain or nausea, or because there is actual distaste for food. But there are exceptional cases in which the appetite continues to be very good. Nausea and vomiting are often present. The vomiting is of food, of brownish or yellow fluid, of coffee-ground matter, or of blood. The vomited matters may have an offensive odor. This foul smell is more constant in the contents of the stomach when they are washed out than when they are vomited. When the stomach is dilated from stenosis of the pylorus the quantity of vomit at one time is often very large. The vomiting may be an early symptom and continue throughout the disease. Or it may not come on until the disease is far advanced. Or the vomiting may accompany the early stages of the growth and then stop, not to begin again. In a moderate number of cases there is no vomiting at any time, this may be the case even when there is stenosis of the pylorus. It is said that the situation of the cancer exerts great influ- ence upon the frequency of vomiting, and the time of its occur- rence after meals ; that when the cancer involves the pyloric orifice, vom.iting is rarely absent, and generally occurs an hour or more after a meal. As the stomach becomes dilated the vomiting comes on longer after a meal, sometimes not until after one or more days. Next to pyloric cancer it is cancer involving the cardiac orifice which is most frequently accompanied by vomiting. Here the vomiting occurs immediately after taking food. If there is stenosis of the cardiac orifice the food is regur- gitated.. When the cancer is situated in other parts of the stomach and does not obstruct the orifices, vomiting is more fre- quently absent. There are a great many exceptions to these rules, so many that the rules themselves are not of much practi- cal importance. Bleeding from cancers of the stomacli is usually in small quantities, and the blood remains in the stomach long enough to be changed into coffee-ground matter, but sometimes there are very large hemorrhages. 198 THE STOMACH. The absence of free hydrochloric acid in the contents of the stomach in cancer of that organ is the rule. It was at one time thought that this might help in the diagnosis, but it has been found that the free acid is absent with a variety of other diseases of the stomach. Pain referred to the region of the stomach is a frequent symptom, and the pain may be very severe, but the number of patients who do not at any time have any pain is very considerable. The presence of a tumor is the most certain evidence of gastric cancer. We look for tumors of the pylorus in the epigastric re- gion, unless the stomach is dilated, then the tumors are found lower down in the abdomen. The tumors of the greater curva- ture and of the anterior wall correspond in their situation to these parts of the stomach. All tliese tumors are most easily felt if tlie patient takes a deep breath so as to depress the diaphragm. The tumors usually move pretty freely up and down with the m.ove- nients of the diaphragm, but sometimes they are fastened down by adhesions. If they are close to the abdominal aorta the tumors seem to pulsate. As a rule there is no great difficulty in making out that the tiunor is separate from the aorta, but some- times it is exceedingly difficult to distinguish between cancer of the stomach and aneurism of the aorta. Cancers of the cardiac end of the stomach cannot be felt. The ease with which the tumor can be felt depends not only on its position, but also on its size and shape. Some of the flat infiltrations of the w^all of the stomach never make an appreci- able tumor. The flattened and polypoid tumors cannot be felt until they have reached some size, so that often enough we do not make out the tumor until a few months before death. If the lymphatic glands are adherent and infiltrated they increase the size of the tumor very considerably. It is not uncommon for persons to have a chronic gastritis with its attendant symptoms for a number of years before the canqer is formed. The symptoms of the gastritis and those of the cancer then seem to make one continuous history. In the later stages of the disease there may be a moderate rise of temperature. The bowels are usually constipated, but tliere may be diar- rhoea. When there is bleeding from the stomach some of the blood may come away with the stools. The loss of flesh and of strength are sometimes the first symp- THE STOMACH. 1 99 toms to attract attention, but more frequently they come after the gastric symptoms have ah-eady existed for some time. A very considerable loss of flesh accompanying gastric symptoms always makes one think of cancer of the stomach. But it must not be forgotten that there are exceptional cases in which there is no emaciation and the general health continues to be remark- ably good. There is regularly some diminution in the quantity of haemo- globin and the number of red blood-cells, the color of the skin changing to white or yellow. In some cases, however, these changes in the blood are as marked as they are in pernicious anaemia, and when no tumor is present the diagnosis becomes very difficult. Late in the disease there may be oedema of the legs, ascites, and thrombosis of some of the veins, especially those of the legs. A coma with dyspnoea, like that of diabetes, has been observed in a few cases of gastric cancer. The ordinary duration of the disease is about one year, but some cases go on much longer — for two, or even three years. COURSE OF THE DISEASE. 1. A considerable number of cases give a characteristic his- tory — first the gastric symptoms, then the loss of flesh and strength with a tumor in the upper part of the abdomen evidently connected with the stomach. * 2. Not infrequently we see patients with well-marked gastric symptoms and some loss of flesh and strength, but there is no tumor, and the diagnosis may remain doubtful for some time. 3. There are patients in whom the gradual loss of nutrition and cachectic condition are such as to make one feel sure there is a cancer somewhere in the body, but there are no local symp- toms and no tumor to tell where it is. 4. There are patients who up to the time of death have the symptoms and the condition of the blood which belong to per- nicious anaemia, with ver\' little to call attention to the condition of the stomach. 5. There are cases with a primary cancer of the stomach, which is of small size and gives but few symptoms, and large secondary tumors in the liver. These patients behave as if they had cancer of the liver rather than cancer of the stomach. 200 THE SMALL INTESTINE. 6, A primary cancer of the stomach may be followed by the formation of secondary tumors in the peritoneum, with fluid in the peritoneal cavity. In some of these cases the symptoms of the cancer of the peritoneum are much more marked than those of the gastric cancer. Treaimefit.—The patients can often be made much more com- fortable, and even enabled to eat ordinary meals, by the daily washing out of the stomach. Another plan is to feed them every two hours with small quantities of easily digestible food. If the pain is bad, morphine has to be used. A number of operative procedures have been employed by which, in some cases, life has been prolonged. , Acute Catarrhal Enteritis, The small intestine is sometimes the seat of a catarrhal in- flammation which may be of mild or of severe type. Such an inflammation is especially common in young adults, some of whom seem to have a predisposition for the disease. In some cases there is a history of indigestible food, or of exposure to the weather ; in other cases no exciting cause can be discov- ered. Symptoms. — The patients have marked and constant pain and tenderness referred to the lower part of the abdomen. There is a rapid rise of temperature from ioo° to 104° F, There is marked prostration from the first, the patients being at once con- fined to bed. There may be vomiting, the bowels are consti- pated. The invasion of the disease is sudden, the patients often seem seriously ill, but yet they regularly recover. The fever subsides first, then the pain, and in one or two weeks the pa- tients are well. Sometimes, however, the pain pei"sists for a longer time after the subsidence of the other symptoms. Diagnosis. — The disease may be mistaken for inflammation of the vermiform appendix, for peritonitis, or for gastritis. Treatment. — The patients are to be kept in bed ; at first on a fluid diet ; when the fever has subsided, on meat principally. Continuous heat or cold should be applied over the abdomen. At first, morphine and calomel together are given in small doses, later belladonna and ipecac. The bowels are to be moved every day by enemata. THE SMALL INTESTINE. 20I Cholera Morbus. This name is given to an acute catarrhal inflannnation of the gastro-intestinal tract, probably associated with tlie growth of pathogenic bacteria. Lesions. — After death t!ie mucous membrane of tlie stomach and intestines is found coated with mucus, congested, sometimes with little abscesses in the glandular coat. Causes. — The disease is especially common in the hot weather of August and September. As exciting causes improper food and contaminated water are probable. Symptoms. — The attacks are apt to come on in the night. There is first a feeling of abdominal oppression and of prostra- tion. Then the patients empty the stomach of food and the in- testines of faeces. After this there is frequent vomiting and purging of white or brownish fluid. There may be colicky ab- dominal pains, and painful contractions of the muscles of the abdomen and of the legs. The patients are anxious, restless, much prostrated, tormented by thirst, the skin cold, the body soon emaciated, the heart's action rapid and feeble. The pa- tients often seem seriously ill, but yet as a rule recover. Occa- sionally, however, the disease proves fatal, especially in old or feeble persons. In some cases cholera morbus cannot be distinguished from true cholera except by the absence of the cholera bacillus. The vomiting, purging, rapid emaciation, collapse, and death give the same clinical picture in both diseases. Treatment. — The patients are to be kept in bed, hot fomenta- tions are to be applied over the abdomen, and opium and stimu- lants are to be given according to the indications of each case. The food should be in small quantities— koumyss, beef-juice, milk, or cream and water. Cholera Infantum. This name is given to a disease of young children which re- sembles cholera morbus, and is probably due to the growth in the intestines of pathogenic bacteria. Lesions. — After death the intestines contain white or brown- 202 THE SMALL INTESTINE. ish fluid. The mucous membrane is pale, tlie solitary and ag- minated glands are sometimes swollen, sometimes ulcerated. Causes. — The disease belongs to children under two years of age. It is most apt to attack those who, from bad food, bad air, or heat, have their intestinal tract already in an unhealthy con- dition. Symptoms. — The disease may follow an ordinary diarrhoea, or begin suddenly with purging, vomiting, and prostration. Vom- iting is usually, but not always, present, and varies as to its fi"equency and persistency. Purging is constant and frequent. The movements are at first fecal, afterward of white or brownish fluid. The patients rapidly lose flesh and strength, the heart's action is rapid and feeble, there is constant thirst, the skin is cold, the urine is diminished. The patients are always restless and miserable, some of them have muscular tvvitchings, general convulsions, alternating delirium and stupor. The disease may not last more than twenty-four hours, or it may continue for several weeks. It is always serious, and often fatal. Treatment. — The children are to be fed with small quantities of koumyss, cream and water, wine-whey, beef-juice, or milk and barley-water. In the prolonged cases oil may be rubbed into the skin. The children should be kept as cool as possible, and sent to a different climate from that in which they have been taken sick. Of drugs the most reliable seem to be combinations of mercury, alkalies, and opium in small doses. Stimulants maybe necessary. Constipation. In the healthy adult there should be a movement from the bowels once in each twenty-four hours. The faeces should be formed, of natural consistence and color. In some individuals the regular interval is shorter, in some it is rather longer, the character of the faeces remaining normal. If the bowels cease to move regularly, .and the fecal matters accumulate in the colon, the patient becomes liable to a variety of disorders. In the treatment of constipation it is important to determine its cause and then to manage it, principally by attention to the diet and mode of life. In some persons constipation is merely due to the habit of only going to the water-closet when they feel the impulse to def- THE SMALL INTESTINE. 203 ecate, whether it is once a day or once a weetc. In many of tliese patients the temporary use of a simple laxative or of a glycerine enema, with the enforcement of a regular daily hour for the defe- cation, is all that is necessary. In some patients tiie constipation is due to chronic gastritis. If the gastritis is improved by treatment, the constipation will disappear. Tlie constipation may be due to an insufficient production of bile. Then we must at first use the drugs which increase the formation of bile — ipecac, podophyllin, bichloride of mercury, sulphate of magnesia, the alkalies, or the mineral acids. Later the patient must take sufficient exercise and gradually give up the use of the drugs. The constipation may be due to general bad health or anaemia, and the treatment has to be directed principally to the relief of these conditions. Improper food and drink may be the cause of the constipa- tion. The patients require fruits, vegetables, and starches in considerable quantities. Thev must take sufficient water, or one of the alkaline waters, coffee, or beer. The most difficult cases to manage are those in which the sensibility of the mucous coat of the colon is diminished and its muscular coat relaxed. In these patients we apply massage and electricity to the abdomen, enforce proper exercise and diet, and give strychnia, aloes, and belladonna. In elderly persons the rectum may become filled with re- tained faeces to such an extent as to give a good deal of trouble. In the milder cases the condition is not constant, but occurs from time to time. The patient fails to have an operation of the bowels for several days. He feels dull, languid, loses his ap- petite, has headache, is troublea with flatulence and uncomfort- able feelings in the abdomen, which may even amount to colic. After a few days there is a slight diarrhoea. The passages are small, painful, do not give a feeling of relief. The patient is, at the same time, very much prostrated, vomits his food, and may even take to his bed. If you are called to attend these patients after the diarrhoea has begun, it is very important that you siiould recognize the true nature of the case. The administration of any preparation of opium, or of any drug which merely checks the diarrhoea, only does harm and prolongs the sufferings of the patient A mild laxative, on the other hand, will very promptly 204 THE LARGE INTESTINE. relieve all the symptoms. The ordinary dinner-pill is one of the best preparations for this purpose. Eneniata of castor-oil and olive-oil mixed together are serviceable. In the more severe cases the symptoms come on gradually. The patient is at first only a little constipated ; the bowels move every few days, either of themselves or with an enema, or with some laxative. And yet during this time the large intestine is not really emptied, but there is a constant accumulation of faeces in the rectum. The constipation becomes gradually more pro- nounced, and the patient finds that enemata and mild laxatives no longer give him a movement. Then he may use more active purgatives, which produce a number of fluid stools and yet do not empty the large intestine of the hardened faeces, which are still accumulating. So the patient goes on from bad to worse, alternating between constipation and diarrhoea, always uncom- fortable, often with very severe pain in the abdomen, losing strength rapidly. If the condition is not relieved, an old per- son may be so reduced in this way as to die without any other disease than constipation. The first point in the treatment is to introduce your finger into the rectum and ascertain whether or not it is filled with hardened faeces. If it is, the faeces must be scooped out with the finger or some convenient instrument, and then the rectum should be washed out repeatedly until it is entirely emptied. After this the patient must be constantly watched and exam- ined from time to time, to ascertain that the faeces are not accu- mulating again. The diet must be regulated, and aloes and strychnine may be employed to assist the action of the large in- testine. In young and middle-aged adults constipation may be pro- longed for many days, and the fecal matters accumulate in the ascending and transverse portions of the colon. When this is the case the patients often become quite seriously ill. They are in bed with severe abdominal pain, an anxious face, some dis- tention of the abdomen, and a considerable rise of temperature. Many of them look as if they had general peritonitis. In some of them the fecal tumor can be felt. The cases vary as to the relative prominence of the fever, or the fecal tumor, as symptoms. As a rule, by the use of calomel, castor-oil, and enemata, the colon can be emptied and the patient recover. THE LARGE INTESTINE. 20 = DiARRHCEA, A person is said to have diarrlioea if lie has every day several loose fecal or watery evacuations from the bowels. Causes. — Apart from the diarrhoeas which are d'.ie to inflamma- tions or new-growths of the colon, we find the condition pro- duced by a variety of causes. Mental emotions often produce a transitory diarrhoea, which requires no treatment. Extremes of heat and cold may cause a diarrhoea for which it is necessary to put the patient to bed, with a restricted diet and the use of a little opium. Partly decaved fruit and vegetables, or undigested pieces of food in the intestine, often set up a diarrhoea. When this is the case it is necessary first to give a purgative to remove the irrita- tive substances, and afterward to use opium. Drinking-water which contains an excess of inorganic or or- ganic substances is a frequent source of diarrhoea ; some persons being especially susceptible to this source of irritation. There is a form of diarrhoea in adults which is often very troublesome. In some of the patients the colon seems to be un- naturally irritable, so that improper food or atmospheric changes frequently bring on attacks of diarrhoea, abdominal pain, pros- tration, and mental depression, which last for a few days and then disappear. In other cases the same symptoms — diarrhoea, abdominal pain, prostration, and mental depression — are present during so much of the time that it seems probable that the patients have a sub- acute catarrhal colitis. In these protracted cases the diarrlioea is usually in the morning, or immediately after each meal. These symptoms often continue for years, and come back repeatedly after ceasing for a time. In the severe cases there is a decided loss of flesh and strength. An exclusive diet of milk, or of scraped beef ; change of cli- mate ; cold-water enemata ; castor-oil, arsenic, iron, quinine, sali- cylic acid, salol, and naphthaline are among our most efficient methods of treatment. 206 THE LARGE INTESTINE. Infantile Diarrhcea. Diarrhoea is a common disorder of infants and of young chil- dren. It is especially common during- the period of dentition, in hot weather, and in bottle-fed children. The diarrhcea may follow an acute gastritis, an acute coli- tis, or begin of itself. The children have every day a number of loose, bad-smelling, green, or light-colored fecal passages. There may be a febrile movement, especially in the afternoon. The patients gradually lose flesh and strength. Such a diar- rhoea may last for days, weelis, or months. Treatment. — If the children have a good nurse they continue to nurse. If not, they are fed on cream and water, milk diluted with a thin gruel, or koumyss. Older children can take beef- juice and scraped meat. The medicines usiially employed are : calomel, bichloride of mercury, sulphate of magnesia, castor-oil, podophyllin, rhubarb, ipecac, bismuth, and opium. Occasionally we see cases in which there is first an ordinary diarrhoea. Then the passages become white, larger and larger, until the child passes three or four times a day enormous quan- tities of white, pasty faeces. The children are tormented by hunger and thirst, and become very much emaciated. They should be removed to as different a climate as possible from the one vi'here they were taken sick. The most efficient medicine seems to be a combination of hydrochloric acid, arsenic, and opium. Intestinal Colic. This name is given to attacks of pain due to spasmodic con- traction of the muscular coat of the colon. Such attacks may be due to the presence in the intestine of irritating pieces of food, or fecal matter. In some persons the colon seems to be much more irritable than it is in others, so that attacks of colic are easily produced. Symptoms. — The attacks are apt to come on suddenly with pain as the first symptom, and, in the mild cases, the only symptom. The pain is referred to some part of the colon, or to any part of the abdomen. Besides the pain, there may be re- traction, tenderness on pressure, distention or hardness of the THE LARGE INTESTINE. 20/ abdominal wall, nausea and vomiting, a skin ccjld and bathed in perspiration ; rapid and feeble heart action, and a rise of tem- perature. The attacks vary greatly as to their severity and duration. The mild attacks last half an hour, or a few hours, the yjain is the only symptom, and it is evident that the patients are not se- riously ill. The severe attacks last for days, with nausea and vomiting, a good deal of tenderness as well as pain over the colon, prostration, and sometimes a febrile movement, so that the patient may look very badly. The same patient may have one attack of colic, or several. It may be very difficult to dis- tinguish intestinal colic from biliary colic without jaundice. Ti'eatment. — The object of treatment is to relax the muscular spasm and to remove irritating substances from the intestine. To relax the muscular spasm we use hypodermic injections of morphine and belladonna, hot fomentations over the abdomen, and hot-water enemata. To remove the irritating substances we give castor-oil or some other piurgative. In some persons the predisposition to attacks of intestinal colic exists in an unusual degree. These persons will go on year after year with repeated attacks, at first at intervals of months, then at shorter intervals, until finally the attacks may occur every day. These patients also usually suffer from flatu- lence and constipation. When it takes this protracted form in- testinal colic becomes a serious matter. The patients lose flesh and strength, they are unable to work, the severe pain gets them into the habit of using opium. Of these protracted cases some are easily relieved by treat- ment, others are very troublesome. It may be necessary to put them for a time on an exclusive diet of scraped beef, or it mav be sufficient to exclude milk, tea, coffee, beer, soup, and most of the fruits and vegetables. The bowels must be kept open and sufficient exercise insisted on as soon as the patient can bear it. Opium must only be used at the time of an acute attack, it must not be continued for any length of time. The drugs which seem to be of the most service are : belladonna, ipecac, nux vomica, cannabis indica, and sodium sulphocarbolate. 208 THE LARGE INTESTINE. Acute Colitis. The glandular coat, the connective-tissue coat, the muscular coat, the peritoneal coat, and the lymphatic glands of the intes- tine are often the seat of acute and of chronic inflammation. It has been customary to include all these inflammations under the name of dysentery, or to group them under the names of catar- rhal, croupous, and follicular colitis. I think that our knowledge of the different forms of colitis is sufficient to warrant us in using more exact terms. Etiology. — Sporadic cases of colitis occur in all climates. In New York they are especially common in August, September, and October. Contaminated water and food and atmospheric conditions seem to act as exciting causes. Whenever large numbers of people are brought together with irregular supplies of food, contaminated water, and imperfect sanitary arrangements colitis is likely to prevail. In every war there is always a large mortality from colitis. Local epidemics of colitis are of frequent occurrence. Some- times they can be accounted for by contaminated water, at other times it is difficult to account for their origin. There can be no question that colitis is especially prevalent and frequent in tropical countries and in malarial districts. The bacteriology of colitis is still incomplete. There can be little doubt that the amoeba coli causes many of the cases of necrotic colitis. It is probable that the streptococci are respon- sible for some cases, farther than this we have no exact knowl- edge. Classification. — A convenient classification of the different forms of colitis is as follows : 1. Acute exudative colitis. 2. Acute purulent colitis. 3. Acute productive colitis. 4. Necrotic colitis, a. Colitis with superficial necrosis (strep- tococci), b. Colitis with necrosis, croupous form. c. Colitis with deep necrosis (amoebae), d. Colitis with deep necrosis (without amoebae). THE LARGE INTESTINE. 209 I. ACUTE EXUDATIVE COLITIS. Synonyms. — Acute catarrhal colitis, dysentery. Definition. — An acute exudative inflammation involving the glandular and connective-tissue coats of the colon, attended with congestion, exudation, and an increased production of mucus. Lesions. — As this form of colitis is rarely fatal in adults our knowledge of the lesions is derived from it as it occurs in chil- dren, as it is associated with other forms of colitis, as it is pro- duced experimentally in animals, and from the character of the discharges from the bowels during life. In the more acute cases of this form of colitis the inflammation is usually confined to tlie lower end of the colon. The glandular and connective-tissue coats are swollen and congested and more or less infiltrated with serum and pus-cells. There is an increased production of mucus, which coats the inner surface of the colon and comes away with the stools. There may be bleeding from the surface of the in- flamed mucous membrane. In the more subacute cases the inflammation involves a con- siderable part of the length of the colon, there is less congestion, but the quantity of serum exuded may be large. Symptoms. — In the more acute cases, when the lower portion of the colon alone is inflamed, the inflammation regularly runs its course within a week and the patients recover. The princi- pal symptoms are the local ones: pain in the rectum, an irrita- bility of its mucous membrane, which makes it try to discharge everything in contact with it, and the passage of small quanti- ties of blood and mucus. Although the passages of blood and mucus are frequent, but little fecal matter comes away with them. Besides the local S3miptoms there is a moderate rise of temperature, v;ith more or less prostration. If, however, the inflammation not only involves the rectum but extends up into the colon the patients are more seriously ill, especially if they are young children. The quantity of mucus discharged from the bowels is considerable and no fecal matter may appear in the stools for one or two weeks. As the inflam- mation subsides the quantity of mucus decreases and the quan- tity of fecal matter increases. Minute examination of the stools (Councilman) shows red blood-cells, white blood-cells, epithe- lial Cells, and bacteria. In these patients the temperature is 2IO THE LARGE INTESTINE. higher, the duration of the disease longer, and the prostration greater. Adults regularly recover, but children often die. In the more subacute cases the inflammation may only last for a few days, but not infrequently it continues for several weeks. There is no pain in the rectum, no irritability of its mu- cous membrane, no small passages of blood and mucus. But during each twenty-four hours there are a number of large pas- sages composed of fluid faeces, serum, and mucus. A single one of these discharges may measure more than two quarts. There may also be colicky pains. The patients, as a rule, are not con- fined to bed, although they feel weak and miserable. Tliere is no febrile movement. Treatment. — In the acute form of the disease the patients are to be kept in bed. The diet is restricted to milk, gruel, beef- juice, and scraped beef. The colon is to be emptied of faeces, by the use of castor-oil or the sulphate of magnesia. The pain is to be relieved by opium. For the subacute cases, the treatment is to be varied with the individual. Most of the patients need opium at first. In addi- tion to tins we find that ipecac, naphthaline, salol, beta-naphthol, bismuth, subnitrate of bismuth, and castor-oil in small doses are of service, either given separately or in different combinations. 2. ACUTE PURULENT COLITIS. Synonyms. — Acute catarrhal colitis, dysentery. Definition. — An acute exudative inflammation of the colon with congestion, exudation, a large emigration of white blood- cells, and an increased production of mucus. Lesions. — The changes are the same as in exudative colitis, with the exception of the large emigration of white blood-cells These are found in large numbers infiltrating the connective-tis- sue coat, and the tissue between the tubules of the glandular coat. Sy?nptoms. — The clinical picture is that of an acute exudative colitis of severe type. In some cases the whole appearance of the patients is that of septic poisoning with diarrhoea. The in- flammation is frequently fatal, but it is impossible to determine what the proportion is between deaths and recoveries. THE LARGE INTESTINE. 211 3. ACUTE PRODUCTIVE COLITIS. Synonyms. — Catarrhal colitis, dysentery. I}efiuition. — An acute inflammation of the colon attended with exudation from the vessels, an increased production of mucus, and a growth of new tissue between the glandular tubules and in tlie connective-tissue coat. Lesions. — The inflammation, as a rule, involves a considerable part of the length of the colon. The gross appearance is that of congestion and moderate thickening, sometimes a number of small, superficial ulcers can be seen. The principal changes are in the glandular coat. We find there a growth of fibro-cellular tissue between the glandular tubules, with disappearance of the tubules. There is also a growth of cells in the connective-tissue coat. The little ulcers are formed by necrosis of small portions of the glandular coat. Symptoms. — In children, who are only sick for a few days and then die from the colitis, the symptoms are those of acute exu- dative colitis. But after death we find that the growth of new tissue between the glandular tubules has already begun. More frequently the inflammation continues for a longer time. The patients are ill for weeks or for months, or go on to have chronic colitis. In these long-continued cases we usually find small superficial ulcers of the glandular coat if the disease is fatal. The patients begin with more or less abdominal pain, and a number of loose fecal passages. Besides the fecal matter, there may also be discharges of mucus and blood. Tenesmus may be present or absent. The temperature varies very mucli. In some cases it will hardly be above the normal at any time, in other cases there will be a temperature of between 100° and 103° F. throughout the disease. The afternoon temperatures are the highest. The patients are not at first very sick, but gradually lose flesh and strength, until they are glad to go to bed and stay there. Vomiting is often present at the beginning of the disease, and there may be so much nausea as to make feeding very difficult. As long as the colitis continues the patients have numerous fluid fecal passages, and from time to time they pass blood and mucus. 212 THE LARGE INTESTINE. A considerable number of the patients recover, but a duration of three or four weeks is not uncommon even in the favorable cases. Treatjnent.- — The patients are to be put to bed and on a fluid diet, but in the protracted cases they must not be deprived of solid food for too long a time. The drug which answers the best purpose is castor-oil in doses of from five to twenty drops, three or four times a day. At first opium has to be given with the castor-oil, later it is given by itself or with salol. 4. NECROTIC COLITIS. (