®itrpn by '3/ ' y^j^/ty 'S^^j-e-'y i^yccey Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookonpractiOOfren PLA TE I. Practice of Medicine — French. Fig A. ^''-A,. ^*- ''^rf-W^' 4 FigB. 2 ^i??>^' 1 THE BLOOD IN LEUKEMIA. FIG A Splenomyelogenous Leukemia: yellow cells, erythrocytes; 1, Polymor- phonuclear NEUTROPHILES; 2, EOSINOPHILES ; 3, LYMPHOCYTE ; 4, MYELOCYTES ; 5. NUCLEATED ERYTHROCYTES. FIG. B. LYMPHATIC LEUKEMIA: YELLOW CELLS, ERYTHROCYTES ; 1, POLYMORPHONUCLEAR NEUTROPHILE. ALL OTHER CELLS ARE LARGE OR SMALL LYMPHOCYTES. A TEXT-BOOK ON THE PRACTICE OF MEDICINE Designed for the Use of Students JAMES MAGOFFIN FRENCH, M.D. Lecturer on the Theory and Practice of Medicine, Medical College of Ohio ; Attending Physician, St. Mary's Hospital ; Consulting Physician, St. Francis Hospital for Incurables ; Cincinnati. ILLUSTRATED BY TEN FULL-PAGE PLATES AND FIFTY WOOD-ENGRAVINGS NEW YORK WILLIAM WOOD AND COMPANY MDCCCCni Copyright, 1903 By WILLIAM WOOD & COMPANY THE PUBLISHERS' PRINTING COMPANY NEW YORK PREFACE. There are many excellent textbooks on the Practice of Medicine. Nevertheless, an experience of nearly twenty-five years as an instructor has convinced me that a book of the character of this one cannot fail to meet the requirements of medical students. It has been my aim to state only the facts of medicine accepted by the best authorities, and to express them in simple, concise language, and, as far as possible, in logical sequence. Personal experience has been kept in the background, and the pleasant diversion of case reports has been entirely omitted. The names of authorities have been given only when it seemed improper to omit them. While I am indebted to all the recent textbooks and larger treatises, and although I have scanned the current periodicals, I have endeavored to make use of only the established facts, omitting discoveries that rest solely upon theory or undemonstrated observa- tions. Both the English and metric systems of weights, measures, and tem- peratures are given throughout the text, the metric system in paren- theses. When the exact equivalent is unimportant, the nearest round number is given, as an aid to memory. Part I, entitled Principles of Medicine, is inserted for the purpose of affording the student a convenient means of refreshing his memory in the pathological processes constantly recurring in the study of diseases. And it is hoped that Part III, on Clinical Methods, will serve the same end and prove of continued, if not of greater, value, after the erstwhile student has attained to the higher station of a practicing physician. JAMES M. FRENCH. Cincinnati, September i, 1903. CONTENTS. PART I. Principles of Medicine. PAGE Disease 3 Classification of Diseases (Nosology) 4 Causes of Disease (Etiology) 5 Pathology 7 Disturbances of Nutrition and Metabolism 7 Generalization of Disease 8 Changes in the Blood and Circulation 9 Fever. 19 Retrograde Processes 20 Inflammation 29 Regeneration 31 The Bacteria of Disease . . 32 General Bacteriology 32 Pathogenic Bacteria 36 Infection 37 Antagonism of Infection 39 ■ Immunity 42 PART II. Practical Medicine. SECTION I. The Infectious Diseases. Typhoid Fever 47 Typhus Fever 78 Relapsing Fever 80 Influenza (La Grippe) 82 Dengue 84 Cholera 86 Yellow Fever 89 Plague 94 Climatic Bubo 97 viii CONTENTS PAGE Malta Fever ny Beriberi g8 Scarlet Fever loo Measles . . .106 German Measles (Rdtheln) 109 Rubella Scarlatinosa ("Fourth Disease") no Cerebrospinal Meningitis .111 Pneumonia 115 Diphtheria 129 Diphtheroid 141 Whooping-Cough 142 Mumps 144 Septicemia . . .146 Pyemia 150 Erysipelas 151 Acute Rheumatism . . . . , . . _. . . .154 Gonorrheal Infection . . . 160 Syphilis . . .162 Tuberculosis 169 Leprosy 220 Tetanus 223 Infectious Diseases of Doubtful Nature . . . . . . .224 Febricula , .224 Acute Febrile Jaundice 225 Glandular Fever 226 Mountain Fever .227 Spotted Fever of the Rocky Mountains 227 Miliary Fever .228 Infectious Diseases Common to Man and Lower Animals . . 229 Glanders •. . . .229 Hydrophobia . . . 230 Anthrax . . . . . 2;^2 Actinomycosis . . -235 Psittacosis 236 Milk Sickness . . .327 Foot and Mouth Disease . . 237 SECTION 11. Diseases Due to Animal Parasites. Protozoan Diseases 239 Malaria 239 CONTENTS ix PAGE Dysentery 249 Smallpox . . .* . . 256 Vaccination . 265 Chickenpox 266 Psorospermiasis 268 Infusoria 268 Trematodes (Distomiasis) 269 Diseases Caused by Nematodes 270 Ascariasis 270 Trichinosis 271 Ankylostomiasis 275 Filariasis 276 Drachontiasis . .. . . *• 277 Other Nematodes 278 Diseases Caused by Cestodes . . 279 Tape-Worms 279 Visceral Diseases 282 Cysticercus Cellulosae 282 Echinococcus Disease 283 Parasitic Arachnids . . . . . . . . = . .287 Larger Parasitic Insects . . 287 SECTION III. Diseases of the Blood and Ductless Glands. Diseases of the Blood 289 Polycythemia 289 Polycythemia with Chronic Cyanosis 289 Anemia 289 Primary or Essential Anemia 290 Chlorosis ............ 292 Secondary Anemia 294 Leukemia 295 Splenomyelogenous Leukemia 297 Lymphatic Leukemia . 294 Pseudoleukemia 299 Purpura • .301 Hemophilia 304 Hemorrhagic Diseases of the New-born 305 Scurvy 306 Scurvy in Infants 308 X CONTENTS PAGE Status Lymphaticus 310 Diseases of the Suprarenal Bodies . . '. 310 Addison's Disease 310 Diseases of the Spleen . . . .313 Diseases of the Thyroid Gland -315 Goiter 316 Exophthalmic Goiter 317 Myxedema . 320 Diseases of the Thymus Gland . . 321 SECTION IV. Diseases of the Circulatory System and Mediastinum. Diseases of the Pericardium 324 Diseases of the Heart 324 Endocarditis 329 Simple Acute Endocarditis .329 Malignant or Ulcerative Endocarditis -331 Chronic Endocarditis 334 Valvular Heart Disease 335 Mitral Incompetency 337 Mitral Stenosis 340 Aortic Incompentency 342 Aortic Stenosis . 346 Tricuspid Insufficiency . . . 347 Tricuspid Stenosis 347 Pulmonary Valve Lesions 348 Association of Valvular Lesions 348 Hypertrophy of the Heart 351 Dilatation of the Heart . -354 Diseases of the Myocardium 356 Acute Myocarditis . . . 356 Chronic Myocarditis 357 Aneurism of the Heart 361 Rupture of the Heart 362 New Growths and Parasites of the Heart 362 Wounds and Foreign Bodies in the Heart . . . '. .362 Neuroses of the Heart . 3^3 Palpitation 363 Arrhythmia . 363 Tachycardia (Rapid Heart) 365 Bradycardia (Slow Heart) 366 COXTENTS xi PAGE Angina Pectoris 3^6 Congenital Defects of the Heart 3^9 Diseases of the Arteries . 3^9 Acute Aortitis 3^9 Arteriosclerosis 3 "9 Aneurism 3 73 Aneurism of the Aorta 374 Aneurism of Other Vessels 37^ Diseases of the Mediastinum 37^ SECTION V. Diseases of the Respiratory System. Diseases of the Nose 3^1 Acute Coryza 3^i Chronic Nasal Catarrh 3^^ Hay Fever S°3 Epistaxis 3<^4 Nasal Neuroses 3^4 Diseases of the Larynx . . . • • • • • • • 3^5 Acute Laryngitis • • • • • 3^5 Chronic Laryngitis . . 385 Edematous Laryngitis 38° Neuroses of the Larynx 3°° Diseases of the Bronchi 3^7 Acute Bronchitis 3^7 Chronic Bronchitis • • -3^9 Fibrinous Bronchitis 39^ Bronchiectasis 393 Bronchial Asthma 394 Diseases of the Lungs 397 Hyperemia of the Lungs 397 Edema of the Lungs 39^ Pulmonary Hemorrhage 399 Bronchopneumonia . . . • 4° 2 Chronic Interstitial Pneumonia 4°^ Pneumokoniosis 4° 7 Emphysema 4o8 Pulmonary Collapse 4^2 Abscess of the Lung . . • 4^3 Gangrene of the Lung 4i4 Neoplasms of the Lung . 4^5 xii CONTENTS PAGE Parasitic Diseases of the Lung . .416 Diseases of the Pleura 417 Acute Pleurisy . . 417 Purulent Pleurisy ■ . .420 Chronic Pleurisy 425 Hydrothorax . .426 Pneumothorax, Hydropneumothorax, Pyopneumothorax . 427 SECTION VI. Diseases of the Digestive System. Diseases of the Mouth 430 Stomatitis 430 Catarrhal Stomatitis 43 a Aphthous Stomatitis 430 Parasitic Stomatitis 431 Ulcerative Stomatitis .0 43.r Gangrenous Stomatitis 432- Membranous Stomatitis , -433 Syphilitic Stomatitis 433 Mercurial Stomatitis 433 La Perleche . 434 Riga's Disease 434 Ludwig's Angina 434 Diseases of the Tongue 434 Acute and Chronic Glossitis , 434 Glossitis Desiccans 435 Geographical Tongue 435 Leukoplakia Buccalis 435 Macroglossia . '. . 435 Hemiglossitis . . . . 435 Epithelioma of the Tongue 435 Diseases of the Salivary Glands 435 Supersecretion 436 Xerostomia 436 Inflammation of the Salivary Glands 436 Symptomatic Parotitis ........ 436 Diseases of the Pharynx 436 Circulatory Disturbances of the Pharynx 436 Neuroses of the Pharynx 437 Acute Pharyngitis 437 Chronic Pharyngitis - . .438 CONTENTS xiii PAGE Retropharyngeal Abscess 438 Acute Infectious Phlegmon 438 Diseases of the Tonsils 439 Acute Tonsilitis 439 Chronic Tonsilitis 440 Enlargement of the Lingual Tonsils 441 Diseases of the Esophagus . . . . , . . . . 441 Acute Esophagitis 441 Chronic Esophagitis . , . . 442 Stricture of the Esophagus 442 Cancer of the Esophagus 443 Neuroses of the Esophagus 444 Diseases of the Stomach 445 Examination of the Stomach 446 Acute Gastritis 447 Phlegmonous or Suppurative Gastritis 448 Toxic Gastritis 449 Chronic Gastritis 450 Dilatation of the Stomach 455 Peptic Ulcer . . . . . .459 Cancer of the Stomach . . . . . . . . . 463 Other Tumors ... o ....... . 468 Hypertrophic Stenosis 468 Hemorrhage of the Stomach 468 Neuroses of the Stomach . . . . . . . , .470 Neuroses of Secretion , .470 Neuroses of Motion . . . . . . . . .472 Neuroses of Sensation 474 Diseases of the Intestines 476 Acute Catarrhal Enteritis 476 Chronic Catarrhal Enteritis 478 Cholera Morbus 480 Enteritis in Children . . .481 Cholera Infantum 483 Acute Enterocholitis 484 Celiac Disease 485 Sprue or Psilosis 485 Diphtheritic Enteritis 486 Phlegmonous Enteritis 486 Ulcerative Enteritis . . 487 Hemorrhage of the Intestine 488 Hemorrhagic Infarction of the Intestine 488 xiv CONTENTS PAGE Amyloid Disease of the Intestine 489 Appendicitis 489 Intestinal Obstruction 498 Constipation 503 Hemorrhoids 505 Enteroptosis 507 Dilatation of the Colon 507 Neuroses of the Intestine 508 Enteralgia 509 Mucous Colitis 510 Intestinal Sand 511 Diseases of the Mesentery 511 Diseases of the Liver 512 Disturbances of the Hepatic Circulation 513 Diseases of the Blood-Vessels of the Liver 514 Acute Hepatitis 515 Cirrhoses of the Liver . 517 Atrophic Cirrhosis 521 Hypertrophic Cirrhosis 521 Perihepatitis 522 Abscess of the Liver 524 Fatty Liver . . .... . 526 Amyloid Liver - • -5^7 Cancer of the Liver .......... 528 Other Tumors of the Liver . . 5^9 Parasites of the Liver 530 Diseases of the Bile-Passages and Gail-Bladder 530 Jaundice (Icterus) 53° Icterus Neonatorum 53^ Angiocholitis (Cholangitis) 53 2 Cholelithiasis (Gall-Stones) 53 ^ Cancer of the Gall-Bladder and Bile-Ducts 539 Diseases of the Pancreas 539 Hemorrhage of the Pancreas 539 Acute Pancreatitis -54° Chronic Pancreatitis 54^ Fat-Necrosis 54^ Pancreatic Cyst . 542 Tumors of the Pancreas 543 Pancreatic Calculi -543 Diseases of the Peritoneum 543 Acute Peritonitis . . - 543 CONTENTS XV PAGE Chronic Peritonitis 548 Cancer of the Peritoneum 549 Ascites 549 SECTION VII. Diseases of the Kidneys. Anomahes of Form and Position 552 Movable Kidney 552 Hyperemia of the Kidney . . -554 Anomahes of Secretion 555 Anuria 555 Albuminuria , 555 Hemoglobinuria , , . . -557 Hematuria . . . ., 557 Hematoporphyrinuria . -558 Albumosuria 558 Chyluria 558 Pyuria 558 Lithuria . . . . . 558 Phosphaturia 559 Oxaluria 559 Cystinuria -559 Indicanuria 559 Melanuria . 559 Alkaptonuria . . . . . . 559 Uremia : 560 Acute Nephritis -. . . .561 Chronic Nephritis . 567 Amyloid Kidney . . . . .572 Pyehtis . . . . ' 573 Hydronephrosis . . . . . . . . . . . -575 Nephrolithiasis 576 Perinephric Abscess 578 Cystic Kidney 579 Tumors of the Kidney 579 SECTION VIII. Co-NSTITUTIONAL DISEASES. Arthritis Deformans 581 Chronic Rheumatism 584 xvi COXTEXTS PAGE Muscular Rheumatism 586 Gout 587 Rickets 593 Diabetes • 595 Diabetes Insipidus 602 Obesity 603 SECTION IX. Intoxications and Miscellaneous Diseases. Alcoholism 605 Morphinism 608 Cocain Habit 6og Chloral Habit 610 Lead-Poisoning 610 Arsenical Poisoning .613 Food-Poisoning 614. Sunstroke 616 Diseases of the Muscles 618 SECTIOX X. Diseases of the X'ervous System. Diseases of the Xerves 621 Xeuritis 621 Neuromata 625 Diseases of the Cranial X'erves 623 Olfactory X'erve and Tract 623 Optic X'erve and Tract . . . , 624 Oculomotor Xerve 625 Fourth Xerve 626 Fifth or Trigeminus X'erve 626 Sixth X'erve (Xervus Abducens) 627 Facial X'erve . • .627 Auditory X'erve 628 Glossopharyngeal X'erve 629 Pneumogastric (Vagus) X'erve 6.-? 9 Spinal x\ccessory X'erve 630 Hypoglossal X^erve 631 Diseases of the Spinal Nerves 632 Cervical Plexus ^32 Brachial Plexus 633 CONTENTS xvii PAGE Lumbar Plexus 634 Sacral Plexus 634 Sciatica 634 Diseases of the Spinal Cord and Meninges 635 Spinal Pachymeningitis 635 Spinal Leptomeningitis 636 Affections of the Blood-Vessels and Circulation of the Cord . 63 7 Caisson Disease . .638 Myelitis 639 Compression of the Spinal Cord ....... 641 Acute Anterior Poliomyelitis 642 Acute Ascending Paralysis 644 Progressive Muscular Atrophy 645 Glossolabiolaryngeal Paralysis 646 The Spinal Scleroses , 647 Posterior Spinal Sclerosis . . . . . . . . 647 Primary Lateral Sclerosis 651 Ataxic Paraplegia (Cowers) 652 Hereditary Ataxia 652 Syringmyelia 653 Tumors of the Spinal Cord 654 Malformations of the Spinal Cord 655 Diseases of the Brain and its Meninges 656 Diseases of the Meninges 656 Affections of the Blood-Vessels and Circulation of the Brain . 658 Cerebral Hemorrhage 661 Cerebral Paralyses of Childhood . ... . . , 666 Acute Encephalitis . . 667 Suppurative Encephalitis . . .667 Chronic Meningoencephalitis 669 Sclerosis of the Brain .. . .671 Tumors and Cysts of the Brain 672 Aphasia 674 Hydrocephalus 675 Functional Nervous Diseases 677 Acute Delirium 677 Paralysis Agitans , . . . ,678 Other Tremors 679 Acute Chorea 680 Choreoid Affections . . 682 Convulsions of Children 682 Epilepsy ■ 684 xviii CONTENTS PAGE Tetany - . . . 688 Migraine ^ 689 Neuralgia 690 Hysteria . . . . . . 693 Neurasthenia 696 Occupational Neuroses 699 Traumatic Neuroses 700 Functional Paralyses 701 Periodical Paralysis 701 Astasia — Abasia 701 Vasomotor and Trophic Disorders 701 Raynaud's Disease 701 Erythromelalgia . 703 Angioneurotic Edema 703 Facial Hemiatrophy . 704 Scleroderma . 704 Acromegaly 705 Rare Vasomotor Affections 706 PART III. Clinical Methods of Examination. Examination of the Blood 711 The Blood-Count 711 Widal Serum Test 717 Specific Gravity of the Blood . . . . . . . .717 Bacteriological Examination of the Blood . . . . . 718 Tests for Blood ...» . 718 Examination of Stomach-Contents 719 Qualitative Tests . . .720 Quantitative Tests • .722 Microscopic Examination -7^3 Examination of Stomach-Washings .724 Examination of Vomitus 7^4 Examination of Intestinal Discharges 724 Disinfection of Dejecta 7^7 Examination of the Urine • • • T^l Tests for Normal Ingredients .728 Abnormal Constituents . 73° CONTENTS xix PAGE Drugs in the Urine . 734 Urinary Sediments 736 Urinary Casts 738 Animal Parasites 739 Vegetable Parasites 740 Cryoscopy 741 Bacteriological Methods 741 Examination of Sputum 748 PART I. THE PRINCIPLES OF MEDICINE. A TEXT-BOOK ON THE PRACTICE OF MEDICINE. Disease is an abnormal state of the body, a perversion or interruption of the function of any organ or tissue, with or without corresponding structural change. The disturbance must be more or less continuous. A temporary al- teration of function, due to a transient cause, may be strictly physio- logical and it may result in the removal of some harmful agent or substance and thus prevent more permanent disturbance. The rapid respiration and quickened heart's action which follow active exercise, for example, do not denote disease, for experience has shown that they are normal and necessary to the vitality of the tissues ; but if a similar acceleration of these functions habitually follow slight exertion, it is to be regarded as pathological, an indication of disease. In many instances disease is first manifested by either an increase or a diminution of functional activity, on the order of that just referred to, or there may be an evident loss of harmony between two or more physiological processes. As a rule abnormal function denotes an impairment of structural integrity, although we may not be able to discover it. But an interruption or perversion of function may undoubt- edly occur in an organ free from structural change. Our knowledge of the pathological changes which underlie the manifestations of disease is becoming daily more exact, but it does not yet enable us to exclude from our classification all those affections which have been regarded as functional. In a systematic study of medicine, the diseases are studied as indi- viduals, as entities. The first aim of the student is to become able to recognize each disease by its cause, the structural changes and clinical manifestations in which it differs from all others. In some affections it is one of these features, in some another, that is most important to its recognition. But Medicine is not yet an exact science, and it is prob- able that many affections which we now regard as distinct diseases will, in the course of time, be found capable of more accurate subdivi- sion. The acute exanthemata as we know them were at one time re- garded as varieties of a single disease, and at the time this is written it is a matter of dispute whether or not there is yet a " Fourth disease" in the measles and scarlatina group. In the study of individual diseases, again, we must often take into consideration two or more subvarieties of the same affection, owing to differences in the symptomatology of dif- ferent cases, as in malaria and rheumatism. And it is not improbable 4 PRACTICE OF MEDICINE that many of these will, in the future, be resolved into independent affections when their causes become more definitely known. CLASSIFICATION OF DISEASES (NOSOLOGY). It is customary to classify diseases according- to their origin, clinical course, duration, and other features. No entirely satisfactory classifi- cation has ever been devised, however, and the chief object in presenting the following brief classification is to familiarize the student with the terms that are generally employed : I. Every disease may be classed as general or local in character. (i) A general disease involves the entire system. The class embraces (a) most of the acute infections, as typhoid fever, measles, smallpox, (Ji) the so-called constitutional or blood diseases, as pernicious anemia, g-out, and scurvy, and (r) the intoxications by lead, arsenic, opium, and other poisons. (2) Local diseases are those which affect particular organs or tissues. They may be subdivided into (<;?) organic, or structural, embracing af- fections of the brain, heart, lungs, skin, or other organs or tissues, and (J)) functional disorders, in which the action of an organ is impaired without discoverable structural lesion. The number of functional disorders has been greatly reduced in recent years by the discovery that many which were formerly so regarded depend upon lesions more or less remote from the part in which the clinical manifestations appear. And, since the disturbing influence often originates in the nervous system, or is at least conveyed through the nervous system to the point of its expres- sion, these affections have been grouped under the head of reflex ?ieu- roses. It should be remembered also that many of the general diseases have their local expressions in some organ or tissue, and that a pri- marily local disease may lead to general disturbance of the system. II. A disease may be acute, subacute, or chronic, (i) It is acute when it is severe in character, of short duration, and runs a rapid course, a feature of the acute exanthemata, (2) subacute when these features are less marked as in some cases of rheumatism, and (3) chronic when of slow progress and long duration, as in tuberculosis and syphilis. The distinction between acute and subacute is entirely one of degree and not always clearly defined. III. The course of a disease may be paroxysmal, periodic, continuous, or recsurrent. (i) K paroxysmal disease is characterized by sudden ex- acerbations of severity, or it manifests itself in sudden, explosive seiz- ures, as in epilepsy and some forms of neuralgia. (2) h.pe7-iodic disease is one which occurs with regularity at definite intervals of time, as ter- tian and quartan malaria. (3) The term continuous is applied to some fevers to describe their uninterrupted course, and (4) recurrent, to desig- nate a disease that returns during or soon after apparent convalescence, as relapsing fever. The term recrudescence is applied when the symp- toms unexpectedly return after a remission and when their return is due to a revivifying of the original infection or to a reinfection by the same organism, as occasionally occurs in typhoid fever. IV. Diseases are further classified as sporadic, endemic, epidemic, and pandemic in the extent of their prevalence. (i) A sporadic disease is one that may occur in any place at any time; the term is employed THE CAUSES OF DISEASE 5 chiefly to distinguish such affections as sporadic cholera from similar affections of an epidemic character. (2) An endemic distaiSe is one which, owing to some local influence, is more prevalent in a certain locality than elsewhere, as is usual with malaria and yellow fever. (3) An epidemic disease attacks simultaneously or in quick succession a large number of individuals in the same locality, or spreads rapidly over a large territory, as is frequently the case with smallpox, scarlatina, and measles, and (4) a. pa7idci?iic is one that attacks almost without excep- tion the entire population of a city or country, as occurs in influenza, cholera, and bubonic plague. V. With reference to their mode of origin, diseases are hereditary, congenital, or acquired. They are (i) hereditary when communicated to an individual by his progenitors. In most instances it is only a sus- ceptibility to the disease that is thus handed down. (2) A congenital disease either exists or originates at the time of birth, and (3) an acquired disease is one that develops in after-life, independently of either hereditary or congenital influences. VI. In their causation, diseases may be infectious, parasitic, or toxic. (i) The term infectious is now generally limited to diseases that are more or less definitely known to owe their origin to the presence of bacteria. Their number is continually being added to as new discoveries are made in bacteriology. The class is sometimes subdivided into («•) contagious and (/;) non-contagious, to denote that the disease can or cannot be communicated to a health}^ person who comes into contact with one who is infected. The contagion is said to be mediate when it can be carried through the medium of fomites, such articles as clothing, furniture, draperies; or immediate when actual contact is necessary. (2) The ttXTsx parasitic i^s, generally restricted in its applica^tion to the diseases due to the presence of animal parasites. (3) A toxic disease, or intoxication, is caused by a chemical poison. The poison may be ((?) organic, including ptomains and leucomains, or (Ji) inorganic, phosphorus, arsenic, lead, etc. VII. Such terms as primary, secondary, and specific are sometimes employed. An affection is prima?y, or essential, when it develops spon- taneously or independently of any other affection. A specific disease is one that is due to a definitely recognized virus or microbe and runs a definite course. THE CAUSES OF DISEASE (ETIOLOGY). Any influence that is capable of impairing the integrity of an organ or tissue or of disturbing its function may become a cause of dis- ease. In the production of most affections a succession or combina- tion of such influences is operative. The causes of disease may be divided into two classes, predisposing or remote, and exciting or determinate. I. A predisposing cause is one which prepares the individual for the action of the exciting cause by rendering him susceptible to its action. It is owing to some predisposing influence that one individual falls vic- tim to a disease from which another individual similarly exposed escapes. Predisposition may be either inherited or acquired. Among the influences that are recognized as the most common predisposing causes are {ji^ 6 PIL^CTICE OF MEDICINE age, Qf) sex, (^) race, (^/) occupation, (^) diet, ( /") habits of life, (^) climate, and (/;) previous illness. 2. The most prominent exciting causes are (c?) infection by bacteria, (<^) autointoxication, (r) invasion by animal parasites, and (^d^ poisons. Injury, exposure to heat or cold, improper food or drink, and many other influences may act as either predisposing or exciting causes. All these influences will be considered in connection with the individual diseases. Infection is the condition produced in the body by the entrance and propagation of pathogenic bacteria. It is considered under the head of Bacteriology, on page 37. Autointoxication, or self-poisoning, is a term applied to a class of diseases not yet fully identified, which result from the accumulation in the system of the products of metabolism or those of bacteriological decomposition. It results in some instances from processes which are in themselves normal, the poisonous effect arising from a disturbance of the relation between production and elimination. There may be («;) overproduction alone, or (/^) only deficient elimination; or these con- ditions may be combined. We are indebted chiefly to Bouchard for the knowledge we possess of the conditions. 1. Leucomains. — The products of metabolism have been named leucomains. They are believed to be derived from the nuclein in the nuclei of the cells. The best known members of the class are : adenin, creatin, creatinin, guanin, xanthin, hypoxanthin, and paraxanthin. Vaughan and Novy have found them nontoxic, except paraxanthin, which has been found only in the urine. To their presence are, neverthe- less, attributed many disturbances, especially on the part of the nervous system. Urea is closely related to these bodies in its origin and sup- posed action. 2. Ptoma/ns. — The decomposition of proteids by the action of bac- teria gives rise to another class of poisons, alkaline bases, known as ptomains. Among those which have been isolated are cadaverin, putres- cin, neuridin,.saprin, and the aromatic group, indol, phenol, and cresol; there are many others which have been produced for the most part through experimentation. They may enter the body preformed, in food that has previously undergone putrefaction, as when partially decomposed meat or fish is ingested, or they may be formed by the decomposi- tion of proteids in the intestine, through the action of bacteria. 3. Acid Intoxication. — Another form, of intoxication is due to the metabolic production of such acid bodies as uric, lactic, sarcolactic, sulphuric, phosphoric, and fatty acids, especially as a result of fever, inanition, anemia, acute yellow atrophy of the liver, diabetes, and cancer. The production of these bodies is attributed both to decom- position of proteids and to defective oxidation. Their presence in ab- normal quantity is supposed to be indicated (^?) by disturbances of the nervous system, mental dulness, and especially the coma which so often announces approaching dissolution; (/;) by the production of a cachexia ; (r) but especially by excessive elimination through the kidneys. 4. The retention of bile salts and their entrance into the circu- lation produce a form of autointoxication, cholcmia, which is mani- PATHOLOGY 7 fested by the characteristic discoloration of the skin and other tissues, accompanied with various systemic disturbances. The remains of dis- organized blood and broken-down tissues, the results of injury, may be absorbed and cause intoxication, often manifested in the so-called aseptic fev 67'. Many of the substances which are capable of producing autointoxi- cation are always present in the body, and we are not fully acquainted with the influences that cause them to be absorbed into the blood only at certain times. It has recently been attributed to a change in the osmotic pressure of the blood. Our knowledge of the autointoxications is not yet so complete as to enable us in all cases to refer a group of symptoms to its specific cause. The most prominent manifestations are generally seen in the derangement of nervous functions, frequently accompanied with disturb- ances of the gastrointestinal tract and changes in the composition of the urine. Headache, drowsiness, anorexia or vomiting, hebetude or coma, sometimes convulsions, characterize most of the cases. The symptoms are often erroneously assumed to be due to uremia. Bouchard regards autointoxication as a frequent cause of trophic disturbances in the muscles, joints, and other tissues. Animal Parasites. — A large group of diseases arises from the pres- ence of animal parasites within the body. The lowest class of these parasites embraces the protozoa, to which belong the parasites of malaria and dysentery; the psorospertns, known also as cytozoa on account of their being found within cells, and the coccidia, sometimes classed with the psorosperms. The best example for study is the coc- cidium oviforme, found in small saccular dilatations of the bile-ducts of rabbits. Different parasites of this class have been described by vari- ous investigators, but not fully demonstrated, as the causes of carcinoma, epithelioma, sarcoma, measles, scarlet fever, pernicious anemia, and other diseases; and others are occasionally associated with skin diseases or intestinal disturbances. Of the more highly organized animal parasites there are two classes, namely, the epizoa and the entozoa. The former exist only in the skin or upon its surface ; the latter, about fifty in number, penetrate to the deeper parts of the body. The entozoa are more familiar to us as worms. They may be divided into three classes : cestodes, nematodes, and trematodes. (a) The ces- todes are the tapeworms. (Ji) The nematodes are round or threadlike worms, including the lumbricoids, filiaricE, and trichina, (r) The tre- matodes constitute a class to which belong the liver-flukes. Some of the entozoa enter the body as mature worms, some in a larval state, while others develop within the body from eggs that have been taken in with food or drink. Their relation to the production of diseases is further considered under the diseases attributed to them. PATHOLOGY. Disturbances of Nutrition and Metabolism.— The term metaboHsm is applied to the processes constantly going on in the body through which (i) the tissues appropriate the nutriment that is brought to them in 8 PRACTICE OF MEDICINE the blood, and (2) prepare the protoplasm of the cells for special uses or for excretion. It is in the first instance a constructive process (anabolism) and in the second a destructive one (katabolism). So long as these two processes maintain a proper balance, the body re- mains in a normal state of nutrition. The source of supply is the food. In order to fully replace the losses of heat and energy occasioned by all the vital activities, the food ingested must be not only sufficient in quantity and suitable in kind, but its essential elements, proteids, fats, and carbohydrates, must be appropriated in sufficient amount. Excessive Nutrition. — Oversupply of food does not necessarily pro- duce excessive nutrition. The appropriation depends in part upon the character of the food, in part upon such extrinsic influence as exercise, but to a greater extent upon individual peculiarities of the metabolic processes. In many cases oversupply leads to only an excessive retention or discharge of such end-products of metabolism as urea. The overappropriation of nourishment seen in obesity is derived in part from the fat ingested with the food, but more particularly from the carbohydrates. It is very often out of proportion to the quantity of these substances ingested. Obesity is therefore regarded, in most in- stances, as a result of abnormal metabolism the nature of which has not been fully determined. By some investigators it is regarded as a result of deficient oxidation, especially when it is associated mth anemia. Diminished Nutrition. — A deficient supply of food, or an inability of the system to prepare and appropriate that received, results in a condition of inanition which may be slight or so extreme as to result in death. The first indications of inanition are generally a loss of body weight and a diminution of the energy of the various organs. The loss of weight results from the consumption by the organism itself, first of the fat and later of other tissues. The body appropriates its own tissues for food. The tissues are said to undergo atrophy. Impairment of the nutrition of a single organ or tissue from any cause leads to local atrophy, as in the wasting of a paralyzed member. General lack of nutrition is seen in many pathological processes, notably in fevers and in infectious diseases. When the result of chronic disease or of the growth of a tumor, the wasting is called ■marasmii.s or cachexia; when the result of toxic matter carried in the blood, it is sometimes spoken of as a dyscrasia. Generalization of Disease. — An organ often becomes diseased as a result of a morbid process in another organ. Some diseases are definitely local in character and produce little or no disturbance in other parts of the body ; while others begin as local processes and rapidly become generalized. The generalization of the infectious diseases depends in part upon the action of the toxins upon the nervous system and in part upon their affinity for particular cells. A similar generalization occurs in many noninfectious diseases, especially in the autointoxications, producing, as prominent manifestations, elevation of temperature, loss of strength, and emaciation. An impairment of the function of one organ sometimes exercises an important influence upon other organs. At first functional, such dis- turbances may become organic. The original impairment of function in PATHOLOGY 9 some instances throws toxic matter into the circulation which acts in- juriously upon the parenchyma cells of other organs, causing more or less pronounced degenerative changes in them. Or a similar result may follow the loss of an agent normally secreted by the organ which be- comes the seat of a morbid process. The heart, voluntary muscles, glands, and kidneys are especially liable to become the seat of such degenerations, the kidneys more than other organs, perhaps, because they are called upon to remove from the system a greater part of the poisonous materials resulting from the disease processes. The blood serves as the carrier of the toxic matters resulting from disease, as well as of those producing it, and consequently undergoes im- portant changes in composition and quantity. These changes diminish the supply of nutrition to the organs and tissues and therefore consti- tute another factor in the generalization of the morbid processes. Changes in the Blood and Circulation.— TAe B/ood.— The quantity and composition of the blood remain remarkably constant during health, despite the many influences to which it is exposed. Slight changes take place from hour to hour, it is true, with the ingestion of food and drink, and the circulation is made the avenue of the effete products of metabolism on their way to elimination. Plethora, or overabundance of blood, formerly regarded as of much importance, is believed to be unusual and of short duration. In the oligemia, or reduction of quantity, which results from hemorrhage, the loss is quickly compensated for by the contraction of the blood-vessels, the appropriation of fluids from the tissues, and generally by an increased supply of water that is drunk in order to quench the imperative thirst. An abnormal increase of the water in the blood gives rise to hydremia, a condition which is overcome by a rapid formation of new blood-cells and the elimination of the water through the secretions. Hydremia is believed to occur in some conditions of anemia. The opposite condition, anhydremia, in which the water of the blood is deficient, is produced by a profuse discharge of water through the bowels in cholera, through the kidneys in diabetes, or by excessive sweating. The diseases involving changes in the erythrocytes are considered under the Diseases of the Blood. Leucocytosis (hyperleucocytosis) is a recognized feature of an in- creasingly large number of diseased conditions. When moderate, it is sometimes regarded as physiological. The number of leucocytes in the cubic millimeter of normal blood varies from 4,000 to 10,000. In- crease or decrease beyond these limits indicates a pathological condition. Diminution of the number is termed hypoleucocytosis. Leucocytosis may be active or passive. The best example of the former is seen in phagocytosis (p. 40). The principal causes of leucocytosis are : ((/) Infection and the resultant toxemia, Q)) disease of the blood-forming organs, (<:) malignant disease, (/^) hemorrhage, and (.?) the action of certain drugs. It sometimes develops also immediately before death, although absent during the course of the disease. As a result of toxic influences, leucocytosis occurs in probably all the acute infectious diseases, except typhoid fever, uncomplicated tubercu- losis, measles, and perhaps influenza. As an autointoxication it is seen lo PRACTICE OF MEDICINE in acute disorders of digestion, gout, cirrhosis and acute yellow atrophy of the liver, acute and chronic nephritis, and hydronephrosis. In both these classes of cases it is an active process having for its object the protection of the system. Hypoleiicocytosis is always pathological and met with : («) In the infections, typhoid fever, measles, tuberculosis, and influenza; (^) under certain conditions, in infections ordinarily attended with leucocytosis; (t) in some cases of leukemia and pseudoleukemia; and (^) as a result of the action of certain drugs. The development of a mixed infection in these cases immediately induces a hyperleucocytosis. The Circulation. — The circulation of the blood is maintained almost entirely by the rhythmical contractions of the heart; the uniformity of blood pressure, by the elasticity of the blood-vessels. The pressure in the pulmonary artery is never so strong as that in the aorta. The normal relation between the heart's action and the blood pressure is under the supervision of the nervous system, to a great extent under that of the ganglia situated in the heart itself. Deficient Blood F?-essu7'e. — The systemic blood pressure is diminished by every impairment of the integrity of the heart, whether involving its muscle, its valves, or its ganglia, unless the defect is fully compen- sated for by increased force of action. The heart muscle may be im- paired by fatty and other degenerations resulting from (a) long-con- tinued fevers, (Z-) the presence of poisonous matter in the blood, or (r) such impairment of nutrition as that caused by sclerosis of the coronary arteries. The action of the heart is interfered with also by ((^z) adhesions which bind the organ to adjacent structures, Qf) an accumulation of fat or fluid in the pericardium, (<:) the pressure of tumors above or below the diaphragm, as well as by (^d^ hydrothorax or ascites. Deficient blood pressure in the arterial system, due to defective car- diac action, is generally attended with an increased accumulation of blood in the veins ; a venous stasis, passive hyperemia, or engorgement. Incompetency of the mitral valve, for example, permitting the regurgi- tation of the blood into the left auricle, produces engorgement of the pulmonary circulation. The increased action of the right ventricle pre- vents for a time a further retardation of the circulation. But when, as sooner or later happens, the right heart loses its ability to compensate, the engorgement becomes general. When the right side of the heart is primarily affected, passive hyperemia rapidly develops in all parts of the body. Weakness of the circulation, aided by gravitation of the blood, es- pecially after long confinement to bed in chronic febrile diseases, often leads to such local disturbances as hypostatic congestion of the lungs or an accumulation of blood in the vessels of the more dependent por- tions of the body. Extravasations occur in the same manner and are seen as ecchymoses in the skin. They are often followed by edema and sloughing, as in the formation of bedsores. Increased blood pressure is generally transitory, like that which results fi-om overaction of the heart during violent muscular exercise or ner- vous excitement. It may result also from the presence of toxic sub- stances in the blood, but it then gives place, as a rule, to weakness. PATHOLOGY n Overaction from violent effort may lead to hemorrhage, especially when there is a defect in the blood-vessel walls. The increased action of the heart occasioned by an effort to compensate for abnormal conditions within itself, or by changes in the blood-vessels, as in general arterio- sclerosis, leads first to hypertrophy of the ventricles, but later to de- generation of its muscles, with permanent dilatation of its chambers. Many disturbances of the heart's action and of the circulation are to be attributed to the influence of the nervous system expressed through the vasomotor nerves. Local Anemia. — When from any cause the blood supply of a part is diminished or completely cut off, a local anemia, or ischemia, is pro- duced. This varies from a very slight deficiency to complete absence of blood. When an artery is suddenly obstructed, as by an embolus, this anemic condition is immediately produced. This is true especially of those organs whose circulation is supplied through terminal or end arteries, where an immediate relief of the anemia through anastomotic circulation is impossible. Here the anemia becomes the first step in the development of an infarction. The term ischemia is often restricted in its application to anemia caused by arrest of the arterial blood entering the part. A collateral anei7iia is the condition produced when the blood is withdrawn from a region to meet the demand for it in an adjacent area which is in a state of congestion. Causes. — Local anemia is caused for the most part by («;) disease of the walls of the vessels supplying the area, Qi) compression of the vessel by cicatricial tissue, tumors, or accumulated fluids, (r) inflamma- tory processes around it, or (^) by influences operating upon it through the nervous system. The most important of the diseases of the vessel walls capable of operating in this manner are acute inflamma.tion, sclero- sis, atheroma, syphilis, and amyloid disease. Thrombosis and embolism produce anemia of the part supplied by the obstructed vessel. The ap- plication of cold to a part renders it relatively anemic by constricting its vessels; freezing produces absolute anemia. Anemia resulting from hemorrhage is, most profound in the extremities. Among the instances of local anemia produced through the action of the nervous system may be mentioned the early symptom of Raynaud's disease, the blanching often seen in a part affected with neuralgia, and the pallor of the face accompanying nausea or fright. A more or less profound anemia of the brain and of the skin accompanies inflammatory diseases of the abdominal viscera. An anemic part becomes pale, sOx'"ter, and cooler than normal; its nutrition and function are impaired. Long-continued partial anemia of a part or organ leads to fatty and other degenerations, with atrophy; complete anemia leads to necrosis. Local hyperemia is an increase in the quantity of blood in a circumscribed region of the body. It may be active, when the blood is arterial, or passive, when there is an accumulation of venous blood. I. Active hyperemia, or congestion, may be due to an increased ■demand for nutrition in the part, such as occurs in reparative processes. Pathologically it may be due to a dilatation of the vessels through vasomotor influences, central or peripheral in character. This occurs when the vasoconstrictor influence of the sympathetic nerves is inter- 12 PRACTICE OF MEDICINE rupted, as by the pressure of a tumor, or when the vasodilators in the spinal cord are stimulated, as sometimes occurs in neuritis. An inter- esting example of it is seen also in the unilateral flushing of the face in pneumonia. Active hyperemia occurs also when a tissue is injured mechanically or chemically; it may occur as a reaction from local anemia. A collateral hyperemia sometimes develops in consequence of profound anemia in another part. Hyperemia is always present in inflammation. Increased heat, redness, and slight swelling of the part are its usual manifestations. Its results are, at first, an increase of functional activity; later, inflammation or degenerative changes. 2. Passive Hypereniia. — When the presence of an increased amount of blood is due to a retardation or arrest of the flow of venous blood from the region, the hyperemia is passive. This occurs when a vein is compressed or closed in any manner. It varies in degree from a slight retardation to a complete stoppage (venous stasis). It is caused by inflammation of the vein or of the parts around it, by thickening of its walls through sclerosis, calcification, or syphilitic induration, or by compression of a new growth. A more general passive hyperemia is seen in the various organs, especially in the lungs and liver, as a result of valvular disease of the heart. The aff"ected tissues at first become swollen and intensely red, then a transudation of serum occurs, and edema is produced ; later, if the condition continues, fatty degeneration and ultimately necrosis may take place. The destroyed area is sometimes replaced by new fibrous tissue which is often deeply pigmented. The condition is then known as brown ah'ophy. The best example of it is found in the myocardium as a result of arteriosclerosis of the coronary arteries. Dropsy and Edema. — Dropsy is a generic term and embraces all abnormal accumulations of fluid within the connective-tissue spaces and serous cavities of the body. Although the condition is practically the same in all cases, usage has given us several names for the designation of dropsical accumulations in different regions. When only the connec- tive-tissue spaces of organs are involved, it is spoken qf as an edema; an accumulation in the subcutaneous-tissue spaces, especially those of the lower extremities, is an anasarca; that in the peritoneal cavity, ascites; in the pleural cavity, a hyd?-othorax, or pleuritic effusion. WTien in the arachnoid space and ventricles of the brain, it is a hydrocephalus, and when in the pericardium, a hydropericardiu?n. In general dropsy there is a progressive involvement of the connective tissue spaces and cavities. The serous and connective tissue spaces normally contain a small quantity of plasma, which is fairly constant in each part. It is derived for the most part from the capillary blood-vessels, but in part, perhaps, from the lymph-vessels. Under normal conditions the plasma is taken back into the circulation after it has remained in the tissues for a time, performing its function of supplying nutrition. Some authors refer this return of the fluid entirely to the action of the lymph-vessels, while others believe that the blood-vessels are even more active in picking it up. A normal condition of the blood-vessel walls with reference to permeability and normal blood pressure in the capillaries is regarded as essential to the maintenance of a normal quantity of this fluid in the spaces, PATHOLOGY 13 and it has been suggested that osmosis through the capillary walls is responsible for its ebb and flow. It is no longer regarded as a product of secretion. Causes of Dropsy. — i. A dropsical accumulation of fluid is generally the result of a disturbance of the relation between transudation and absorption. This in turn may be due to ((2) increased blood pres- sure, (/') changes in the capillary walls which render them more perme- able to the plasma, (r) changes in the composition of the blood which render it more diffusible, or ((^/) influences which otherwise retard the return of plasma to the circulation. The first of these causes, an increased blood pressure, is generally due to a "retardation of the capil- lary and venous circulation and is therefore on the order of a hyperemia. It is a passive hyperemia, an increase of venous rather than of arterial pressure. Weakness of the circulation favors the transudation of serum, and the best examples of dropsical effusion are seen in cases of heart disease after compensation has failed and the blood has become stag- nated in the veins. 2. Arterial Edevia. — The existence of a strictly arterial edema has been questioned. The term is generally limited to the edematous con- dition in an inflamed area, always a transient condition. The permea- bility of the vessel walls is increased by thermal or chemical injury as well as by degenerative changes consequent upon disease. 3. Alterations in the character of the blood are looked upon as a most important factor in the production of dropsies of renal origin. A hydremia has been described in these cases in which the blood becomes watery through a reduction of its solid constituents, but the condition cannot always . be demonstrated even in advanced stages of nephritis. The hydremia has been referred also to the retention of toxic substances in the blood owing to an inability of the kidneys to remove them. A third explanation refers it to deficient oxidation. 4. Interference with the flow of lymph through the larger channels may sometimes be a cause of dropsical accumulations, especially in the thoracic and peritoneal cavities. Probably nothing short of an ob- struction of the thoracic duct is capable of acting in this way, and such obstruction is known to increase an already existing ascites. 5. The nervous system is not regarded as operative in the produc- tion of dropsical accumulations, except so far as the vasomotor nerves may sometimes b& involved in it. 6. In some instances an accumulation of fluid replaces tissue that has been lost, as when a portion of the brain or spinal cord has been removed. This is called edema ex vacuo. The fluid of a pure edema corresponds in its saline and aqueous com- position to the serum of the blood, but it is deficient in albumin. The fluid of ascites is richer in albumin than is that of edema. When the effusion is due to disease of the blood-vessel walls, it contains more albumin and as a rule a larger number of blood-cells. The swelhng which accompanies an edema varies from a slight tumefac- tion to the most extreme distention. In extreme anasarca the skin becomes tense and glazed, and it is often rent to permit the escape of the fluid. The swollen part usually appears anemic; it may be cyanotic; it feels doughy or sodden, pits on pressure, and degeneration or necrosis is 14 PRACTICE OF MEDICINE apt to result. Edematous organs are lighter in color and ''juicy"' when incised. Their function is impaired. The gravity of the condition de- pends largely upon the part affected. Edema of the brain, glottis, or lungs is always attended with danger to life, and a general dropsy with serious failure of the circulation. Hemorrhage. — Hemorrhage signifies the escape of blood from a vessel — the escape of all the elements of the blood in contradistinction to the escape of only the plasma, as in edema. It may be external or internal. In the latter form, the blood is retained within the tissues or one of the inclosed cavities of the body. In its origin, the hemorrhage may be arterial, venous, or capillary. Arterial hemorrhage occurs only through a lesion of the vessel-wall (rhexis) ; venous and capillary bleeding may take place either through a lesion of the vessel-wall, or more gradually by diapedesis, a stepping out of the elements of the blood through the normal spaces in the vessel-walls. A migration of the leucocytes from the vessels into the adjacent tissues is normal ; but when the red corpus- cles thus escape, it constitutes a diapedesis and is pathological. The principal causes of diapedesis are degenerative changes in the vessels due to the action of toxic substances, mechanical or thermal injury, or arrest of the circulation. Hemorrhage of this character is not usually great in quantity. * Causes. — The causes of arterial hemorrhage are : (rt') Laceration or rupture of the wall of the vessel while in a state of health, a surgi- cal condition, ((^) disease of the blood-vessel, (r) increased blood pres- sure, and (^) nervous influence. Disease may affect the blood-vessel either internally or externally. The most important internal affections are fatty and other degenerations and sclerosis, often leading to miliary or larger aneurisms. Degeneration of the tunics of the vessel results chiefly from the toxemia of the infections or from malnutrition incident to fever, anemia, or the cachectic states. Among the causes of external disease of the vessels are the pressure of tumors, suppuration, and tuberculosis, thermal and chemical irritation. Increased blood pressure is sometimes spoken of as absolute when it follows violent muscular effort, paroxysms of intense joy or grief, the coughing of acute bronchitis or pertussis, and convulsions. It is relative when due to the withdrawal of normal external pressure, as in asphyxia, or when induced by ascent to high altitudes. Hemorrhage of nervous origin is due to paralysis of the vasomotor nerves or to a reflex mechanism which is not fully understood. Bleeding from the nose, lungs, stomach, or bladder, or into the substance of such organs as the kidneys and suprarenal bodies is sometimes of this char- acter. Another interesting class of hemorrhages is exemplified in the stigmatization of hysterical ecstasy, in which blood infiltrates the skin of different regions, most frequently those wounded in the crucifixion. Some persons have a natural tendency to hemorrhage; they are called bleeders, and the condition is known as the hemorrhagic diathesis. When inherited, it constitutes hemophilia. The hemorrhagic diathesis is sometimes acquired by persons not previously predisposed to hemor- rhage, in the course of typhus, yellow fever, cholera, the plague, scurvy, hypertrophic cirrhosis of the liver, septicemia, pernicious anemia, purpura hemorrhagica, and certain other aftcctions. PATHOLOGY 15 Varieties. — External hemorrhages are generally classified according to their source. Hemorrhage of the nose is designated epistaxis, hemor- rhage of the lungs hemoptysis, that of the stomach hematemesis, that of the intestine enterrhagia. Uterine hemorrhage is subdivided into menorrhagia and metrorrhagia, occurring during or between the men- strual periods. Interiial hemorrhages receive their nomenclature in part from their location and in part from their character. Hemorrhage into the peri- cardium is called hemopericwrdiuni, that into the pleural cavity hemo- thorax. A hemorrhage into or beneath the skin or a mucous mem- brane is an ecchyjtiosis; if this is confined to small areas and it. produces small reddish or dark brown spots these are called petechice. A larger accumulation of blood in a tissue is a suffusion, but if the accumula- tion be large enough to form a tumor it is call a hematoma. (See also Infarction.) Results. — Sudden profuse hemorrhage of any kind produces pro- found prostration, syncope, or shock. The individual is rendered uncon- scious and death may result. If not fatal, the unconsciousness is recovered from as soon as the blood-vessels, by contraction and by appropriation of fluid from the tissues, have in a measure compensated for the loss. Hemorrhages are spontaneously arrested by the decrease of blood pressure, by the retraction of the injured vessel, by the pressure of overlying structures, or by coagulation of the blood at the point of hemorrhage. A more or less profound secondary anemia may result from repeated small losses of blood. A hemorrhagic accumulation of blood is reduced in size by absorption of the serum after coagulation has taken place. The remaining coagu- lum may also be more or less completely taken up by absorption, especially when it is in a serous cavity. It is sometimes replaced by the formation of new, deeply pigmented fibrous tissue. The coagulum, on the other hand, may undergo decomposition, through the action of micro- organisms, and serious toxemia may follow. In other instances the clot becomes encapsulated and remains indefinitely as a harmless cyst. Thrombosis. — Coagulation of blood within the heart or blood-vessels during life is termed thrombosis. It may occur anywhere within the chambers of the heart, in the arteries, capillaries, or veins. The coagu- lum is called a thrombus. Causes. — The recognized causes of thrombosis are damage or removal of the endothelium lining the vessel, slowing of the blood-current, and changes in the blood which favor its coagulation, i. Injury of the vessel-wall is the most important. It is doubtful, indeed, whether throm- bosis ever occurs independently of such defect. The most common causes of such damage, aside from trauma, are fatty or other degeneration of the intima, inflammation of the vessel or of surrounding tissues, arterio- sclerosis, and such dilatation as occurs in aneurism, enlargement of the heart cavities, and varicosity. Inflammation is a more frequent cause in the veins than in the arteries. The intima of the vessel may be im- paired also by deficiency of nutrition, producing fatty degeneration ; by foreign bodies, parasites, or neoplasms. The endocardium may be injured by inflammation, and both these membranes by the toxic agents developed in infectious diseases. 1 6 PRACTICE OF MEDICINE 2. Slowing of the blood-stream probably does not produce throm- bosis so long as the walls of the vessel are intact. It is believed that coagulation is often prevented in cases of advanced atheromatous dis- ease, for example, by the rapidity of the current. A slowing of the current aids coagulation by favoring the preliminary accumulation of the blood-cells along the sides of the vessel and their attachment at any defective point. This tendency to stagnation of the blood may result from weakness of the heart, diminished elasticity, with either dilatation or contraction of the vessel. The circulation is normally slow in the cerebral veins and sinuses, and in the veins of the pelvis and lower extremities, especially when varicose dilatation is present. These are therefore frequent seats of coagulation. When the heart is dilated the apices of the ventricles, the space between the trabeculae and the auricular appendages are frequent sites of thrombosis. In the veins the thrombus generally forms just back of the valves. The thrombus is composed of superimposed layers. The first layer is known as the primai-y th?'o?7ibus, subsequent layers as secojidary. A thrombus remaining attached to the side of the vessel is a lateral throm- bus; when it completely obstructs the vessel, it is an obliteratmg throm- bus. Peculiar ball thrombi have been described as occurring in the heart. They are polyp-like masses attached by only a slender pedicle or lying free within the auricle. A thrombus which has formed in blood that has almost stagnated in the vessel is dark and soft and resembles a post-mortem clot. When it forms in circulating blood it is yellow or white in color. These facts depend upon the changed circulation that results from retardation. In the normal circulation the red corpuscles and blood-plates travel through the center of the current, leaving a zone along the vessel-wall consisting of plasma and leucocytes. When the circulation becomes slow, the blood-plates leave the central zone and cling in little clumps to the vessel-wall. Leucocytes soon join the accumulation and fibrin is then formed. The white thrombus is, therefore, composed of blood-plates, leucocytes, and fibrin. The importance of the blood-plates in coagulation of extravasated blood, as well as that within the vessels, has been studied by Arnold and others, who regard them as the most important factor. Results. — Collateral circulation may be established so quickly after the formation of a throm^bus as to prevent serious consequences; but in organs provided with terminal arteries, and when the anastomotic circulation is poor, infarction results. Thrombi are sometimes removed. The exact process by which this is accomplished is not known, but the softening which is known to occur in them is doubtless one step in it. They may be organized. In other words, the thrombus may be replaced by new vascular connective tissue which is nourished from the vessel- wall as though it were a normal part of the body. The other results of thrombosis are ((/) changes in the vessel-wall, (^) obstruction of the circulation, and (^) embolism. a. When the thrombus becomes organized, the vessel-wall is at first thickened, but it later undergoes atrophy. It may undergo suppurative softening through the action of micrococci ; suppurative arteritis or phle- bitis is then produced and septic infection of the system may follow. PATHOLOGY 17 b. Obstruction of the circulation produces results which vary with the size of the vessel, its location, the character of its anastomotic connections, and the suddenness of the obstruction. It is usually of less gravity than embolism. WTien an artery is obstructed, the result is a local anemia, •which, if continued, leads to degenerative changes in the parts supplied. When a vein is closed, con- gestion and edema follow. d A not unusual example of ^^^?®^^^^^P v.'-^^>'i$^rM^{ in the plugging of the ihac -^^^^g-D^OC^fi^^^'^^^'®' or femoral vein after ty- r-^'^OSDQ^'.^^'' phoid fever or in the late bjM^^^^J^ stages of tuberculosis and other chronic diseases. In Fig. i. -Greatly retarded blood-stream, a. Ax- the latter conditions it is ial stream b, Pei-jpheral ^one ^^•ith blood-plates .6% -A. collection ot blood-plates. (Alter hberth and known as marasmic throm- Schimmelbusch.) bosis. Embolism. — Embolism is the lodgment of any solid substance, carried by the blood, in a vessel whose lumen is too small to permit its further passage. The solid substance while passing through the vessel is called an embolus. The most frequent forms of embolus are : (-m ^^^^ otjj Results. — Fatty degeneration is of more ^ \P^^ff ^^^ *^v^r serious consequence than fatty infiltration, ^^^ °'W for it implies the death of the affected cell. C|k. ^^k a^Qf.: A moderate degree of degeneration does not W ^^^m ^tf!^'.°^Q necessarily cause an arrest of function and ^ ^^ ^';p/©}%* possibly may be recovered from; but a cell Fig. 3. -Fatty liver-cells, which is in an advanced state of fatty de- (Ziegier.) generation can never be restored. ALBUMINOID DEGENERATION 23 Fatty infiltration consists of a deposit of fat within the cells. It differs from fatty degeneration in that the fat is formed outside of the cell and merely replaces the protoplasm of the cell. It cannot always be distinguished from fatty degeneration. It is a physiological proc- ess in the growth and development of adipose tissue, as well as in the intestinal epithelium and liver parenchyma, after the ingestion of fatty food. As a pathological process it is more apt to occur in regions nor- mally containing fat, as in the subcutaneous and subserous tissues, in the bone marrow, the' liver, the mesentery and omentum, under the pericardium, 'about the kidneys, and between the muscles. Fat may be deposited in a tissue as a substitute for a part that has been destroyed or that has undergone atrophy. Causes. — Many persons inherit a predisposition to the accumulation of fat, and these are probably more liable than others to the patholog- ical infiltration. The common exciting causes of it are the excessive formation of fat or a diminished oxidation. Both these influences are doubtless operative in many wasting diseases, tuberculosis, chlorosis, diabetes, and cachectic conditions. Lack of exercise is probably an im- portant factor in its production in tuberculosis and other chronic cachexias. Results. — The effect of fatty infiltration is an increase of the size, diminution of color, and more or less complete loss of function of the cell. But the fat may be removed and the cell may be fully restored to its normal state and function. On the other hand, continued fatty infiltration may, chiefly by compression, incite a fatty degeneration of the protoplasm of the cell. ALBUMINOID DEGENERATIONS. Amyloid Degeneration. — Amyloid degeneration is a process as a result of which there is found in various tissues, especially in the walls of the smaller blood-vessels, a firm, colorless, translucent substance. Whether this substance is formed by a degeneration of the tissues themselves or is merely deposited in them has not yet been determined. The amy- loid substance is composed of carbon, hydrogen, nitrogen, and sulphur, and some investigators have referred its formation to a union of chon- dratin-sulphuric acid and a proteid, a combination which is rendered possible by the normal presence of chondratinic acid in bone, cartilage, and elastic tissue. The liver, spleen, kidneys, intestines, and lymph- glands are the most frequent locations of the degeneration, which begins generally in the middle coat of the smaller arteries, but sometimes in the trabecula of the lymph-nodes. It rarely involves connective tissue elsewhere. It may occur in the larger blood-vessels, in the heart, or in the mucous membranes of the respiratory passages. Few or many parts are simultaneously involved in difterent cases. The organs affected by it are markedly enlarged and much increased in firmness. Their color is usually pale, though this may be altered by the presence of other degenerations or by pigmentation. Causes. — It results from wasting diseases, particularly from sup- puration and ulceration, more especially when these involve bone, and 24 PRACTICE OF MEDICINE yet more certainly when the disease is of tuberculous or syphilitic origin. It is rarely encountered in the absence of any of these influences, as a result of mixed infection, severe malarial infection, dysentery, leukemia, and in cachectic conditions. Results. — A moderate degree of amyloid degeneration does not im- mediately jeopardize life, but recovery never occurs. The individual is always anemic and has a peculiar waxy, cachectic appearance. The local impairment of function corresponds to the degree of degeneration. Mucoid degeneration affects the cells or intercellular tissue and pro- duces a semifluid, translucent substance containing mucin. Its occurrence may denote only an increased functional activity of the cells, as in catarrh ; but in many instances, more truly pathological, the mucin formation appears to be entirely in the intercellular substance. It is generally found in the subcutaneous tissue in myxedema and scle- roderma, and it is a common degeneration in neoplasms. It may affect also cartilage, bone, and other tissues. The cells and tissues aff'ected may be entirely destroyed. When only the intercellular substance is involved, the cells may be destroyed as a result of compression. Colloid degeneration is closely related to mucoid, but the substance produced is not the same. It resembles rather the colloid matter of the thyroid gland. It is usually confined to the cells and aff'ects the intercellular substance only by inducing atrophic changes. It may involve the cell but partially, or it may entirely replace the protoplasm and cause its rupture. It occurs in goiter and neoplasms of the thyroid gland, in the kidneys and adrenals, the prostate and seminal vesicles; but very seldom in tumors elsewhere than in the thyroid. Colloid matter may be transformed into mucoid or hyalin, and mucoid mat- ter may be converted into colloid. The colloid substance may undergo solution in the products of serous transudation, leaving cysts filled with a brownish fluid often containing blood, pus, and cholesterin crystals. Hyalin degeneration (waxy or vitreous degeneration) resembles amyloid except in the character of the substance produced. The hyalin deposits are generally in the form of sharply defined, round or oval, rarely bottle-shaped bodies. The nature of the process is unknown. Some investigators refer to mesoblastic, epithelial, or blood hyalin, referring the origin of the hyalin matter to one or other of these tissues. It is generally found in the smaller blood-vessels in old age, following prolonged fever, or as a result of arteriosclerosis; in the brain, lymph- glands, ovaries, renal tubules, and voluntary muscles (Zenker's degenera- tion); in the walls of aneurisms, in the lesions of tuberculosis and syphilis, and in the retina and choroid coats of the eye. It has been observed also in leucocytes. Wood-plates, and fibrin. It is probably a feature in coagulation necrosis. It is caused by infection and intoxica- tion, especially by lead-poisoning. Glycogenic degeneration is a condition in which clear, globular masses of glycogen are formed in cells where this substance is not present, or in abnormal quantity where its presence is normal, as in the liver, cartilage, and muscle. The glycogen bodies are closely allied to the amylaceous bodies of the prostate, and resemble amyloid bodies in ap- pearance except that they may be concentrically striated. The degenera- RETROGRADE PROCESSES 25 tion occurs especially in diabetes. It sometimes involves leucocytes, pus- cells, and various tumor structures of mesoblastic origin. Dropsical infiltration is a term applied to a condition in which the cells become edematous. In ordinary dropsy the fluid accumulates in the intercellular spaces, and the cells are affected only by compression. It occurs for the most part as a re- sult of cloudy swelling or in such conditions as burns, pemphigus, and other vesicular diseases of the skin, and probably in erythema nodosum, urticaria, herpes, and other nervous affections. The cells are much en- larged and may rupture. The pro- toplasm is compressed and is con- sequently liable to undergo fatty Fig. 4.— Transverse section of a bun- degeneration ^^^ '-'^ muscular fibers in a state of h)'- Calcification consists of a deposit '^'X' defeneration '^/Muscular fibers . . ^ with small drops of fluid; o. Fibers with of the earthy salts m the tissues, large drops. (The preparation was especially the carbonate and phos- hardened in Muller's fluid, then stained phate of hme. It is purely a passive ^^'ith hematoxylin, and finally mounted • r-i, . • ]• 4.- • I- in Canada balsam. Maernified 66 diam- process, an mnltration as distmguish- ^ n ^v 1 n '^ A c A *-• T^- n eters). (Ziegler.) ed from a degeneration. It usually occurs in tissues that are dead or in a state of advanced fatty, h3^alin, or other degeneration. Deficient nutrition is an important factor in predisposing to the infiltration. In some conditions, as in old age and after extensive necrosis of bone, it is attributed by some writers to an abnormal accumulation of lime within the system. It is believed that the salts, as a rule, are simply deposited in the tissues, although it has been suggested that they, perhaps, form combinations with proteids and fatty acids. And another theory holds that soluble salts become insoluble within the tissues. In psammomata the salts are probably deposited in hyalin matter previously formed. The infiltration usually occurs first in the form of fine granules scattered throughout the intercellular substance, but it may later invade the cells. It generally forms irregular spherical bodies showing concen- tric striations, but in the blood-vessels it often assumes the form of plates. It also forms incrustations around foreign bodies and in the walls of cysts. In neoplasms so great an extent of tissue may be involved as to produce large masses of mortar-like matter or large, irregular, solid concretions. The most serious consequences of calcification are met with in the heart and blood-vessels, especially in sclerotic endocarditis of the valves and in arteriosclerosis. The aorta, coronary artery, and the vessels of the brain are common seats of calcification. As a rule it affects the middle and internal coats of the vessels. In the pericardium it follows inflammations, and, after the obliterative form, it sometimes incloses the heart in a calcareous sheath. Calcification sometimes as- sumes the magnitude of an almost universal invasion of the body. The nonvascular neoplasms are especially liable to calcareous infiltration, 26 PRACTICE OF MEDICINE but it is found also in sarcomata. The gall-bladder and urinary blad- der, the walls of cysts, old abscesses, hematomata, thrombi, cicatrices, dead ganglion cells, dead epithelium like that of the kidney tubes, espe- cially after mercurial poisoning, and dead parasites are often infiltrated. The occurrence of the infiltration in the form of brain-sand and as a senile change in the vessels and cartilages is not regarded as patho- logical. Results. — The deposit of a small amount of calcareous matter in a region does not necessarily destroy its vitality, but complete cal- cification denotes the death of the tissue, and no restoration is pos- sible. Pigmentation consists in the formation or deposit within the tissues of substances which give them an abnormal color. There are four varieties, based upon the origin of the pigment. These are termed meta- bolic, hematogenous, hepatogenous, and extraneous. 1. Metabolic pigmentation is due to cellular activity. It is illus- trated in freckles and some of the skin diseases, possibly also in the melanotic sarcoma. It occurs in Addison's disease, in some cases of diabetes, and in the anemias and cachexias. The pigment is doubtless derived from the hemoglobin of the blood, but the mode of its forma- tion is not known. It may be deposited within the cells or between them, in the form of granules, rarely as crystals. 2. He7natogenous pigmentation, in which the pigment is derived from the hemoglobin, is divided into two classes : («-) Siderous, from iron- containing pigment, and (Ji) nonsiderous, free from iron. The chief siderous pigments are hemosiderin and its modifications; the nonside- rous pigments are various derivatives of hematin. It is possible that the latter modifications are the result of cellular activity. There are two groups of siderous pigmentation, one in which the pigments are set free in the blood, the other in which they are deposited in the tissues. In malaria, pernicious anemia, and certain infectious and septic processes, we see examples of the former; and in bruises and the diffusion of pig- ment from thrombi and in- terstitial hemorrhage, ex- amples of the latter form. 3. Hepatogetwiis pigment is derived from bilirubin or biliverdin. These are depos- ited in solution, granules, or crystals in almost every tissue except the brain, and especially in the liver, skin, mucous membranes, and glands. 4. Extraneous pigmenta- tion occurs principally in the respiratory passages and is generally called pneumono- koniosis. It results from the inhalation of minute particles of stone (calcicosis), iron (siderosis), or coal (anthracosis). The pigments are deposited in the submucosa of the bronchi and in the fibrous tissue of Fig. 5.— Hemosiderin in liver-cells (rt). b. Fatty degeneration of cells (osmic-acid stain). (Ziegler,) NECROSIS 27 the lungs, or they may be carried to the tracheobronchial and medi- astinal glands. They rarely pass into the circulation and are carried to the liver, spleen, kidneys, and elsewhere. Argyria is a form of pigmentation which results from the ingestion of soluble silver salts and affects especially the skin, gastric and intestinal mucous membranes, the liver and kidneys. NECROSIS. By necrosis is meant the death of a tissue. Death of cells is termed necrobiosis ; that of an entire part, gangrene. The latter term is applied also to a putrefactive change in necrotic tissues of any kind. Causes. — The different forms of necrosis are caused: (i) By insuf- ficient nutrition, especially by complete interruption of the blood supply; (2) by the toxic products of bacteria or chemical agents ; (3) by mechanical injury; or (4) by trophic disturbances. 1. Profound local anemia, however it may have been produced, is capable of causing necrosis; venous stasis, especially that produced by mechanical obstruction or chemical agents, may be its cause. Senility, general anemia, cachexia, abnormal metabolism and its products, are among the special predisposing causes. 2. The toxic products of the bacteria are often the immediate cause of necrosis; heat, cold, the alkaloids, metallic salts, acids, alkalis, and many other substances act in the same manner, producing it either directly or indirectly by first causing various degenerations. Inflam- mation may lead to necrosis, and on the other hand necrosis almost invariably incites inflammation in the surrounding tissues. 3. Chief among mechanical injuries is pressure which acts directly upon the tissue, or indirectly by causing circulatory disturbance, as for example, in the pressure of neoplasms, calculi, and other concretions or exudations. 4. Trophic disturbances are not regarded by all authorities as opera- tive in the production of necrosis. Many attribute to disturbance of nutrition or pressure a class which Stengel and others maintain are due to a disturbance of the biological mechanism of the cells. Among the examples of this character are bedsores, the skin lesions sometimes accompanying trigeminal neuritis, and various arthropathies. Varieiies. — Several distinct forms of necrosis are recognized, chief among them: (i) Coagulation necrosis, (2) liquefaction necrosis, and (3) fat necrosis. I . Coagulation necrosis is a peculiar form of tissue death in which, through a process resembling coagulation, the cell contents are replaced by a hyalin-like substance. The process is supposed to be a species of fibrin-formation. Causes. — Among the causes that are especially likely to produce this form of necrosis are the toxic effects of the pus-forming bacteria, and the bacilli of tuberculosis and diphtheria. Coagulation necrosis often occurs in the products of exudation or transudation. Results. — A tissue that has undergone coagulation necrosis loses its function. The necrotic mass may be separated by ulceration and cast 28 PRACTICE OF MEDICINE Fig. 6. — Tubercular caseation. a, Granular, cheesy material, b, Fi- brocellular tissue, c, Degenerated giant-cells with bacilli. (Ziegler.) off; it may undergo caseation, liquefaction, or suppuration, or it may be removed by absorption and its place filled with cicatricial tissue. 2. Caseation is a term applied to coagulation necrosis when the result is a mass resembling cheese, but less homogeneous and more granular. It occurs especially as a result of tuberculosis, but may oc- cur in other granulomata, especially those of syphilitic origki or as a result of other processes, as in the liquefaction necrosis of the central nervous system. The results are the same as those of coagulation necrosis. 3. Liquefaction Necrosis.— In this form of tissue death, the product is liquefied. It may occur as a primary process, or it may be secondary to in- flammation, the other forms of ne- crosis, the degenerations, or gangrene. The necrotic mass varies in consistency with the duration of the process, and with the character of the tissue af- fected, and in color from white to a dark brown. 4, Fat necrosis is a form which af- fects the fatty tissues. Its occurrence is limited almost exclusively to the sub- peritoneal cellular tissues and the fat of the abdominal walls, and it usually results from disease of the pan- creas. The necrotic areas are small, white, and soft, but frequently become gritty from deposit of lime salts. It is attributed to the action of steapsin, the pancreatic fat-splitting ferment. 5. Gangrene is a putrefactive necrosis. The term has generally been used to designate the death of an entire tissue or member or of exten- sive areas. It may be primary, but is more frequently secondary to other forms of necrosis. Causes. — The predisposing cause of gangrene may be an injury of any kind — mechanical, chemical, electric — or an arrest of circulation in the area, as by a thrombus or embolus. The immediate cause is an invasion of the tissues by micro-organisms, for the most part by sapro- phytic bacteria. Several different microbes have been found capable of producing primary gangrene. Forms.— There are two principal forms of gangrene, designated dry and moist, from the character of the necrotic tissue produced. (ar) I?ry gang7-ene occurs most frequently as a result of arterial ob- struction in regions having insufficient collateral circulation to maintain their vitality. It occurs in senility, Raynaud's disease, ergotism, throm- bosis or embohsm, or as a subsequent change in moist gangrene. The tissue becomes opaque and finally black; it is generally completely mummified, and may be very slow to separate. (^) Moist gangroie is more frequently a result of the closure of a large vein as by the pressure of tumors, or cicatricial bands, or by torsion or swelling, as in intussusception and other strangulations, floating kidney, etc. In the lung it may develop after thrombosis or embohsm of the pulmonary arteries or veins, bronchiectasis, abscess, or INFLAMMATION . 2^ pneumonia. It sometimes affects the extremities in diabetes, and occurs as a primary affection, probably as a result of the action of a specific bacillus, in noma. The tissue affected becomes dark brown and soft, and in most instances it is ultimately liquefied. The tissues often become emphysematous, owing to the liberation of gas by the bacteria. The necrotic mass may be separated from the surrounding healthy tissue by an area of inflammation (the line of demarcation) ; it is always sur- rounded by an area of coagulation necrosis of variable extent. The gangrenous mass is often cast off a,s a slough, or sphacelus; it may become encysted, or converted into a dry gangrene and undergo very slow separation. Hemorrhage sometimes follows the rupture of vessels in the surrounding tissues. A fatal toxemia is not infrequently induced. INFLAMMATION. Inflammation is a complex process of a degenerative, proliferative, and regenerative character, affecting the blood-vessels and tissues as a result of injury. The causes may be mechanical, bacterial, or thermal — any agent, in fact, which is capable of producing strong irritation without occasioning the complete necrosis of the tissues affected. It has been defined as the response of living tissue to injury. The process is probably nearly or quite the same in all instances. The phenomena generally described as occurring in experimentally induced inflammation are: (i) A transitory contraction of the arteries which may be of so short duration as to escape observation. This is still referred by some investigators to the action of the vasomotor nerves, while by others it is looked upon as a result of degenerative changes in the vessel-walls. (2) A dilatation of the arteries, then of the capillaries and veins. (3) Following this, an exudation or transudation of the corpuscles and plasma with other changes to be more fully de- scribed. The blood at first flows more rapidly, then more slowly, and finally may stop, especially in the capillaries of the central zone of the inflamed area. As the blood-current becomes slower the leucocytes in the plasmic zone of the vessels become more numerous and adhere to the sides in a row. In a capillary, a cluster of leucocytes frequently alternates in passage with clusters of red corpuscles or of red and white in normal ratio. The migration of the leucocytes is abnormal only in the excessive numbers passing into the tissues. Large numbers of red blood-cells soon follow, accompanied by highly coagulable plasma rich in albumin. The activity of the leucocytes has been attributed to irritant substances possessing an attraction for the leucocytes (chemosis). These irritant substances are supposed to be set free by the destruction of cells in traumatic inflammations, or to be derived from the toxic substance which induces the inflammation. The escape of the red corpuscles and plasma is regarded as purely mechanical, a result of the blood pressure within the vessels. In the connective tissue about the vessels a proliferation is set up leading to karyokinesis and the formation of small round cells (round- cell infiltration). The new cells are formed, in part at least, from the 3° PRACTICE OF MEDICINE cells of original connective tissue. The changes in the tissues are at first degenerative in character; later they become proliferative. The degenerations, cloudy swelhng, fatty, mucoid, even necrosis, affect pri- marily the walls of the blood-vessels or the connective tissues about them. The proliferation of connective tissue produces small round for- mative cells, larger than leucocytes and having large, round or oval, pale nuclei, which often show karyokinesis. The same form of prolifer- ation is sometimes seen in parenchymatous cells. Ziegler describes, among others, the following forms of inflammation, basing the distinctions between them upon the character of the exudates belonging to each, and the changes which they subsequently undergo, rather than upon any essential difference in the process : 1 . Serous inflammation is characterized by a fluid exudate containing comparatively few cellular elements. When affecting the skin or sub- cutaneous cellular tissue, it is called inflammatory edema. It affects also the mucous membranes, serous sacs, parenchyroa of the kidney and other organs. The fluid is rich in albumin and fibrin factors. 2. Fibrinous inflammation is characterized by immediate coagula- tion with the production of fibrin. It occurs especially upon serous and mucous surfaces, after desquamation of the epithelium, and forms whitish, more or less adherent membranes. It sometimes forms usider the epithelium, or spreads over the epithehal covering, of adjacent areas. 3. Hemorrhagic inflammation is usually associated with the fibrinous form, as in fibrinous pneumonia. It differs from that form of inflamma- tion only in the greater number of red blood-cells that are present. Hemorrhagic inflammation occurs also in the central nervous system, kidneys, lymph-glands, and skin. Hemorrhage into an inflamed area is to be ex- cluded from this class. 4. Purulent or suppura- tive inflammation is gener- ally a result of infection by pyogenic micro-organisms, iDut may be produced by a number of chemical irritants in the absence of bacteria, or by bacteria which are not or- dinarily regarded as pyo- genic, as the typhoid and colon bacilli. It is often a result of bacterial infection ^ r. ■ r I f. J- u^-i V ^„ of an area involved in an- FiG. 7.— Section of uvula after diphtheritic de- , ^ r • n struction of its epithelial covering, a, Micrococci. Other form of mflammation. b, Mucous membrane, infiltrated and broken When the suppuration OC- down. c, Small-celled infiltration, d, Fibrinous ^^-^^ \^ |-}^g midst of a tissue exudate. ^^ organ, it constitutes an. abscess ; when it causes destruction of the surface of the skin or of a mu- cous membrane, it is an ulcer; when confined to the substance of the skin, it is a furuncle. When the micro-organisms enter the blood they produce. REGENERATION 31 pyemia; when only the toxins are absorbed into the circulation, a con- dition of septicemia, or sepsis, is produced. 5. Diphtheritic inflammation occurs, not only in diphtheria infection, but as a result of other infections, or of the action of a chemical irritant for the most part upon a mucous membrane. It is characterized by a coagulation of the exudate and coagulation necrosis of the cells of the inflamed area. The exudate consists, as a rule, of coagulated fibrin in- closing degenerated cells and bacteria. The exudate of true diphtheria is distinguished by the predominance of the Klebs-Loffler bacillus, that of croupous pneumonia by the fibrin and pneumococci. 6. Necrotic inflammation is a form in which infection has been in- duced by gas-forming bacteria, producing putrid necrosis of the tissues. Terminaiion of Inflammation. — Inflammatory processes terminate : («:) By delitescence, a sudden, early cessation, with rapid restoration of integrity; (^b^ by resolution, a slower return to the normal condition; or ((t) by the development of degenerations or necrosis. 7. Chronic Inflammation, — This term is used to describe, not only inflammations of long duration, due either to slow progress or a con- tinuation of the causal irritation, but more particularly with reference to their results. When the process involves the proliferation and repro- duction of connective tissues, it is sometimes spoken of as interstitial inflammation. It generally results in induration and contraction of the tissues, as in the scleroses of the liver, kidneys, and other organs. \^Tien on or near the surface, it forms bands of adhesion between adjacent structures. REGENERATION. Regeneration is a reparative process by which new cells and tissues are formed to replace those that have been destroyed. It ma)- be nor- mal or pathological in character. Normal regeneration is constantly going on in the body for the restoration of cells that have been consumed in the vital processes. So far as it is understood, normal or physio- logical regeneration consists in a proliferation of cells without other changes. Pathological regeneration produces cells and tissues to replace those lost as a result of disease or injury, but the new-formed cells and tissues are not always of the same type as those which they replace. The cause and limitation of the process probably lie in the inherent tendency of cells to proliferate, but we do not know why it is developed or by what influence it is ordinarily arrested when the proper limit has been reached. Some authors regard the process as a part of inflammation, but in most instances the tissue changes are quite distinct from those of inflam- mation. The new tissue consists at first of new blood-vessels, loops formed by a process of budding from the old vessels, surrounded by embry- onic tissue formed in part from leucocytes and in part, by proliferation, from the connective tissue cells. Cell-proliferation alone is capable of restoring lost surface epithelium. In the regeneration of connective tis- sue there occur an enlargement and elongation of the original round formative cells into fibroblasts, which, together with the homogeneous 32 PRACTICE OF MEDICINE intercellular substance, undergo fibrillation, through a process of cleav- age. In the regeneration of muscular tissue the original formative cells are designated sarcoblasts; in that of cartilage, chondroblasts; in that of bone, osteoblasts. The subsequent changes in the cells are not, however, identical with those in the regeneration of connective tis- sue. In some instances, too, the regeneration of these tissues occurs by a direct growth from the pre-existing cells of the same type ; less fre- quently from those of another type (metaplasia). In the repair of lesions in glandular organs, the normal tissues of the organ are to a greater or less extent reproduced, generally, however, in an atypical form, the new tissue remaining imperfect ; but the greater part of the destroyed tissue, as a rule, is replaced by new fibrous connec- tive tissue. In some instances the new, atypical formation is exuberant and results in the formation of adenomatous tissue. THE BACTERIA OF DISEASE. General Bacteriology. — Bacteria are the smallest, and in structure the simplest, members of the vegetable kingdom. From their resem- blance to the fungi, and from the fact that they are reproduced for the most part by transverse division, they are sometimes referred to as fission-fungi, or schizomycetes. Their size is measured in micromillimeters (designated ,a). They receive their nutriment by direct absorption of soluble living or dead matter; but, being devoid of chlorophyll, they are unable to decompose substances into their simpler elements suitable for absorption. From the character of the nourishment they are able to appropriate, bacteria are divided into two major classes, the sapro- phytes and the parasites. The former are the more numerous and live upon dead organic matter; the latter live upon or within some other living organism and receive from it their nutrition. But there are some members of each class that are able to adapt themselves to the con- ditions of the other ; parasites that can for a time live upon dead mat- ter, and saprophytes that can exist as parasites. These are called facultative parasites and saprophytes. The saprophytes are for the most part harmless to man; they are often, indeed, beneficial, in so far as they consume dead animal and vegetable matter. Structure. — A bacterium consists of a cell believed to have a cell mem- brane, not always clearly defined, within which is a protoplasmic layer and a central fluid. No nucleus has yet been discovered. The interior of the cell is generally homogeneous, but occasionally it appears granu- lar, as is the case with the diphtheria bacillus under the action of suitable stains. Babes named these granules metachromatic bodies, but Ernst regards them as sporagenous granules. Mo7-phology. — All micro-organisms fall under one of three classes when compared with reference to their form. The first class consists of the micrococci, spherical in form; the second, bacilH, rod-shaped; the third, spirilla, shaped like a spiral : and the members of each group are capa- ble of reproducing bacteria only after their kind. The cocci multiply chiefly by transverse division; sometimes by division in two or more planes; sometimes they divide irregularly. The bacilli and spirilla mul- tiply almost entirely by transverse division, but occasionally, perhaps, BACTERIOLOGY ^^ by the formation of spores. The form of the micro-organism under- goes considerable change in the process of division. The spherical coccus, as a rule, becomes enlarged and oval, and division into two cells gives each half a more or less perfect semilunar shape. When more than one division occurs, the young cocci have the appearance of imperfect spheres ; they are sometimes lanceolate or biscuit-shaped. A short bacil- lus produces two nearly" round or square cells; sometimes, indeed, the short diameter may be distinguished with difficulty from the long. The mature micrococci vary in diameter from 0.3//. to 3//.; those of the same species are generally of uniform size. They occur singly, in pairs (diplococci), in chains (streptococci), in groups of four (tetrads), in cubes (sarcina), and in irregular grape-like clusters (staphylococci). Bacilli may be compared, when mature, to minute cylinders whose longitudinal and transverse diameters are never equal. They vary in length from 0.2a to 30// and in width from o.i,a to 4;/. The largest pathogenic bacilli do not average more than 3,a in diameter. It is cus- tomary to speak of a bacillus as being slender when the ratio of its length to its width is from 4:1 to 10:1, and as thick when the ratio is about 2:1. The typical bacillus is straight, uniform in diameter, with flat ends, but many of the more slender forms are bent, as is oc- casionally seen in the tubercle bacillus. Others, as the bacillvis of diph- theria, are not of uniform thickness, often appearing nodular or thicker at one end. The formation of spores also gives the rod an irregular outline. A beaded appearance is often seen, also, which is not due to spore-formation. Some forms, especially those endowed with the power of motion, have rounded ends. Bacilli occur singly or in chains of greater or less length; sometimes only two or three remain united. Spirilla may be compared to segments of a spiral. They occur singly, in pairs, or as a continuous chain and have the appearance, according to their length, of a comma, an S, or a complete spiral. They may be slender or thick ; dichotomously branching forms are also seen. Sporulation. — Reproduction by the formation of spores has not been determined to the satisfaction of all investigators ; but there seems to be little doubt that it is the 'mode of propagation in some species. Two methods of sporulation have been described. In one the spores develop within the cell (endospores) ; in the other they produce a sprout- like separation of the end of the cell. Spores are much more tenacious of life than is the parent cell, being more resistant to the action of many harmful agents. The )'Oung cell grows from one or other surface of the spore. Chemical Composition. — Bacteria consist largely of an albuminous matter which has been called mycoprotein, fats, salts, and water. They contain also small quantities of extractives. Cellulose is found in some species, and a gelatinous carbohydrate, similar to hemicellulose, in others. The presence of grape-sugar in any species is denied by Cramer. Nuclein has been separated in very minute quantity, but the nuclein bases, xanthin, guanin, and adenin, are more abundant. Sulphur is found in one group. The quantities of the various substances vary so widely with the character of the culture medium upon which the bacteria are grown that estimates are of little practical value. Vital Phenomena. — The vital phenomena of bacteria are of little im- 34 PR.A.CTICE OF MEDICINE portance to us here, in comparison to their chemical activities. The power of motion possessed by some, the abihty to produce hght, heat, or coloring matter, acids, etc., interest us only as means of distinguish- ing different species. Motility. — A peculiar, trembling motion may be observed with the microscope in all minute particles, whether living or dead. This is known as the Brownian movement and is in no way attributable to vitality when seen in a micro-organism. Many living bacteria, however, have a power of independent motion which can be readily seen when they are examined suspended in a drop of fluid. The movement varies from a slow, undulating, or wormlike creeping to a darting progression, so quick that it will not permit a close examination of the germ. This movement is produced by means of flagella, fine hairlike processes pro- jecting from the sides or ends of the cell and not unlike the cilia of epithelial cells. The character and rapidity of the motion are to some extent characteristic of the species, but it depends to a great degree upon the culture medium and the temperature of the fluid in which the bac- teria are suspended. Nearly all motile bacteria are attracted by certain substances, especially by pepton and urea. This attraction is known as positive chemotaxis. They are nearly all repelled by such substances as alcohol and by some of the metallic salts — negative chemotaxis. Many substances possess a variable degree of chemotaxis, positive or negative in character, for one or more species, which they do not have for others. Chemical Action. — In chemical activity the bacteria are truly remark- able. I. Hueppe gives us four methods by which they are able to build the chemical substances required for their own nutrition : (c/) Polymeri- zation, by which a simple compound appears to be doubled; (^li) S3'nthe- sis, a union of simple compounds into one or more complex substances; (<;) the formation of anhydrids, by which new substances are formed through the abstraction of water from old ones; and (^) reduction or the removal of oxygen, which is accomplished by the entrance of hydrogen into the molecule. They are able also, through oxidation, hydration, or the overcoming of polymerization, to convert bodies of complex organic structure into simpler ones. 2. One of the most interesting features in the vital phenomena of micro-organisms is their behavior in the presence or absence of oxygen. To some the presence of oxygen is essential; to others it is harmful or destructive. The former group are called aerobes, the latter anaerobes. Most bacteria are facultative in this respect, but their products are not the same under the two conditions. They produce, in the presence of oxygen, profound molecular changes in the substances upon which they act, which they do not produce in its absence, and the quantity of ma- terial disintegrated is much less. The products of anaerobes in the presence of oxygen are frequently further decomposed by the aerobes and thus rendered inert. 3. Fermentation is a process of decomposition of organic matter : (i) By the direct action of bacteria, (2) by the substances contained in the bacteria (organized ferments), or (3) by chemical substances (chemi- cal ferments or enzymes) produced by the bacteria and capable of acting independently of them and without loss of their own identity. Several BACTERIOLOGY 35 processes are recognized as fermentations and named by some observ- ers which are not so regarded by others. Some authorities do not recognize as fermentation any process which is not attended with a Uberation of gas, while others apply the name to all forms of decompo- sition through the action of bacteria, or to any process developed by a ferment. The principal kinds of ferments are : (4 ■ T8 oz Ul L Jr '■ 06 zs Si S ■" L.. 08 ^z Ul •^ ^ '■■ S8 ZZ 8i 5 ~1 ~ ■1 ■'^ 08 n Ul r-- 08 85 s S J r^ ">i ZL fZ Ul ~z "1 08 8Z § S .. _ ~ ~ ^ 08 OZ Ul ■-t:. Zi ... 06 OS 05 5 _Z] t - r= t" 08 fZ Ul ... - i^-l' 26 8S 00 S ~- - 9i OZ Ul 96 OS t- S ~~~T - ,z r = '=< 88 ZZ Ul "^-- L."" 96 8Z S " - == 88 OZ ul 'T"- ;;_ OOT OS 10 S ~~ rl=J 06 fZ Ul - j: ~Zl S6 sz ■* 2 ~^ ::i -=\ OS TZ ul k r _ ^ 06 8S CO 2 - _b pM T8 ZZ Ul »c Z J "■ - 86 9Z Oi 5 "~r -^ 88 OZ Ul » ~ " OOT SZ ^ 5 - " ~'^ 08 K Ul - - ■ 86 ZS 2 J ^8 9S Ul c: C ^ 96 ZS oa 2 - ■" ;:i R=i 88 SZ Ul q y- ■ ' 00 OS 00 2 ;; 88 8Z Ul z. 1 06 ZS t- 2 "" -t" 98 SZ Ul ^ 88 OS to 2 ■~~^ i fS 9Z ul «i 26 se «3 2 ""1 ' T8 OS Ul "^3. 06 ZS •<* 2 ~~ t? OS OS Ul _, Si ?z CO 2 7: := 9i 81 Ul 1-' 01 61 (N 2 Ul 2 _ °io 2; CO u. °c« °i-i °o °OJ "oo °l- OS Ci 3 i < C. 40.6° 40.0° 89.5° 38.9° 38.3° 37.7° 37.2° 36.6° 36.1° >- "3 "^ -a o ^ 41 > C rt Ji F. (41.1° — 42.2° C.) in the evenings. Such cases are usually fatal. (4) A chill sometimes occurs during the second or third week, and the temperature is elevated two or three degrees above its former course, TYPHOID FEVER 57 especially when malarrial infection complicates the case. (5) Recrudes- cence sometimes occurs; the temperature, after running a mild course for a few days, if not from the beginning, suddenly becomes elevated. This may occur during convalescence, when it is usually a result of errors in diet, constipation, or nervous excitement. (6) Hemorrhage of the bowel causes a sudden drop of temperature to the normal or below it, although the blood is sometimes retained within the bowel and the hemorrhage is said to be concealed. Perforation is followed by a similar decline. (7) Sometimes the fever continues at its former range or pursues a more or less irregular course for six or eight weeks. Such cases arouse suspicion of sepsis or tuberculosis, unless the diagnosis has been confirmed by bacteriological and blood tests. (8) Occasionally the temperature curve is reversed, the morning record being higher than the evening. With the exception of hyperpyrexia and a sudden fall of temperature, these deviations do not necessarily indicate danger in the absence of other grave symptoms. The persistence of fever after all symptoms on the part of the alimentary canal have disappeared is often a nervous manifestation. The fever of relapse frequently pursues a course similar to that of the original disease, showing a gradual rise, a few days of fluctuation, and a decline. It is usually shorter than the original pyrexia. Chills occurring during the course of the disease are often indicative of a complication, notably hemorrhage, sepsis, malaria, pneumonia, or thrombosis. They may be produced also by the administration of anti- pyre'„ics or by constipation, but they cannot always be accounted for. Circulatory System. — The Blood. — Typhoid bacilli can be found in the blood by cultivation on suitable media. At the end of the disease other pathogenic germs may also be found in such cultures. The coagula- bility of the blood and the fibrin-formation are normal until the ap- proach of defervescence, and the specific gravity varies only with the hemoglobin. During the first two weeks of the disease, the blood shows little change except concentration, with apparent increase of the cellular elements, due, as a rule, to diarrhea. In the third week the red cells begin to decrease, and reach the minimum about the time of deferves- cence. They seldom sink below 2,000,000. The hemoglobin undergoes a relatively greater diminution, and it is restored more slowly after re- covery. The number of leucocytes seldom departs from the normal (8,000 per c.mm.), except in the beginning, when the count is relatively higher on account of concentration. The larger forms predominate. A slight leucocytosis may develop, however, at the beginning of convalescence. Cabot does not find it a constant condition at this time, but observes that leucocytosis may fail of development through inability of the system to react, even in the presence of pneumonia or suppuration, in a very exhausted patient. The polymorphonuclear cells diminish as the other forms increase, often falling below 60 per cent, toward the end of the disease, thus contrasting strongly with their behavior in other infections. They begin to increase again in from three to ten days after defervescence, and become normal in number in the sixth or seventh week. Eosinophiles are present in small numbers. When acute inflammatory processes develop, as after perforation, leu- 58 PRACTICE OF MEDICINE cocytosis immediately develops, the polymorphonuclear forms predom- inating. During convalescence the coagulability of the blood is some- times greatly above normal. The pulse is increased in rapidity, as in all fevers, but not usually to so great a degree. In the first week it is generally above loo, but full and of low tension, often dicrotic. With the progress of the disease, it becomes small, feeble, and more rapid, sometimes reaching 150. It is rendered suddenly rapid, small, or even imperceptible by hemorrhage or perforation and by cardiac dilatation. It becomes rapid and irregu- lar, during convalescence, upon the slightest exertion or excitement. Bradycardia (slow heart) sometimes occurs, especially during conval- escence, and inay persist for two or three weeks, the rate in some cases being as low as 40 or 30. The Heart. — Myocarditis sometimes occurs. In protracted cases the heart muscles become soft and flabby to a variable extent, but the fibers show little or no change microscopically, except a granular degeneration in some instances. Fatty or hyalin degeneration is found only in the most protracted cases and in association with jjrofound anemia. Other degenerations are rare. Endocarditis is one of the rarest complications. It is attributable to the direct action of the toxin upon the endocardium. Pericarditis is infrequent and is found almost exclusively in children or associated with pneumonia. Two cases of suppurative pericarditis are recorded. The heart-sounds often remain normal, but in asthenic cases the first sound becomes weak and may become inaudible. In extreme weakness the first and second sounds become much alike and the long interval "becomes shortened (embryocardia). A soft blowing murmur may re- place the first sound. The systolic impulse becomes feeble and some- times imperceptible. Tlie Arteries. — Thrombosis and embolism are not common, but some- times cause obliteration of one or more arterial trunks. They generally form during the second or third week, sometimes during convalescence. When the femoral artery is closed, the circulation of the leg and foot is arrested, and gangrene of the foot and leg may result, as in the remark- able case recently recorded by Nammack. In a few instances both femo- rals have been obliterated. Embolism is thought to be a result of frag- mentation and detachment of clots formed in the dilated cavities of the weakened heart, favored by the increased coagulability of the blood. Infarcts are sometimes found in the kidneys, spleen, and lungs, in association with arterial thrombosis. The Veins. — Venous thrombosis is a complication in about one per cent of cases, occurring most frequently in the veins of the lower ex- tremities, especially in the left femoral, rarely in the popliteal. It gen- eraHy develops during convalescence. Its more frequent occurrence on the left side has been attributed to the slight pressure of the left common iliac artery upon the vein at the point of crossing. The clots are sometimes remarkable in size, extending from the deep femoral, through the iliac, into the vena cava. The fact that the bacilli have been found in the walls of the affected veins and in the clot suggests the probability that the coagulation is due to local infection of the TYPHOID FEVER 59 wall of the vein. As a result of the thrombosis, the leg becomes much swollen, painful, and tender ; convalescence is prolonged, and permanent disability may remain. Gangrene of the leg has been observed in a few instances, but perhaps not solely as a result of the venous obstruction. Thrombotic obliteration of the left iliac vein has been followed by sudden death. Thrombosis may involve also the cerebral sinuses and very rarely the veins of the upper extremities. Symmetrical gangrene sugges- tive of Raynaud's disease has been seen. Thyroiditis has been observed during convalescence. . The spleen is enlarged to such an extent that, by the end of the first week, it can generally be felt below the margin of the ribs, unless, as is frequently the case, it is pushed back by the distended colon. In this condition the dullness may be unrecognizable on percussion. By the end of the third week it usually becomes reduced in size. Sometimes in elderly patients and generally after profuse hemorrhage, it is of small size. Owing to its friability, it may be ruptured by a blow, or, possibly, by too forcible palpation, as noted by Bartholow. Spontaneous rupture sometimes occurs. Hemorrhagic infarction may be found at autopsy. Digestive System. — Complete loss of appetite (anorexia) is general-ly one of the earliest symptoms and the appetite does not return until several days after the fever has subsided. During convalescence it often becomes ravenous. Thirst is constant. In the height of the fever, when the demand for liquids is greatest, the patient rarely asks for drink, owing to his mental dullness, although he drinks with avidity the liquids that are put to his lips. The tongue is generally moist, but coated with a thin white fur during the incubation. It is often tremulous when protruded. During the first week it becomes slightly swollen, the coat heavier and usually of a yellowish color, except at the tip, which is, as a rule, clean and of a bright red color. This appearance may persist throughout the course of the disease, but in most cases by the end of the second week the mouth and tongue become excessively dry, partly owing to a deficiency of saliva, and the coating often becomes dark brown. Catarrhal stoma- titis may develop. If the patient breathes through the mouth, the dry- ness becomes extreme, the coating almost black, and deep fissures are formed. A similar coating (sordes) often forms on the teeth and lips. The condition of the lips is often aggravated by the patient's picking. As convalescence becomes established, the moisture returns to the mouth and the tongue loses its coating. In some cases, especially in children, the tongue remains clean throughout the disease. The fauces and pharynx often become dry and red, as in scarlatina, or coated with a tenacious mucus that interferes with swallowing. Occasionally ulcers form, and a fatal membranous pharyngitis has been observed in the third week. Thrush sometimes arises as a complication and may extend from the mouth into the esophagus. Noma has also been observed, affecting either the cheek or the genitalia. Otitis media may arise from extension of inflammation through the Eustachian tube. The Parfllid (JA?/?!/.— Complications on the part of the parotid gland occur in some cases. The inflammation is usually suppurative and con- fined to one side. It is more liable to develop during convalescence. 6o PRACTICE OF MEDICINE The infection may be either by extension through Steno's duct or by metastasis. Some authors regard the condition as highly fatal. The submaxillary gland may be similarly affected. Vomiting is not a frequent symptom. It may occur early, however, especially in children, and sometimes persists throughout the disease. Repeated vomiting during the second and third weeks may indicate the development of peritonitis, nephritis, gastric ulcer, or a cerebral lesion. It has proved fatal in a few instances. Chronic gastritis and dilatation of the stomach have been attributed to a preceding attack of typhoid fever. Keen reports two cases of eso- phageal stricture apparently due to cicatrization of typhoid ulcers in this unusual location. Diarrhea. — There is probably no one symptom of typhoid fever which shows so much variance as this, or in regard to which so much diver- sity of opinion has existed. Probably, as Thompson remarks, it is less common and less severe than formerly. It is absent throughout the disease in fully half the cases and is rarely severe. It is probably a more prominent feature when the follicles of the large intestine are in- volved; but neither its presence nor its absence can be regarded as a reliable indication of the extent of intestinal involvement. Diarrhea usually develops by the end of the first week, but it may not begin until the third or fourth. The number of discharges seldom exceeds three or four a day, but may reach ten or more. The stools are alka- line, usually of a grayish yellow color, often not unlike the normal contents of the small intestine, though more offensive. They separate, on standing, into a thin supernatant layer containing albumin and salts, and a lower, flocculent, layer containing epithelial debris, numerous triple phosphate crystals, and remnants of food. Sloughs from the follicles may be found in them about the end of the second week. Micro- scopic examination reveals also numerous micro-organisms of different kinds and sometimes blood-cells. The typhoid bacilli are found in great numbers, as a rule, after the middle of the first week or beginning of the second. Constipation not infrequently prevails throughout the entire course of the disease. In the experience of not a few writers it is the more usual condition. It occasionally becomes extreme, and fecal impaction with more or less complete obstruction of the bowel has resulted in a few instances. Meteorism or abdominal distention of moderate degree is present in most cases, especially during the second week, the weakened, edem- atous, and probably paretic condition of the intestinal walls favoring the accumulation of gas. When extreme it is one of the most alarming and dangerous complications, preventing the healing of ulcers, favoring the production of perforation, and interfering with the action of the heart and lungs. The intestinal distention is thought also to favor the absorption of the products of food-decomposition and thus to in- crease the fever. It sometimes develops during convalescence as a result of a too liberal diet. Abdomiiial te?iderness and gurgling in the right iliac fossa are present in most cases, and although they are by no means pathognomonic, they are of some diagnostic importance, indicating the presence of fluid TYPHOID FEVER 6i feces and gas in the cecum and colon. Spontaneous pain does not usually occur, and it is generally confined to the iliac fossa. It may be so severe as to cause a suspicion of appendicitis, especially when associated with tenderness. In children the pain and tenderness are often referred to the umbilicus. Intestinal he7norrhage occurs in from 3 to lo per cent of all cases, and it proves fatal in from 30 to 50 per cent of the cases in which it occurs. It generally develops at the time the sloughs separate from the ulcers, toward the end of the second week or in the third; more frequently in cases that have run a severe course, but sometimes in the mildest. The hemorrhage generally comes on without warning. The patient suddenly sinks into a state of collapse, with pallor, restlessness, a sense of suffocation, cold extremities, and profuse cold sweat. The temperature declines rapidly, sometimes dropping six or eight degrees in a few hours and becoming subnormal. The pulse becomes extremely weak, often entirely fading away. Death may supervene before the blood has left the bowel. WTien recovery occurs, the discharges may continue to contain offensive dark clots for several days. Intestinal hemorrhage, like excessive epistaxis, may result from a natural tendency to bleed (hemophilia). It is important, in cases of supposed moderate intestinal hemorrhage, to exclude the bleeding of internal hemorrhoids. Perforation of the bowel is an exceedingly dangerous complication and is responsible for from 2 to 3 per cent of the mortality. The perfora- tion is most frequently located in the ileum, next in the cecum or colon, but it has been found in the jejunum. The time of its greatest liability is from the end of the second week to the beginning of the fourth, but it has been observed as early as the eighth day or late in the convales- cence, even in the sixteenth week. It is more frequent in men and rare in childhood or after the fortieth year. It is more apt to occur in cases that have run a violent course, marked by profuse diarrhea and great abdominal distention, but it is not infrequently seen in mild, ambulatory cases. The cause of the perforation cannot usually be de- termined. Too active movements, as getting out of bed; improper food, meteorism, and vomiting may induce it. A lumbricoid worm has been found in the peritoneal cavity after perforation and the accident has been attributed to the parasite. Cold bathing has been, perhaps un- justly, censured as a possible cause. The immediate result of perforation is the escape of the intestinal contents into the peritoneal cavity. This gives rise to an acute septic peritonitis that speedily becomes generalized. In a few instances the inflammation has remained circumscribed and, by forming adhesions, has shut off the portion nearest the opening and thus prevented an involvement of the general peritoneum. Intestinal hemorrhage is not infrequently associated with perforation. The first indication that perforation has occurred is, in most cases, a sudden, severe pain in the abdomen, immediately followed by collapse, great weakness, pinched features, and generally a small rapid pulse. The abdomen becomes greatly distended and sensitive, the breathing is impeded. The legs are generally drawn up to relieve the tension of the abdominal walls. Nausea and vomiting generally ensue upon the begin- ning of inflammation, and may persist until the patient becomes 62 PRACTICE OF MEDICINE exhausted. In another group of cases the accident is followed by no distinctive symptoms, or the onset is so gradual as to escape observa- tion. This is especially the case when the perforation occurs late in a case that has been characterized by delirium or coma. Percussion re- veals an obliteration of the splenic and hepatic dullness, a sign belonging also to intestinal distention. The most valuable diagnostic feature in most cases is the development of leucocytosis. It is of value, however, only in the absence of suppuration or other complications. The abdo- men may remain flat and hard, the patient soon passes into a moribund state, and the lesion is found after death. In some instances the first shock terminates fatally; but when death is due to pertonitis, it gener- ally occurs on the third or fourth day after perforation. A circumscribed peritonitis not infrequently occurs independently of perforation, and occasionally it becomes generalized. It is a result of the extension to the overlying peritoneum of the inflammation from the ulcers; from a suppurating infarct of the spleen or kidney, or rupture of the gall-bladder. Localized peritonitis of this character is rarely di- agnosticated; it is recognized post-mortem by the adhesions that have resulted. A fatal case of chronic follicular colitis with villous outgrowth was observed, a few weeks after the fever, by Thompson. Abscesses sometimes form in the mesenteric glands, producing sepsis, perforation of the colon, rectum, or vagina, or fatal erosion of a blood-vessel. The ZzWr.— Complications on the part of the liver are not frequent. Particularly is this true of single abscess-formation. Pylephlebitis is more common, and suppurative colangitis has been seen. Necrotic foci frequently occur, but, although they are sometimes numerous, they are ordinarily of little importance and are replaced by new connective tissue. They are attributed to the action of the typhoid toxin. Jaundice sometimes occurs and ma}^ be a result of toxemia, catarrh or ulceration of the bile passages, the presence of calculi, or an exten- sive necrosis of hepatic cells. As previously noted, the mucous membrane of the gall-bladder is a favorite nidus for the growth of the typhoid bacillus. In some cases they cause no disturbance, while in others they give rise to suppuration, perforation, and resultant peritonitis. These disturbances are sometimes delayed until weeks or months after ap- parent recovery. The rather frequent occurrence of gall-stones after typhoid fever has been attributed to this persistence of the bacilli in the gall-bladder. Respiratory System. — Epistaxis is of so common occurrence during the incubation or invasion as to be a symptom of diagnostic value. It is sometimes profuse, especially in the presence of the hemorrhagic diathesis, and it has proved a serious, even fatal, complication. The entire respiratory mucous membrane may become inflamed. The larynx is not often the seat of complications, but simple and ul- cerative laryngitis, edema often associated with ulcer, and perichondri- tis have been observed. Stenosis may follow. Paralysis of the laryngeal muscles, due to neuritis, has been noted. Bronchitis is present in nearly all cases. Although the cough is often so slight as to cause little annoyance, auscultation reveals sibilant rales. It is seldom a serious complication except in children and the aged, in whom it may lead to lobular pneumonia. This aftection is rendered TYPHOID FEVER 63 somewhat more dangerous in this connection by a tendency to suppura- tion or gangrene. Perforation of the pleura with resultant pyopneumo- thorax may follow the formation of a pus cavity. Lobar pneumonia is a more frequent complication. It sometimes develops before the typhoid infection has manifested itself and may have nearly run its course before the latter disease has been recognized. The crisis is usually prevented by the typhoid infection. In other instances, the pneumonic consolidation occurs, sometimes after chill, and usually with some increase of temperature, during the second or third week of the fever or later. It then constitutes a most dangerous com- plication. The symptoms of pneumonia are sometimes so light or so obscured that the condition is probably often overlooked. Whether the pneumonia is induced by the typhoid bacillus or is due to a specific organism has not been determined. Hypostatic congestion and edema of the lungs are generally associated. They occur to a variable extent in the posterior portions of both lungs, in a large proportion of cases, as a result of enfeebled circulation and the dorsal decubitus which the patient is probably too often permitted to occupy. Hemoptysis has occurred during the course of the disease in a few instances. The Nervous System. — The effect of the typhotoxin upon the nervous system is a pronounced feature of the fever in most cases. Head- ache, usually temporal or occipital, sometimes general, predominates in the first week. It is occasionally accompanied by vertigo and in aggra- vated cases by pain in the back of the neck and in the dorsal region. These symptoms may be associated with retraction of the head, photo- phobia, ■ and muscular twitching or rigidity, suggestive of meningitis. Such cases are classified by some authors as belonging to a cerebro- spinal form of the disease. The symptoms probably depend for the most part upon the action of the toxin, although the bacilli have repeatedly been found in the meninges after death. The anatomical lesions are generally limited to a hyperemia of the pia mater of the brain and cord. Meningitis is, however, one of the least frequent complications and is manifested by convulsions, opisthotonos, photophobia strabismus, dis- turbance of the cranial nerves and usually by an increase of fever with diminution or obliteration of the morning remission. Wakefulness and restlessness, especially at night, arc prominent during the first week, but somnolence and apathy soon develop, as a rule, and the patient passes most of his time in sleep. But his rest is not refreshing. The hebetude is generally so marked that the patient must be aroused for the administration of nutriment and drink, and immediately after partak- ing of them he falls into his former state of indifference. Convulsions rarely occur except at the beginning of the attack, and then only in children, or at the onset of complications or intercurrent diseases. They are somewhat more frequent, however, in alcoholic subjects. Delirium is not so often seen as it was before the adoption of present methods of treatment. Delirium of a few moments' duration is not infrequent, especially at night or just after awaking from sleep. It may assume several forms. When it is mild, the patient often mutters especially when he is alone, or he may be quietly delirious at all times. A worse form is accompanied with tremors, twitching of the muscles 64 PRACTICE OF MEDICINE of the face, jerking of the tendons of the fingers and wrists (subsultus tendinum), picking at the bedclothes or at imaginary objects in the air (carphology), and attempts to get out of bed. These patients have re- peatedly escaped at an unguarded moment and the result has frequently been disastrous. The tremulousness and delusions are much like those of delirium tremens, and they are more apt to occur in alcoholic sub- jects. They sometimes assume a hysterical aspect. In the worst cases, the patient sinks into a state of unconsciousness, is oblivious to his surroundings, and cannot be fully aroused. The urine and feces may pass involuntarily. Or the condition may be one of coma-vigil, in which the patient lies with open eyes, apparently seeing, often following the movements of his attendant, although he is entirely unconscious. As Niemeyer expressed it, he lives in an excited dream. These are the most fatal cases, and no doubt represent the highest degree of toxemia. Theodore Diller reports a case of meningomyelitis following the dis- ease in a girl of 15^2 years, and affecting the cord from about the eleventh thoracic segment down. The paralysis of the legs, bladder, and bowel was complete for two months, then gradually improved. Neui'itis is not uncommon and may develop during the height of the disease or not until after convalescence. It may be local or generalized. It sometimes sets in with excruciating pain and great hyperesthesia of the nerve trunks or muscles of one arm or leg, affecting especially the extensors, in which form it leaves more or less permanent wrist-drop or foot-drop. Another form of neuritis has ensued upon a week or two of the cold-bath treatment. It produces the "tender toes" first described by Hanford, in which the pads of the toes become extremely sensitive to pressure. Multiple fieuritis, especially of a paraplegic type, sometimes develops during convalescence, affecting any one of the extremities or all four. The symptoms resemble those of multiple polyomyelitis, and paraplegia or an atrophic paralysis of a single extremity may remain. Acute anterior polyomyelitis has been met with as a complication, particularly in children, and associated with a gradually ascending paralysis, often fatal in a few days. Hemiplegia, from hemorrhage or encephalitis, is rare, coming on during convalescence. It may be accom- panied with choreic movements, or aphasia when the right side is af- fected. Recovery is the rule in children. True tetanic attacks are to be classed with the rarest complications. Following typhoid fever, mental disturbances may remain for a time; the most common are loss of memory and melancholia. Insanity, us- ually of the confusional type, may develop in persons predisposed to it. Acute mania is occasionally encountered. Epilepsy also seems to be brought out in some cases. Brain abscess due to the bacillus typhosus has been observed. The typhoid spine, which was first described by Gibney, as. probably due to perispondylitis, an acute inflammation of the periosteum and of the fibrous structures which bind the vertebra; together, is regarded by Osier as a neurosis. It usually develops several weeks after the fever has subsided and may follow a jar or shock. It is not attended with fever or other signs of inflammation. The symptoms are chiefly of a hysterical nature. TYPHOID FEVER 65 Organs of Special Sense. — Conjunctivitis and keratitis, sometimes with phlyctenuiae, and iritis and choroiditis are occasional comph- cations on the part of the eye. Panophthalmitis is exceedingly rare. Dilatation of the pupil is common; temporary paralysis of accommo- dation is not infrequent. Paralysis of the external muscles of the eye is sometimes met with during convalescence, probably as a result of neuritis. Retinal hemorrhage, alone or accompanying other hem- orrhages, is more frequent, according to De Schweinitz, than is generally realized. Profuse retinal hemorrhage is rare, but amaurosis sometimes develops after severe intestinal hemorrhage, and the blindness is some- times permanent. Single or double optic neuritis may develop independently of menin- gitis, and is generally followed by atrophy of the optic nerve. Cata- ract has been noted as a sequel of typhoid fever. Trelat records the occurrence of double cataract in two cases. Orbital hemorrhage and thrombosis of the veins of the orbit are possible complications. Otitis media occurs in about 2.5 per cent, of cases, but recovery is generally prompt without involvement of the mastoid cells. Renal System. — There is the usual febrile concentration of the urine, with increase of specific gravity and color. As the fever declines, the quantity is increased and the density diminished. The chlorids, on the other hand, are reduced during the febrile stage and increased when the elimination becomes more abundant. Retention of the urine is often an early symptom and may recur periodically. During the somnolent state, the patient seldom expresses a desire to urinate, and a careless nurse may permit the bladder to become distended. Pain and restless- ness are produced. Incontinence may occur during delirium. Febrile albuminuria is observed in nearly a third of all cases. The urine contains also, in nearly all cases, an undetermined substance which yields a peculiar yellow color in the diazo reaction (see p. 734). Acute nephritis occasionally develops, i. It may occur at the onset of the disease, producing a type to which German authors give the name nephrotyphoid. The passage of scanty, bloody urine at this time some- times masks typhoid infection, which, developing later, may be for a time regarded as uremic in character. 2. Developing during, the height of the fever, especially during the beginning of the second week, nephritis often escapes recognition, but should be recognized by the presence of albumin, casts, blood, and epithelium. 3. As a sequel, nephritis is gen- erally promptly recognized, on account of the production of edema. It is not usually serious in its results. The lymphomatous nephritis of Wagner is not attended by symptoms. Pyuria has been noted, some- times early, sometimes as late as the twenty-eighth day. The origin of the pus is obscure. The colon bacillus was found in the pus of seven, the typhoid bacillus in two, and the staphylococcus albus in one of Osier's cases. Suppurative pyelitis is rare. It may be membranous at first and associated with membranous inflammation of the bladder. Later the membrane gives place to an erosion and ulceration. Hema- turia is usually associated with acute nephritis, but may occur indepen- dently; the blood is of renal origin. In some cases hemoglobin alone is found. The toxicity of the urine is increased throughout the entire •course of the disease and convalescence. 66 PRACTICE OF MEDICINE Cystitis may occur later in the disease or during convalescence, es- pecially as ■ a result of retention or from infection by unclean catheters. Urethritis is reported to have originated spontaneously during con- valescence in a few cases in which other organisms than the gonococcus were present. Orchitis and epididymitis, separately or together, have also been observed. They are attributed by Keen to a pure typhoid infection. Abscess of the ovary, of the same character, has been noted. Gangrene of the genitalia (noma) has occurred in a few cases, chiefly in women. The Typhoid Eruption. — The characteristic eruption is a rose-colored rash which ordinarily makes its appearance on the seventh or eighth day, but sometimes as late as the tenth or twelfth. It generally consists of not more than a dozen distinct, round or lenticular, slightly elevated papules flattened on top, from 2 to 4 mm. in diameter, occasionally showing small vesicles in the center, sometimes petechial or dark in color. It appears first on the upper part of the abdomen and lower part of the thorax, sometimes on the back and thighs. When the spots are numerous they may be found also on the extremities, rarely on the face, Successive crops develop, each persisting two or three days, and they sometimes leave brownish pigmentation. They can often be felt with the finger, and, when touched, vanish, but quickly reappear after the pressure is removed. They are rarely to be found after the middle of the third week. They are occasionally absent, particularly in children and old people. Erythema, a scarlet-colored rash, sometimes appears early, especially on the thorax and abdomen, rarely extending to the extremities. Urti- caria, papular eczema, and purpura hemorrhagica have been encountered. Herpes may appear on the lips, but is less frequent than in other fevers. Peliomata, peculiar, pale blue, subcuticular spots of irregular outline and from 4 to 10 mm. in diameter, are sometimes seen. They are be- lieved to be due to the presence of pediculi and, therefore, bear no relation to the disease. Tache cei-'ebrale is the name given to the red line with white margins which appears, especially in nervous subjects, after the finger-nail has been drawn over the skin. It is not peculiar to this disease. Osier calls attention to a pinkish, sometimes mottled appearance of the skin of the abdomen and arms that is seen in some cases when exposed to the air. Ecchymoses rarely appear except in connection with the hemorrhagic diathesis or on the dependent portions of the body in a moribund case. The palms and soles often become dry and harsh, apparently thickened. More or less general edema may occur as a result of anemia, or locally after obstruction of the circulation, as by thrombosis. It is also an important symptom of nephritis in a later stage of the disease. Bedsores occur for the most part in emaciated subjects, or after protracted fever. They are not so frequently seen since cleanly methods of nursing have been adopted. They may occur, however, under the most careful supervision, as a result of profound trophic disturbance, or when the vitahty of the skin has been impaired by one of the eruptive disorders. They occur, as a rule, over the sacrum or buttocks, but some- times over other prominences, the shoulders, spinous processes, elbows. TYPHOID FEVER 67 heels, and occiput. Rarely they appear in places not subjected to pres- sure. Gangrene, as previously stated, is generally a result of throm- bosis or embolism. Boils and abscesses are not infrequent sequelae, resulting from pyog- enic infection of the skin, especially of the axillge, back, buttocks, arms, or legs. Curschmann thinks that they are more frequent after the cold- bath treatment. They are sometimes so numerous as to greatly weaken the patient and prolong convalescence. They may continue to appear for a month or more after recovery. As a result of these suppurative affections, the pus-forming cocci sometimes gain access to the blood and produce pyemia. It is quite probable, indeed, that in many cases the multiple abscesses are themselves the result of pyemic infection. Atrophic lines are sometimes left in the skin of the abdomen and sides of the thighs similar to those produced by pregnancy. They are probably due to neuritis. Sweats. — During the height of the fever, the skin is generally dry and hot; sweating is rare. The chest and abdomen may, however, become moist for a while after a bath. A sudoral form of the disease, characterized by profuse sweating, is described by French writers. Chills occurring during the course of the disease are sometimes followed by sweating similar to that at the close of a malarial paroxysm, although no malarial infection is present. A suspicion of sepsis often is aroused. During defervescence, however, sweating is more common. Sudaminal and miliarial eruptions are occasionally seen in cases characterized by free sweating. They are generally limited to the axillae, abdomen, and inner sides of the thighs. They sometimes terminate in a desquamation in the form of flakes or large pieces, especially in children. A peculiar odor is frequently noticeable; possibly it is a cutaneous exhalation. It sometimes appears to be an exaggeration of the individ- ual odor, but in some cases it is better described by Nathan Smith as a " semi-cadaveric" smell. Alopecia. — The loss of hair, which is almost universal during recovery from typhoid fever, may be slight or it may reach the degree of bald- ness. It is generally confined to the head, rarely affecting the beard or other parts of the body. The hair is generally fully restored, but in some cases the growth is lighter and other characteristics may be altered. Muscles, Bones and Joints. — The muscles are generally atrophied. Granular, fatty, or hyalin degeneration sometimes occurs. As a result, especially of the last form of degeneration, the muscles become friable and may be easily ruptured. Abscesses and hemorrhages sometimes occur in the substance of the muscles. Bone-lesions are exceedingly common and troublesome sequelae. Of Keen's 237 collected cases, periostitis occurred in no, necrosis in 85, caries in 13, osteitis (bone abscess) in 12, osteomyelitis in 10. The tibia was affected in 91 cases, the ribs in 40. In 51 cases examined, pyogenic cocci were found in 13 and typhoid bacilli in 38. The disease is generally chronic and liable to recur.. It is favored by traumatism received shortly before or after the fever. Witzell thinks that injury on the side of the bath-tub may cause it. Keen believes that muscular strain is sufficient, and that this fact accounts for the comparative fre- 68 PRACTICE OF MEDICINE quency of periostitis of the crest of the ihum, the anterior superior spinous process, and promontory of the ischium, where independent affections are rare. Arthritis. — Keen recognized rheumatic, septic, and typhoid forms of this comparatively rare comphcation in 84 collected cases. Spontaneous dislocation, especially of the hip, is liable to occur. Associated Acute fnfect/ons.— Malaria, sometimes occurs in conjunc- tion with typhoid fever, giving rise to the double infection, typhomalarial fever. This is not a distinct, hybrid disease, as was at one time believed. Some cases of typhoid fever show more or less distinctly remittent or intermittent features, even when the plasmodium is absent. Measles, smallpox, chicken-pox, scarlet fever, diphtheria, whooping-cough, and noma sometimes develop during the course of the fever. Erysipelas has rarely been observed. Typhus fever has been encountered in asso- ciation with typhoid, in a few instances. Miliary tuberculosis is some- times associated with it. It is an interesting fact that choreic move- ments and epileptic seizures generally cease during typhoid fever, and that sugar may for a time disappear from the urine of the diabetic patient. Septic infection may happen during the later weeks of the disease or as late as two weeks after the fall of the temperature. It may take the form of septicemia, indicated by chilliness with moderate fever, sweat- ing, and weakness ; or the infection may be pyemic in character, usually manifested by frequent chills, high but irregular temperature, and the development of thromboses, abscesses or boils about the buttocks, axillae, or joints. Abscess of the breast has been observed. Re/apses. — A relapse is due to reinfection. It usually occurs after complete defervescence, sometimes several weeks after the temperature has been normal. It may occur, however, before complete defervescence. Of the cause we know comparatively little. It has been suggested that the reinfection is due to the inoculation of healthy intestinal follicles by the sloughs cast off from the original ulcers; but in some instances the more recent lesions are found higher up in the bowel than those of the original infection. As Chiari suggests, the reinfection no doubt often arises from the escape of bacilli from the gall-bladder. From one to five relap^ses have been observed in the same patient. The onset of a relapse is sometimes abrupt, often with a chill, and the temperature may rise suddenly, but in most cases it shows the t3^pical daily ascent. There is no prodromal stage. All the symptoms return, including the rash and splenic enlargement. The eruption may appea-r as early as the third or fifth day. The course of the disease is not usually so long or so severe as in the original attack, but in some in- stances, especially when the original attack was mild, it has been much more protracted and even fatal. Its course is often more severe than that of the original disease, especially when it develops early. The differential diagnosis of a relapse is often difficult. Recrudescence is simply a return of the fever without aggravation of the other symptoms after the temperature has been normal for a few days. Its cause cannot always be determined, but in some cases it is due to too free nourishment, nervous excitement; occasionally, perhaps, to malaria. TYPHOID FEVER 69 Diagnosis. — General. — The fact that typhoid fever is the most fre- quent of the continued fevers warrants its consideration in every case of protracted elevation of temperature. When a person between 1 5 and 30 years of age has a shght fever, with a rapid, soft pulse, a furred and slightly tremulous tongue, and gives a history of lassitude, headache, pains in the back and limbs, anorexia, chilly sensations, restless sleep, gradually becoming more pronounced for a week or two, typhoid fever is highly probable. The diagnosis should rarely be made, however, at the first examination. If nose-bleed, constipation, or diarrhea is added to the symptoms, and a cathartic has been found unusually brisk in its action, a tentative diagnosis may be made, particularly if the disease is prevalent in the vicinity at the time or a probable source of infection can be traced. If, after a few days' observation of the case, it is found that the temperature has followed the regular course of elevation; that the pulse has become more compressible, rapid, and dicrotic, the tongue more heavily coated and red at the tip and edges, the abdomen distended and tympanitic, with tenderness and slight gurgling in the ileo-cecal region, and enlargement of the spleen — then the diagnosis is all but positive. Add to these symptoms, after seven or eight days of fever, the characteristic rash, and the diagnosis becomes positive. Un- fortuna,tely such cases are the exception rather than the rule. Some symptoms are usually wanting, and in some cases the patient is not seen until the condition of hebetude obscures the history and subjective symptoms. In the absence of the eruption in such cases the diagnosis becomes exceedingly difficulty, and often impossible, for a time at least. Rarely the diagnosis is revealed by such an accident as a profuse in- testinal hemorrhage, or possibly only by the discovery of pathogno- monic lesions after death. In many instances, particularly in the rural districts, small towns, or summer resorts, it is possible to clear up an obscure case by tracing the infection to a previous case of the disease. To more effectually establish the diagnosis, several tests may be made. Specific Diagnosis. — Bacteriological Test — The bacilli may be found, by plate culture, in the urine and feces of most cases at a variable period from the beginning of the first week to the end of the second and there- after. (For method, see p. 747.) They may be found also in the blood obtained by puncture of the rose-spots ; puncture of the spleen is rarely justifiable. Diazo Test. — For Ehrlich's diazo reaction, see p. 734. Blood Test. — The most valuable feature of the blood-count is the absence of leucocytosis at all stages of the disease. Anemia is also absent until the decline of the temperature. Serii7n Test. — Widal's serum test is described on page 717. Differential Diagnosis. — The chief obstacle to diagnosis is the great diversity of manifestations in different cases, many of which assume a resemblance to other diseases. The most distinctive features are : the peculiar temperature curve, the eruption, the absence of leucocytosis, and the reactions to the diazo and Widal tests. The following summary will assist in its differentiation from the diseases which it most frequently resembles : Malaria. — Typhoid fever may assume an intermittent course, to the extent that the fever is higher on every second or third day, and chilly 7© PJL4CTICE OF MEDICINE sensations may be felt ; but the periodical chills, profuse sweats, and com- plete intermission of temperature are rarely seen. Quinin has little effect on the temperature. It may resemble intermittent fever, especially in children, in whom the eruption does not always appear. The estivo- autumnal type of malaria is excluded with most difficulty, however, especially in malarious districts. In it there is often a history of malaise preceding the fever, the chill may be absent, vomiting and diarrhea are often present, the temperature range may be almost uniform, the cheeks are flushed, the tongue dry and coated, possibly with a yellowish or brownish fur, and the spleen is enlarged. But the rash does not appear, the serum test is negative, and the plasmodium or an abundance •of pigment is found in the blood. Cerebrospinal Meningitis. — Cases that show unusual irritation of the meninges bear a strong resemblance to this disease, but meningitis is a much less frequent disease. The nervous disturbances, rigidity of the neck or opisthotonos, convulsions, photophobia, and strabismus are usually more pronounced than in any case of typhoid fever. The cutaneous and tendon reflexes are very irregular in their responses, the rose-spots are absent, and the abdominal symptoms are less pronounced or absent. For a few days, howeverj a diagnosis may not be possible in some cases. Lobar Pneumonia. — When a double infection occurs and both diseases are present, the greater prominence of the initial symptoms of pneu- monia, as compared to those of typhoid fever, may prevent the early recognition of the latter disease. Again, typhoid sometimes begins with intense pleuritic pain which leads to a suspicion of pneumonia. In the absence of double infection, however, there is little cause for confusion, since there is less cough, no dullness on percussion, the rales are mostly sibilant and not confined to one region, no rusty sputum, and a dif- ferent temperature curve. The blood-count and serum test assist in the diagnosis. Septicemia. — When the location of the suppuration has not been recog- nized, this condition may resemble typhoid fever, but the temperature is not so uniform; leucocytosis is present and careful search will gener- ally reveal suppuration. In pyemia, severe chills are generally present, and the temperature range is wide, with decided hyperpyrexia in many cases. The Widal test fails. Uremia.— K uremic condition may obscure the diagnosis in the begin- ning of some cases, rarely at any other time. But the tense pulse, rapid respiration, contracted pupils, and absence of abdominal symptoms would serve to distinguish the condition. Uremia may, however, occur as a complication, and prolonged uremic coma sometimes resembles typhoid fever so closely as to be differentiated only by careful analysis of the urine. Acute Miliary Tuberculosis.— \rv many cases there is a history of previous tubercular disease; the pulse and respiration are rapid, the mind is usually clear, the cough is more annoying, the sputum is often bloody, the abdominal symptoms are not so well marked, tubercle bacilli may be found in the blood or sputum, leucocytosis and anemia are present, and tubercles may be discovered in the choroid on ophthal- moscopic examination. TYPHOID FEVER 71 Tubercular meningitis usually occurs in children; there is a history of irritability preceding the stupor, constipation is persistent, the ab- domen is usually flat, leucocytosis is present, and tubercles may be found in the choroid. In tubercular peritonitis, the temperature is irregular, sometimes sub- normal, the abdominal tenderness greater and more general; ascites may be present, and the leucocytosis excludes typhoid fever. Appendicitis is usually more sudden in development, with greater pain and ileo-cecal tenderness; or, if of slow development, the constitutional symptoms are less prominent. Vomiting is often present. Percussion of the region elicits tympanitic dullness, as distinguished from the res- onance of distention, and tumefaction may be felt. Tenderness at McBurney's point and, more particularly, leucocytosis and the failure of the Widal test establish the diagnosis. Influenza of the abdominal type is sometimes excluded with difficulty for a time on account of the headache, abdominal tenderness, pain, and diarrhea. But the onset is generally more sudden, the prostration earlier developed; the symptoms more numerous and painful. The tongue in influenza is bright red with prominent papillse. Malignant endocarditis sometimes resembles typhoid fever, but is an infrequent disease. Abdominal tenderness, diarrhea, splenic enlargement, and stupor are sometimes present. There is generally, although not always, great cardiac pain and distress. The onset is sudden, the tem- perature irregular, and leucocytosis is present. Relapsing fever is very infrequent in America. The invasion is sudden, with a chill; the pain is epigastric in location; there is no rose-eruption; the nervous phenomena are less pronounced and the spirilla are readily found in the blood. Typhus fever is seldom encountered except in epidemics confined to a single institution or ship. The onset is sudden, the stupor profound, the face is dusky, the eyelids swollen, the pupils contracted; there is a macular eruption usually appearing on the fourth or fifth dav, changing into petechias; the duration of the disease is short and its termination is by crisis. The Para- Infections. — There remains a not well defined group of dis- eases, clinically almost identical with typhoid fever, but due to infection by the so-called paratyphoid or paracolon bacilli. In many instances a differentiation can be made only by the bacteriological or serum tests. The Widal reaction is almost always absent. Ptomainpoisoning and autointoxication with leucomains are generally to be excluded by the abruptness of onset, often with vomiting, diarrhea, and prostration, and by the absence of serum reaction. Prognoses. — An unconditionally favorable prognosis should never be made in this disease, for the most distressing complications often arise in the mildest and most hopeful cases; and in the absence of compli- cations a sudden, even fatal, collapse may occur. The mortality in pri- vate practice is usually from 5 to 10 per cent, and in hospital practice from 7 to 15 per cent. The death-rate has been reduced about one- half since the introduction of the cold-bath treatment. Some epidemics are characterized by a low mortality, others by an excessively high rate. Regional difl'erences may also be o'bserved in some instances. The mor- 72 PRACTICE OF MEDICINE tality in women is higher than in men and in fat persons than in lean. From puterty on, the disease becomes more fatal with the advance of years, yet old people often make excellent recoveries. The disease is usually mild in children. An impoverished state of nutrition, partic- ularly that due to chronic alcoholism, diminishes the chance of recovery. The severity of the type of infection has a great influence on the mor- tality and probably accounts for the difference in different epidemics. The extent to which the nervous system is involved and the degree of pyrexia are important factors. Hyperpyrexia is indicative of danger only when it is continuous for a number of days with but slight remis- sions. No definite degree of fever is necessarily fatal, but recovery sel- dom occurs after the temperature has reached io6° F. (41.1° C.) four or five days in succession; the danger lies in the profound intoxication of the nervous system revealed by the high temperature. Delirium is an unfavorable symptom, especially when it develops early and assumes the low muttering form. Excessive meteorism and hemorrhage are also dangerous symptoms, but not necessarily fatal. The prognosis is espe- cially bad in the ambulatory form of the disease, owing to the greater frequency of complications. Sudden death sometimes occurs without premonitory symptoms and without discoverable cause even after con- valescence has been well established. It is probably due in most cases to a failure on the part of the weakened heart, a "delirium cordis." But, on the other hand, it should be remembered that recovery often occurs in the most hopeless cases, and a positively unfavorable prognosis should not be too soon pronounced. Treatment.— Prophylaxis.— T\\^ measures to be adopted for the pre- vention of typhoid fever are in part municipal and in part personal. It is the duty of physicians to enhghten the people in the possibility of preventing the disease, and the measures to be adopted. The impor- tance of a pure water-supply, free from possible contamination, and the necessity of a proper system of sewers should be promulgated. Dairy- men should be taught the importance of using only boihng water for the cleansing of cans and utensils. Individual protection theoretically requires the abstaining from every- thing that has not been disinfected by heat. Drinking-water ard mil'k must be thoroughly boiled and cooled in bottles, for the addition of ice is not safe. All utensils must be cleansed in water that has been boiled. Green vegetables, to be eaten raw, must be thoroughly washed in sterihzed water or refrained from. Oysters fed in the mouths of streams contaminated with sewage must not be eaten raw. In times of danger, these requirements are imperative, and there are few cities in which the requirements in regard to water must not be carried out at all times. In villages and in the country, however, the purity of the water is often a matter of certainty, and boiling may be neglected. Filtration has done much to reduce the prevalence of the disease in some places, notably in London, but it is absolutely untrustworthy for the purification of contaminated water, since the bacilli are capable of passing through many of the house filters. Visitors and recent resi- dents should be particularly careful to obtain their food and drink from uncontaminated sources, or to thoroughly disinfect them. Z?m>//^r/w?/.— Methods of antisepsis must be applied to the patient, to TYPHOID FEVER 73 his excreta, to the bed-linen, and more or less generally to all articles, coming in contact with the patient. The best disinfectants for feces and urine are: a i ;5oo acidulated solution of mercuric chlorid, a i :20 solution of commercial carbolic acid, and fresh chlorinated lime. Re- cently a I :2o solution of formaldehyd has been much employed. For solutions and methods, see p. 727. Preventive inoculation has been practiced with apparently some de- gree of success. In Maidstone, 95 persons escaped infection after inocu- lation. In the recent Boer war, 200 English troops were inoculated, of whom 3, or 1.5 per cent., took the disease; none died. The inoculation produces local reaction, a rise of temperature and the serum of the person acquires agglutinative properties, reacting to the VVidal test. The results are not conclusive, but justify a hope for future success. General Management. — Good nursing is more important than drugs. The patient should be put to bed immediately when the disease is suspected, and kept there until convalescence is fully established. This is usuaHy from ten days to two weeks after the temperature has ceased to rise above the normal. The sick-room should be large and airy, if possible on the sunny side of the house. An abundance of fresh air should be admitted without too much draft. The temperature of the room should be 68° F. (20° C.) in daytime and 65° F. (18'' C.) at night. Perfect quiet must be maintained. The attendants should be limited to a nurse and one member of the family ; visitors should be excluded. Unnecessary talking, but, above all things, whispering, must be prohibited. The bed should be narrow and low enough to permit easy handling of the patient. A woven-wire spring, with a soft hair mattress covered with a double blanket, affords the greatest comfort. A rubber cloth should be placed under the sheet. The bed must be kept clean and smooth at all times to prevent bedsores, and an air- cushion should be used if their formation is threatened. The head should not be too high. A competent nurse should be employed when circumstances permit. The physician should write out daily his instructions as to diet, nursing, disinfection, and medication, and in return should receive from the nurse a daily record of the temperature, taken every three hours, with a re- port of the number of dejections, baths, h6urs of sleep, amount of nourishment and drink administered, and any unusual symptoms — in short, a history of the case for the last 24 hours. The temperature chart should be kept from the patient's view. He should not be informed of any unfavorable symptoms or complications; he need not be made aware of intestinal hemorrhages. He should not be permitted to lie constantly on the back, but should be carefully turned upon either side from time to time. He must never be allowed to rise for any pur- pose. It is better to have him naked in bed, for a gown becomes wrin- kled and rough. Food and drink must be given through a tube. The bedpan must always be used. The patient generally finds difficulty at first in its use, but rarely fails to become accustomed to it in a few days. It is only in the rarest cases, when the nervous excitement occa- sioned by unsuccessful attempts to use the bedpan is a positive menace to the patient, that the physician should consent to his being carefully 74 PRACTICE OF MEDICINE lifted upon a commode. The patient must not be allowed to make the slightest exertion. The mouth, tongue, and lips should be cleansed once or twice daily. A solution of borax, or equal parts of hydrogen peroxid and glycerin, or listerin, on a soft rag may be employed. It may be necessary to scrape the tongue. The system requires an abundance of water for the maintenance of the secretions, especially that of the kidneys, which are burdened with the elimination of the toxic matters. At least a quart a day of pure cold water should be given with the regularity of medicine, for the patient seldom asks for it. This is one of the most important items in the treatment. The addition of a few drops of dilute hydro- chloric or phosphoric acid or a little lemon-juice is beneficial and gener- ally agreeable. The aromatic sulphuric acid may be substituted when the diarrhea is excessive or the sweating profuse. Hydrothe7'apy. — The Brand method, or cold-bath treatment, is the most esteemed of the methods of hydrotherapy. The benefits obtained from it are: (i) The reduction of temperature. This is, however, one of the minor considerations. (2) The stimulating effect upon the ner- vous system. There is no other method that will so promptly and so eftectually clear the intellect and arrest the tremor. After the bath the patient generally falls into a tranquil sleep of several hours' duration. (3} Stimulation of the heart's action. The danger of sudden failure of the circulation is removed; the pulmonary circulation is rendered stronger, and thus the tendency to hypostatic congestion and throm- bosis is diminished. The increased renal circulation results in a more abundant elimination of the toxic matter. (4) An increase of respira- tory movements, especially deep respiration, through which the tendency to bronchitis is lessened. The full Brand method is contraindicated : (i) WTien pneumonia or pleurisy is present; (2) when alarming paroxysms of dyspnea, cough- ing, or cyanosis are induced by the bath; (3) after perforation or peritonitis has developed; (4) when there are extensive bedsores which would be injured by the cold water. A modified bath must sometimes be administered to very elderly persons and those who cannot become accustomed to the full bath. As in all therapeutic methods, however, it is, as a rule, better to omit the treatment altogether than to give it in a half-way or careless manner. The first sensation of a dip into cold water when the temperature of the body is abnormally high is by no means pleasant, but there are few persons who will persistently object to it after they have experienced the after-eff"ects and have been made to understand the benefits they will derive from the treatment. The Brand treatment should be begun early, always before the fifth day if possible. The baths should be repeated ever}^ three hours as long as the rectal temperature exceeds 103° F. (39° C.) or as long as the sensorium continues depressed, even \\dth a lower temperature. The Method.—.^ portable bath-tub of sufficient length and width to accommodate the patient should stand in readiness at his bedside, protected from his view by a screen. It should be filled to three- fourths of its depth with water of 90° F. (32° C.) for the first bath. The temperature of the water should be reduced 5° F. (2.5° C.) at each successive bath until it has reached 65° F. (18.5° C.) and no TYPHOID FEVER 75 lower. The patien-t is given a stimulant, brandy or black coffee; he is then uncovered, a napkin placed over the genitals, and the face bathed with cold water. He is now transferred to the bath by two attendants, one grasping him under the shoulders, the other just below the knees. This should be done as gently as possible. Brisk friction is performed during the bath. Every part of the body except the lower abdomen should be gently but firmly rubbed in order to prevent chilliness and to stimulate the cutaneous reaction. Nothing short of chattering teeth or a cyanotic appearance of the face should be regarded as an indication to discontinue the bath in less than twenty minutes. While the patient is in the water, the bed should be prepared for his return. This is done by laying over it a double blanket, and over this a sheet. He is laid upon this and the sheet is folded over him, a fold being passed between the arms and sides and between the legs, and the blanket is wrapped around this. Here he is permitted to lie undisturbed for five or ten minutes. If, however, the temperature was but moderate before the bath he may be dried at once, first with the sheet, and afterward with soft towels. Hot bottles should be placed at his feet. Reaction is generally prompt. Prolonged shivering after the bath, Baruch tells us, points to some defect, either in duration or temperature, or the friction may not have been properly performed. It is often a difficult question to determine whether the cold-bath treatment should be administered to a patient first seen in the second or third week of the disease. It must be left to the judgment of the physician, based upon the condition of the patient. A young physician would perhaps better select a mild case in the beginning of its course for his first application of the treatment, particularly if he be located in a community where the method has not been practiced. A great many intelligent physicians oppose the cold-bath treatment upon various grounds, others employ it in a modified form. Probably the best modification, especially for the treatment of children, the aged, and persons who persistently refuse to become accustomed to the Brand bath, is found in the use of water at 90° F. (32° C.) at the beginning of every bath, subsequently reducing the temperature of it by the gradual addition of ice-water until 70° F. (21° C.) or even 65° F. (18.5° C.) is reached (Ziemmsen's method). As substitutes for the cold bath, sponging and the cold pack are the most popular. The cold pack is applied by wrapping the patient in a sheet wrung out of water at 60° or 65° F. (15.5°— 18.5° C.),and then sprinkhng him with water of the same temperature from a watering-can. It does not compare favorably in its results with either the cold bath or sponging. Cold sponging should be practiced in all cases that are not subjected to the cold-bath method. The entire body is sponged with likewarm, cold, or iced water for 15 or 20 minutes at a time. The effect of the ice-cold sponging is an almost as pronounced stimulation of the nerve centers as is obtained from the, bath, and it is secured with much less labor. Dietetic Treatment. — Nourishment must be administered entirely in fluid form. Milk is the best food. Four pints should be given to an adult in twenty-four hours, which is about equivalent to a tumblerful every two hours in daytime and a little less often at night. It may 76 PRACTICE OF MEDICINE be given cold or warm. If objectionable to the patient, its taste may be modified by the addition of a little salt, Vichy, carbonated water, a little coffee, tea, or cocoa. In some persons it produces constipation, flatulence, tympanites, or diarrhea, with undigested curd or fat in the stools. In such cases, if the addition of lime-water or Vichy does not relieve the difficulty, the milk may be partially pre- digested, or the quantity must be reduced and other nourishment given. Beef, mutton, or chicken broth and bouillon answer this purpose. A little thoroughly cooked rice or the white of an egg may be added to the broths. If, however, the diarrhea be severe, broths and beef- juice must be omitted on account of their tendency to increase it. The whites of five or six eggs may be given during a day, beaten with milk or sherry, or in the form of albumen-water, flavored with lemon or orange. Panopepton or other predigested food may be tried with cau- tion. But it should be borne in mind that every unavoidable departure from a strict milk diet adds risk and an occasion for regret in case of a fatal issue. -Dief of Convalescence. — It is a safe rule not to allow solid food for eight or ten days after the fever has remained normal, and to exercise especial caution in the addition of meat to the dietary. After a few days of normal temperature, a soft egg, milk toast, custard, and junket may be added, one at a time and at only one meal each day. Then blanc-mange, bread and milk, boiled rice, bread pudding, and other articles made of eggs and milk may be given in small quantity, the eff'ect of each article added being carefully watched. If elevation of temperature, diarrhea, or other disturbance be produced, the milk diet must be resumed for a few days. Medicinal Treatment. — No routine course of medication is required. Symptomatic indications should be met, but these are generally if^. In some localities, the administration of quinin for a few days is judi- cious, in order to exclude the possible presence of malaria. Small doses of calomel, gr. i-io (0.006), may be given for a few da3^s, for its anti- septic effect, especially if constipation exist. Salol, /?-naphthol, creosot, guaiacol, and other intestinal antiseptics are in favor with some author- ities. They probably have little eff'ect upon the infection. Inoculation Treatment. — Several attempts have been made to treat the disease with sterilized liquid obtained from cultures of the bacillus typhosus or the bacillus pyocyaneus; with blood-serum obtained from convalescent patients, or with the serum of dogs that have been inocu- lated with typhoid cultures. In most instances the only apparent result was a reduction of temperature; that the course of the disease was modified could hardly be asserted. The recent experiments of Richardson, in which normal blood-serum was added to the curative serum, seem to promise better results. Treatment of Special Symptoms. — Fever. — The best means of reducing the temperature when the cold-bath treatment is not employed is by repeated sponging with ice-water. Antipyretics of the coal-tar series, as phenacetin and acetanilid, should be carefully used, if at all. A mixture of equal parts of guaiacol and glyercin or guaiacol carbonate may be applied with friction to the outer side of the thigh. Its action should be watched, however. TYPHOID FEVER 77 Diarrhea. — Four or five stools a day cannot be regarded as harmful. If moderately excessive, they may be checked by the administration of bismuth, grs. x to xv (0.65 — i.o), Dover's powder, grs. iij to v (0.2 — 0.35), or camphorated tincture of opium in teaspoonful doses repeated every three hours. If the diarrhea be profuse, the lead and opium pill or morphin, gr. ^/g (0.008), may be required. If the stools are offensive, salol, grs. v (0.35), may be given with the opiate. The cause of the diarrhea should be sought by examination of the stools, especially for undigested milk. Constipation is best overcome by enemata of soapsuds, oil, or glycerin. Small doses of calomel may be employed in the first days of the attack. Tympanites. — Turpentine stupes or hot fomentations should be ap- plied. Ten drops of turpentine internally, in emulsion or on a lump of sugar, are often effective. When the colon is greatly distended, the introduction of a rectal tube often gives vent to the gas. Delirium. — Such causes as meteorism or deficient action of the kidneys should be looked for. Quiet restraint must be exercised. The bromids act well in some cases; morphin must be employed in others. Hydro- therapy is probably the most certain means for its prevention. Mania requires the most careful attention. The patient should not be left alone for an instant. Hyoscin hydrobromate in i-ioo grain (0.0006) doses may be given, and, this failing, morphin in full doses must be resorted to. Hemorrhage of the Bowels. — Absolute rest and quiet must be secured. The patient should be kept in a quiet doze for several days by the ad- ministration of lead and opium pills, laudanum, or morphin in sufficient doses. The foot of the bed should be raised and a Leiter coil or other cold application should be applied to the ileo-cecal region. Alcoholic stimulants should not be given, except in case of extreme collapse. Even in this condition, strychnin given hypodermically is safer. Trans- fusion of 0.7 per cent saline solution into a vein or the subcutaneous tissue may assist in tiding the patient over. Perforation. — Surgical aid should be at once called, unless the con- dition of the patient is so extreme as to clearly preclude the possibility of an operation. In the mean time the patient should be kept under morphin. Cardiac Weahiess. — Strychnin should be given every three or four hours in increasing doses, up to 1-20 grain (0.003) if necessary. Whisky or brandy may be given in the absence of contraindications, from a table- spoonful every three hours to an ounce every hour until reaction is obtained. Bedsores can be generally prevented by thorough cleanliness and keep- ing the bed and skin dry. The prominences should be bathed twice daily with alcohol, brandy, or spirits of camphor, dried, and dusted with an an- tiseptic flesh-powder or the stearate of zinc. Treatment of Convalescence. — As soon as the patient has begun to take solid food, he may begin to sit up in bed. He may be partially raised on pillows for fifteen to thirty minutes at a time. This should be practiced for several days, gradually lengthening the time, before an attempt is made to sit in a chair. As strength returns, the amount of exercise permitted may be increased. As soon as the patient is able, 78 PILICTICE OF MEDICINE he should spend much of his time in the open air, getting as much sunshine as he can bear. A trip to the country, or, better, to the moun- tains, is a pleasant and profitable mode of recuperation. He should be fully instructed before departure, however, as to the danger of over- exertion and, more particularly, as to that of overeating. A bitter tonic should be prescribed, and iron or arsenic is often required for the anemia of convalescence. The elixir of iron, quinin, and strychnin is one of the most serviceable preparations at this time. TYPHUS FEVER. HOSPITAL FEVER, TAIL FEVER, CAMP FEVER, SHIP FEVER, SPOTTED FEVER. Typhus fever is endemic in England, notably in London, in Ireland, Scotland,,. Russia, southern Europe, and Mexico. It is seldom met with in the United States. Cases have, however, occurred in Boston, New York, Philadelphia, and Baltimore, for the most part among Irish immigrants. Dafinition. — A highly contagious acute infectious disease having a sud- den onset and definite course, with macular eruption, terminating with crisis in about fourteen days. Etiology. — Overcrowding, un cleanliness, poor food, poverty, and intem- perance are the principal predisposing factors, hence the comparative frequency of the disease in jails and camps. The disease occurs at all seasons, but especially in winter and spring, probably because this is the s-eason of overcrowding among the poor. The sexes are attacked about equally and no period of life is exempt. A majority of its victims are between 20 and 40, and those between 10 and 30 are about equal to those between 30 and 50. The specific infectious agent is not known. A streptobacillus, a dip- lococcus, and a peculiar spirocheta have been found in the blood or other fluids by difterent investigators. It is one of the most contagious of the infectious diseases; in some epidemics the physicians and nurses have been almost universally attacked. This feature is much less fre- quently noted, however, in cases that occur in private residences, where careful attention can be given to methods of prophylaxis, including the removal of all unnecessary furniture, carpets, and draperies from the room, and to the disinfection of the patient, especially his mouth and nostrils. The infection is beheved to be transported by the desquamated epidermal scales, by the sputum of the patient, and by fomites. The poison may be retained in articles of clothing for several months. Morbid Anatomy. — ^No characteristic lesions are found in any of the organs. The eruption remains upon the skin after death, and ecchymoses are found upon dependent surfaces. The blood is dark and abnormally fluid. It has been compared to a mixture of serum and snuft". The muscles have a dark red color, frequently show granular degeneration, particularly in the heart, and sometimes extravasations of blood. My- ocarditis is often found, and the endocardium may be reddened. There are no constant lesions in the intestines, but the lymph-follicles are frequently enlarged without ulceration. The liver is enlarged and soft, and the spleen is usually large. The kidne3''S are hyperemic and may show the changes of nephritis. The bronchial mucous membrane is con- TYPHUS FEVER 79 gested and coated with mucus; sometimes lobular pneumonia, less fre- quently lobar pneumonia or pleuritis, i-s found. Hypostatic congestion of the lungs is quite common. The discoverable lesions of the nervous system are confined to slight congestion of the cerebral and spinal meninges, sometimes with effusion of serum into the subarachnoid spaces and ventricles. Symptoms. — The incubation lasts from nine to twelve days, during the last two or three of which there is a feeling of languor or a loss of appetite, and headache. The invasion is usually sudden, with a distinct rigor or a succession of chills for several days. Severe headache, pain in the loins and limbs, with profound prostration, early confine the patient to his bed. The face is flushed, the eyes expressionless, the conjunctivEe reddened, the pupils contracted. The tongue has a white fur, soon becomes dry, and sordes form upon the teeth. Nasal catarrh and bronchitis are generally present. Persistent vomiting may be a troublesome symptom. The patient complains of ringing in the ears, of black spots before the eyes, and the nervous manifestations increase in severity until delirium supervenes. The temperature rapidly rises, often reaching 104° F. (40° C.) on the first evening. It may attain its maximum, 105°, 106° F. (40.5° — 41.0° C.) or even higher, on the second or third day. Its course is almost uniform, showing but slight remissions. The pulse is rapid and full; less frequently dicrotic than in typhoid fever. The heart sounds become indistinct, and a systolic murmur is often heard. The respiration is moderate. The urine shows the usual febrile changes — diminution of quantity, with increase of solids, especially of urea and coloring matter, decrease of chlorids, and often a trace of albumin. The eruption appears on the third to the fifth day, first on the ab- domen and upper part of the chest, then on the extremities and face. It has the form of distinct dark red papules under the cuticle, which soon become hemorrhagic and petechial in character. The skin between the papules is often reddened. Herpes is rarely present. The general integument is dry. A furfuraceous desquamation during convalescence has been described. In mild cases the eruption occasionally fades away without passing into the petechial state, and the symptoms begin to abate with the decline of the fever, about the seventh day. Some epidemics have been characterized by the great number of mild cases, and others by the remarkable severity of all. In severe cases the temperature remains high, delirium develops and often becomes violent or it may deepen into coma. Coma-vigil is often seen. The bronchitis may pass into lobular pneumonia, hypostatic congestion becomes marked, and death may ensue from exhaustion. If the case is to terminate favorably, a crisis occurs usually on the 17th day, occasionally a little earlier or later. The temperature sinks almost uniformly to the normal within 24 to 48 hours, and all the symptoms rapidly abate. The crisis is accompanied with profuse sweating or free micturition. An extreme elevation of temperature, sometimes reaching 109° F. (42.7° C), gen- erally precedes a fatal termination and is sometimes observed before the crisis. Relapses are extremely rare. Complications. — The complications are those ordinarily seen in a se- vere febrile disease. In some epidemics gangrene of the toes, fingers, or So PRACTICE OF MEDICINE noee, and, in children, noma, have been observed. The sequelae are few. Sometimes anemia persists, and neuralgia or paralysis, probably due to neuritis, has been seen. Diagnosis. — Owing to the resemblance of mild cases to typhoid fever the diagnosis may for a time be difficult, particularly in the absence of an epidemic. It can generally be determined by the following points : (i) The onset is more abrupt, often with a pronounced rigor. (2) The nervous manifestations appear earlier and are usually more severe. (3) The eruption comes out earlier, is more abundant and of a petechial character, a type rarely seen in typhoid fever. (4) The headache and pains in the limbs are more severe. (5) The temperature is higher, more uniform, terminates earlier and by crisis. Prognosis. — This is determined chiefly by the character of the attack, the severity of the epidemic, and the general condition of the patient. The mortality is as low as 6 or 7 per cent in mild cases, but may exceed 20 per cent in others. Treatment — Owing to the contagiousness of the disease, the patient should be immediately isolated, and the most rigid antisepsis should be practiced. The general indications are the same as those for typhoid fever. Hydrotherapy affords the best means of combating the fever and the depression of the nervous system. In addition to this, the treatment should be supportive and stimulating. Alcohol should be freely given, with an abundance of milk and beef-juice, and the heart's action should be supported with strychnin. Every effort must be made to maintain the strength of the patient until the infection has expended its force. RELAPSING FEVER. RECURRENT FEVER, RELAPSING TYPHUS, SEVEN-DAY FEVER, FAMINE FEVER. Relapsing fever has prevailed more or less epidemically in various parts of the Old World at difierent periods during the last two hundred years, possibly from an- tiquity. It was brought to America by Irish immigrants in 1844, but has not been encountered here since 1869. Definition.— Aji acute infectious disease caused by the spirillum of Ober- meier, characterized by from two to five febrile paroxysms, each lasting about six days and separated by a febrile interval of the same dura- tion. Etiology. — The specific cause of the disease is a spirocheta, a delicate filamentous spirillum about 3o,a in length, or five times the diameter of a red blood-corpuscle. These are found in the blood during the febrile paroxysms and are then actively motile. Shortly before tke crisis they disappear and remain absent during the afebrile period. They have not been detected in any of the other fluids of the body, but are found in the spleen and very rarely in the blood after death. Inoculation with the blood of a patient produces the disease, even in one who has previously passed through an attack. The blood-serum of a person having the disease contains, at certain periods, a substance which is exceedingly toxic to the spirillum. The disease is contagious to a slight- ly less degree than typhus fever. In some epidemics, however, this feature is more prominent than in others. RELAPSING FEVER Si A Russian physician has recently investigated the possible trans- mission of the disease by insects, and found numerous spirilla in the bodies of bedbugs that had feasted upon patients with relapsing fever. From this it is inferred that the disease may be transmitted by the bug to other individuals. Morbid Anatomy.— There axe no typical lesions. Ecchymoses are gen- erally found. After death during a paroxysm, the spleen is large and soft, and cloudy swelling may be found in the parenchyma of various organs. Infarcts are sometimes seen in the spleen and kidneys. Symptoms.— The incubation period is generally from five to eight days. Prodromal symptoms are generally absent. The invasion is abrupt, usually beginning in the morning with one or more chills; the temperature rapidly rises to 102° or 104° F. (38.9^ — 40° C.) by the first evening, with headache, violent pains in the limbs and back, and extreme prostration. Vertigo, nausea, and vomiting are sometimes present. The breath is fetid. The pulse ranges from no to 130. The liver and spleen rapidly enlarge and become sensitive to pressure. Profuse sweating is usual. There is no eruption, as a rule, but occasionally herpes, petechise, or miliary vesicles are observed. The prostration, restlessness, and fever reach their greatest severity from the fourth to the sixth day. There is often a sense of oppression in the right hypo- chondrium, and great dyspnea. The crisis occurs while the disease is at its height, usually on the fifth or sixth day, rarely as early as the third or late as the tenth day. A profuse sweat comes on and the temperature drops from 7° to 10° F. during a single night. The pulse becomes slow and all the symptoms subside. Old persons often sink into collapse. Convalescence is rapid, but recovery becomes more delayed with the repetition of the paroxysms. In some instances the disease terminates after the first paroxysm. A fatal termination may follow collapse or result from prostration or heart-weakness, but it is generally due to some complication. Bilious Typhoid. — A special form of the disease, in which pernicious jaundice greatly adds to its gravity, has been described under this name. A mild icterus is sometimes observed, and other deviations from the usual course are not uncommon. Complications axe not frequent. The most important are pneumonia, nephritis, hematuria, hematemesis, rupture of the spleen, and paralyses. Iritis and other ocular affections are encountered. Pregnant women fre- quently abort. Diagnosis. — The disease often passes unrecognized until the first re- lapse occurs. Examination of the blood during a paroxysm reveals the spirilla. The prognosis is favorable except in the bilious form or after repeat- ed relapses with complications. Treatment. — Beneficial action is claimed for quinin, calomel, arsenic, methylene blue, potassium iodid, and other remedies, but there is no unanimity of opinion in regard to any of them. Hydrotherapy is bene- ficial, although the spirilla are capable of prolonged life in blood of normal temperature. Injection of serum from immunized animals has been resorted to during the first afebrile period, with arrest of the disease in about half the cases treated. In other respects the treatment is symp- 6 82 . PRACTICE OF MEDICINE tomatic. The strength of the patient must be supported and the special symptoms and comphcations must be combated as they arise, by the methods employed in typhoid and other fevers. INFLUENZA. LA GRIPPE— THE GRIP, CATARRHAL INFLUENZA, EPIDEMIC INFLUENZA. Definition. — An acute endemic or epidemic, often pandemic, infection caused by the bacillus of Pfeiffer and characterized by a strong tendency to attack the respiratory mucous membranes. Eiiology. — The bacillus of Pfeififer is found in the blood and nasal mucus, but more abundantly in the bronchial secretion, during the attack and sometimes for a long time after. It is a small, short, non- motile rod with bulbous ends, staining freely with a dilute aqueous solu- tion of carbol-fuchsin. The disease is highly contagious and spreads with rapidity. Some investigators think that it can be carried by the air, and there is some evidence of its transmission by a third person or by fomites. Epidemics are more frequent during the winter, but have occurred in the warmer months. Adults are more susceptible than chil- dren, but no age is exempt. In pandemics few are spared. One attack renders the individual more liable to future infection. Sporadic cases usually occur for several years after an epidemic. The common sporadic influenza is a separate infection (influenza nostras), but its etiology is not known. The influenza poison is thought to be antagonistic to that of malaria, since a marked decrease in the prevalence of the latter dis- ease has been observed during an epidemic of the former. Symptoms. — The disease appears in so many forms that it is cus- tomary to consider them separately. Clinically, however, the distinction is not always clear, for one type may blend with another or merge into it. The incubation varies from one to four days. Prodromal lassi- tude., headache, and dullness are sometimes observed. General Syfnptoms. — A train of symptoms is more or less common to all cases. The invasion is generally abrupt, with a chill or chilly sen- sations and a rapid rise of temperature, often to 104° or 105° F. (40° — 40.5° C.), intense headache, tenderness and aching of the muscles and joints, which are independent of motion. Mental and physical depression, restlessness, and insomnia are often extreme. Catarrhal symptoms are generally, though not invariably, present. Franke has recently called attention to a peculiar redness of the mucous membrane of the mouth, particularly the gums and tongue, with swelling of the papillse at the extremity of the tongue often equal to that seen in scarlatina. He regards it as pathognomonic of the disease. The temperature pursues an irregular course and not infrequently terminates by crisis. The pulse is usually rapid and feeble, sometimes intermittent; in other cases it is extremely slow (bradycardia). Respiratory Type. — This is the most frequent form. It may affect the entire respiratory system from the nose to the air-cells. The symptoms are much the same as those of an ordinary catarrhal fever, but the fever is more intense and the prostration greater. There is frequent sneezing, sufi^usion of the eyes and lachrymation, often accompanied with pharyngeal irritation, hoarseness, and cough. The cough is at first INFLUENZA 83 dry and excessively irritating. In a day or two, however, there is abun- dant bronchial secretion, which rapidly becomes purulent. The sputum is generally of a pale green color and is ejected in firm lumps. Dyspnea is often a prominent symptom. Cyanosis may result from the extension of the inflammation to the finer tubes or from edema of the lungs. Nervous Type. — In this form the patient is often suddenly seized with severe headache, muscular pains or neuralgia, and profound mental and physical prostration. There are frequently cutaneous hyperesthesia and sensitiveness to light and sound, rigidity and tenderness of the neck muscles. Convulsions are not uncommon, and delirium with hallucina- tions appears in some cases. Some cases sink into a typhoid stupor; the resemblance to meningitis is often striking. The analogy to typhoid fever was most pronounced in cases observed by Pelon and by Feindel and Froussard, in which lenticular rose-spots appeared. The Widal test was negative, however, in all the cases. The recovery is generally slow, and melancholia and great mental inactivity often persist for some time. Gastrointestinal Type. — This is characterized by persistent nausea and vomiting, or by intense abdominal pains and diarrhea. The fever may be high. The symptoms are often suggestive of appendicitis, if, in- deed, the appendix is not sometimes implicated. Jaundice sometimes develops. Complications and SequelcB. — Lobar and bronchopneumonia are the most frequent and serious complications on the part of the respira- tory system. Both are peculiar in the great diversity of the patho- logical lesions found in fatal cases. Pleurisy and empyema are not infrequent. Bronchitis characterized by a preponderance of streptococci in the sputum has been noted, especially by Forchheimer. The compli- cations on the part of the circulatory system are of special importance and are attributed to the direct action of the influenza toxin. Tachy- cardia and bradycardia are alike frequent. Pericarditis, myocarditis, phlebitis, and thrombosis are occasionally developed. Endocarditis is rare, and Sansom attributes the systolic murmur that is sometimes heard at the apex during or after the attack to a progressive degeneration of the myocardium which cannot be compensated for by hypertrophy of the ventricles. Neuritis, hemiplegia, monoplegias, myelitis, otitis, and various affections of the eye have been observed. A pre-existent tuber- culosis and cardiac or renal disease are always intensified by an attack of influenza; even the encroachment of old age sometimes seems to be hastened by it. Prognosis. — Uncomplicated cases usually terminate in recovery. The mortality is due chiefly to the complications or to the aggravation of pre-existent disease. On this account the general mortality list of a locality shows an increase during the prevalence of an epidemic which is in but small part accounted for by the deaths directly due to the grip. The prognosis is especially unfavorable in alcoholic subjects and in very aged persons. Diagnosis. — The disease is diff'erentiated from other catarrhal affec- tions chiefly by the severity of the pain and the profound prostration. In the presence of a pandemic, the diagnosis is seldom difificult. The bacteriological examination removes all doubt. 84 PRACTICE OF MEDICINE Typhoid fever, as compared with influenza, shows a longer prodromal stage and slower elevation of temperature; epistaxis is frequent, the rose-rash much more constant. The Widal test establishes the diagnosis. Cerebrospinal meningitis rarely suggests this disease. The catarrhal symptoms are usually absent; the character of the epidemic is different. Dengue is a disease of warm climates and is generally distinguishable by its peculiar febrile paroxysms, early exanthem, and enlargement of lymph-glands. rrea//we/7f.— Prophylaxis is difficult, but may be attempted by gen- eral regard for the health and avoidance of fatigue and loss of rest. Old persons should be as much as possible protected from exposure to the infection. The patient should be confined to bed during the entire attack, in order to avoid complications. An attempt may be made to abort the ■disease. With this end in view, the patient should take a hot bath the first night and follow it with a glass of hot lemonade. He should then be warmly covered in bed in order to induce free sweating. A dose of calomel, grs. ij to v (0.13—0.32), may be given, and followed with a Seidlitz powder in the morning. Quinin and Dover's powder are excellent remedies, to which belladonna may be added to reduce the coryza. The fever and pain are relieved by 5 to lo-grain (0.32—0.64) doses of phe- nacetin, to which 2 grains (0.13) of citrated caffein should be added, particularly if the heart is weak. The prostration calls for stimula- tion, champagne if the stomach is irritable, or brandy and strychnin, gr. 1-60 to 1-40 (0.00 1— 0.0016), three times daily. One-twelfth-grain (0.005) doses of heroin are best for the cough. A menthol and camphor spray reheves the nasal and pharyngeal irritation. A solution of the extract of suprarenal gland or of adrenalin ( i : 1 000) has yielded good re- sults. In the abdominal form of the disease the diet must be carefully regulated and in some cases should be restricted to milk. Broths, poached or soft-boiled eggs, milk-toast, and custard may generally be allowed, and eggnog and milk when stimulation is required. DENGUE. BREAKBONE FEVER, DANDY FEVER. Dengue is a disease of tropical and subtropical regions and is most prevalent in the East and West Indies, India, and Egypt. It is usually confined to the coast and val- leys, but in 1870-73 it spread over the whole of India. During the warmest weather it sometimes invades the more northern countries. In 1880 it reached Charleston, S. C, and Augusta, Ga., and in 1897 and 189S it prevailed to some extent in Georgia and Florida. Definition. — An acute epidemic or pandemic exanthematous infection occurring in two febrile paroxysms with excruciating pains in the head muscles and joints. Etiology. — A specific germ has not been demonstrated. The infectious agent is generally believed to be conveyed by the air, by fomites, or by direct contact. It is exceedingly virulent, often attacking fully 75 per cent of the inhabitants of a district within a few weeks. Heat and DENGUE 85 Kumidity favor its transmission. Susceptibility is almost universal and uninfluenced by age or sex. The recent investigations of Graham, of Beyrouth, indicate that the mosquito (culex) ma}^ inoculate the disease. He carried mosquitoes that had bitten dengue patients up into the mountains, far from any recognized source of infection, and saw the disease develop in two healthy young men who voluntarily submitted to their bites. Symptoms. — The incubation lasts three to five days. The attack consists of three periods, two febrile paroxysms and the interval. The invasion is generally abrupt, with chilliness, sometimes a rigor, rise of temperature to 103° F. (39.5° C.) or higher, even to 107° F. (41.5° C), prostration, and excruciating pains in the eyeballs or back of the head, the loins, and limbs. A deep flushing of the face may be the first symptom. The tongue is furred; gastric oppression and vomit- ing may occur. The initial rash often invades the entire body and the visible mucous membranes. An area around the eyes often becomes a deep purple. The throat may be congested and sore. This stage lasts from one to four days ; it often terminates by crisis with profuse sweat- ing, diarrhea, diuresis, or epistaxis. The pain subsides, and the patient, although weak, may feel well. The interval lasts but three or four days, then there is a return of fever and pain, with a roseolar eruption (the terminal stage). The relapse is usually milder than the first paroxysm; either the fever or the eruption may escape notice. Reddish brown spots appear on the palms and backs of the hands, with prickling and tingling, and quickly spread. On the body the spots coalesce into areas of variable size or into an unbroken mantle. The attack lasts only a few hours or several days. A furfuraceous desquamation follows, which may last three weeks. Recovery is usually rapid. Relapses are common. Convalescence may be delayed by continuance of the pains, anorexia, and weakness; and boils, urticaria, or other eruptions, with intense pruritus, may occur. Other complications and sequelae are rare. Diagnosis.— In^lnenza., malaria, rheumatism, and yellow fever are to be excluded. InJIiienza is a disease of colder chmates and winter. It is characterized by catarrhal symptoms without eruption, adenitis, or inter- mission. The bacillus may be found in the nasal and bronchial secre- tions. Malaria is excluded by the chills or continued fever, the absence of coryza, and the presence of the Plasmodium in the blood. Both artic- ular and muscular rheicmatism are more frequent in the cold months and in regions exempt from dengue. They have no eruptions or inter- missions. Sweating is profuse in the articular form, seldom in dengue. The continued fever, albuminuria, jaundice, black vomit, and grave nervous manifestations oi yellow fever are distinctive. The prognosis is good. Fatal convulsions may occur, however, in young children. A malignant type of the disease with fatal edema of the lungs has been seen in Calcutta. Treaf.menf. — This is directed to the relief of pain and the support of strength. Light liquid diet, rest, the avoidance of chill, the adminis- tration of a saline diaphoretic with aconite, and cold applications to the head at the outset are recommended by Manson. Phenacetin and bella- donna relieve the pain; morphin may be required. Stimulants should be 86 PRACTICE OF MEDICINE avoided. During convalescence small doses of potassium iodid and qui- nin, with the application of electricity, are beneficial, CHOLERA. ASIATIC CHOLERA, EPIDEMIC CHOLERA. Cholera belongs to India. It has prevailed there almost annually for centuries, re- peatedly becoming pandemic and spreading over Asia and a great part of Europe. It did not reach America until 1832, when it was brought by emigrant ships to Quebec and New York. Cases occurred also in 1835-36. Entering at New Orleans in 1848, it extended up the Mississippi and westward to California, and recurrences 'appeared in 1849. In 1854 it again entered at New York and spread over a greater part of the country. Mild epidemics occurred in 1866, 1867, and 1873. A remarkable reduction in its prevalence in the Philippine Islands has been noted since the advent of United States control. Definition. — ^An acute infectious epidemic disease caused by the com- ma bacillus of Koch, and characterized clinically by severe purging and vomiting, with collapse that often proves fatal. Etiology. — ^The comma bacillus, or spirillum, is conveyed to the hu- man being by drinking-water or food which it has contaminated. It is capable of living on meat, milk, butter, or other raw food for a week, in water for perhaps a longer time. The ultimate source of infection is always a previous case. The germs are found in great numbers in the dejections and the vomit of patients. They flourish outside of the body, however, under the influence of heat and moisture, particularly in cess- pools and decomposing animal matter. Infection is favored, therefore, by hot weather, bad sanitation, and uncleanly habits. The poison is carried in such articles as clothing or baled rags, but not by the air. Caravans and ships have been the principal carriers of it. The disease is not highly contagious so long as contamination is avoided. Washer- women are more exposed than nurses. Students have become infected while working in the laboratory with the cultures. The disease prevails best at or near the sea-level and rarely reaches the higher altitudes. Age and sex are of little importance in etiology. Fear, and physical debility from age, intemperance, or illness, favor infection and retard recovery. Bacteriology. — The cholera vibrio is an actively motile organism re- sembling a comma or an S. It is about half as long and thicker than the tubercle bacillus. It grows rapidly, but is not extremely tenacious of life. Drying or exposure to the air for three hours kills it. It will live in water rich in organic matter for a month or more. It gi-ows best at a temperature between 86° and 104° F. (30°— 40° C). A temper- ature of 104° F. (40° C.) destroys it, but freezing does not. In the body it is anaerobic; without, it is aerobic. There is probably no natural immunity further than that afforded by the power of the healthy gastric juice to destroy the bacilli. But living bacilli have been found in the stools of healthy men during an epidemic. It is noteworthy also that lower animals are not infected by cultures introduced into the stomach unless the gastric juice has first been neutralized. Morbid Anatomy.— The body appears emaciated and shrunken, the face drawn, and the skin of dependent portions mottled. A post-mor- CHOLERA 87 tern elevation of temperature is often noted. Rigor mortis comes on early and is extremely developed, and muscular contractions frequently occur after death which cause the eyes, jaws, or limbs to move or the whole body to change its position. In fulminant cases, dying within the first three or four hours, there are no internal lesions, except frequently a distention of the bowels with a flocculent fluid. In ordinary cases the tissues appear dry, the serous membranes feel sticky. The blood is dark and concentrated. The intestines are shrunken and thin, often con- gested throughout. Within them is found a thin flocculent serum, the same as constitutes the "rice-water" dejecta so characteristic of the disease. The flocculi consist of desquamated epithelium and large num- bers of the spirilla and other micro-organisms. The spirilla are found also in the ntestinal walls and lymph-vessels in cases that have not been rapidly fatal. Parenchymatous degenerations and sometimes areas of coagulation necrosis and desquamation of tubular epithelium are found in both the liver and kidneys. The spleen is usually small. The heart is dark, and the left ventricle, as a rule, is contracted. The lungs are congested, particularly at the bases. Symptoms. — The period of incubation usually lasts from two to five days; it is perhaps shorter in some cases. It may pass without symp- toms, or it may be marked by abdominal distress, slight pain and tenderness, visible peristaltic movement, or moderate diarrhea and de- pression. This stage is sometimes called the prodromus. The course of the disease is generally divided into three stages, that of serous diarrhea, t-hat of collapse (or the algid stage), and the stage of reaction. I. The Stage of Serous Diarrhea. — Following the prodromal symptoms the discharges become more frequent and more profuse, or, if no pro- dromes have been present, the onset is indicated by a rapid succession of thin, copious dejections, with or without severe griping pain and tenesmus. Extreme prostration and collapse, with violent cramps in the legs and feet, sometimes precede the diarrhea. Urgent thirst develops, and persistent vomiting follows within a few hours, first of the undigested contents of the stomach, later of transuded fluids. Hiccoughing often accompanies it. After the normal fecal matter has been discharged, the stools become thin and almost clear, often having a specific gravity below i.oio and an alkaline reaction. They contain flocculi which give them the " rice-water" appearance. Blood is rarely present. The collapse rapid'ly becomes extreme. The face appears shrunken, and often has a bluish, livid color; the lips are almost black; the conjunctivae dry and congested, the pupils small, and the eyes have a vacant stare. The cheeks alone are flushed. The mouth is drawn and the nose is pinched, the alge vibrate. The abdomen becomes flat and flabby. The patient appears to dry up. All the secretions become diminished and are finally arrested, with the exception, it is stated, of the lacteal secretion in nursing women. Total suppression of the urine may last for days. Violent cramps develop in the abdomen as well as in the legs. Emacia- tion becomes extreme. The skin is "icy" cold and hangs in folds. A young person appears old and wrinkled within a day. The rectal tem- perature mo.y, however, register 102° F. (39° C). In fulminant cases death often occurs before the diarrhea has commenced (cholera sicca), and, owing, perhaps, to paralysis, the intestine is found distended with 88 PRACTICE OF MEDICINE the fluid. The stage of diarrhea may last from 2 to 24 hours and then merges into the algid stage. 2. Tke Algid Stage, or Stage of Collapse or Asphyxia. — This results from the extreme concentration of the blood, and the feebleness of the heart which permits it to stagnate in the capillaries. Respiration becomes feeble and cyanosis develops. Tonic spasms seize the muscles of the abdomen, arms, and legs, and the suffering is intense. The voice is lost. The pulse, if discernible, is inoderately rapid, 100 to 120, but soon fades away, as the patient sinks into a coma. The alvine discharges become converted into a constant dribbling from the relaxed anus. Death may occur from asphyxia or from heart-failure. Not infrequently the patient lies for hours in a state so close to death that it is difficult to determine at what moment life becomes extinct. In other cases a typhoid condition develops, with rise of temperature, full or flickering pulse, and delirium. This is sometimes accompanied by a "cholera eruption," a roseola, erythema, or urticaria. It may finally end in re- covery, but usually passes again into fatal collapse, whi^ch has been attributed to uremia. 3. Stage of Reaction. — ^When the patient passes the stage of collapse, his condition gradually improves, with a cessation of the diarrhea, vomiting, and cramps; the skin becomes warm and the secretions are restored. The convalescence lasts two or three weeks. Diarrhea may persist. Relapse often occurs. Cholerine. — During an epidemic not a few cases of so-called cholerine are encountered, cases with diarrhea, cramps, and prostration of a milder character than belong to true cholera and without complete collapse or anuria. Complications and Sequelae. — Albuminuria often follows the anuria, and the fatal issue is often attributed to uremia or sepsis. Bedsores, superficial ulcers, furuncles, occasionally gangrene and diphtheritic inflam- mation of the mucous membrane of the throat, colon, or genitals, have been observed. Abscesses sometimes form, especially in the parotid gland. Broncho-pneumonia develops in some cases. Diagnosis.— it is only the first cases in an epidemic that occasion difficulty. Cases of cholera nostras are sometimes almost identical with true cholera. A serum reaction similar to the Widal test has been found almost universally present in a considerable number of cases, with serum diluted from i :io to i :ioo, and as early as the first or second day. But the bacteriological examination is more conclusive. A gelatin cul- ture from the dejections will produce a characteristic growth in a few hours. Prognosis. — The mortality in different epidemics varies from 40 to 90 per cent. Much depends upon the physical condition of the patient and no less upon the promptness of the treatment. Prophylaxis.— T\\Q patient should be isolated and a strict quarantine established. It is only as a result of our national quarantine methods that the disease has been kept out of this country for the last 30 years. The most rigid antiseptic measures must be practiced. All discharges from the patient should be immediately treated with a strong disinfec- tant solution and, if possible, destroyed by fire. The same solutions and methods of disinfection may be employed as in typhoid fever. (See YELLOW FEVER 89, p. 72.) Articles that have come into contact with the patient should be burned 01 thoroughly disinfected and exposed for days to the sun's rays. The dead should be disinfected and immediately placed in a her- metically sealed coffin or cremated. Water used for drink or for bathing should be boiled, and market vegetables and fruit should not be eaten raw. Treatment. — A full hypodermic dose of morphin, gr. Yi to Yz (0.02 — 0.03), should be administered immediately, and repeated upon return of the pain. This should be followed with the deodorized tincture of opium in doses of 20 drops (0.75) at intervals sufficiently short to hold the case under control and to keep the patient quiet. AH food must be withheld during the diarrheal and algid stages. The thirst may be relieved with chipped ice and ice-water acidulated with dilute hydro- chloric acid, gtt. XXX every two hours, since it is antagonistic to the bacilli. Strength should be maintained with brandy and black coffee by the rectum, and strychnin nitrate hypodermically in doses of gr. 1-20 (0.003). After vomiting has been checked, milk may be given in small quantities at regular intervals. The surface temperature must be main- tained by applications of dry heat, and the abdominal pains relieved by hot fomentations. Saline injections afford a most valuable means of counteracting the depletion of the blood. The normal salt solution is injected into the subcutaneous tissue of the abdomen at a temperature of 104^ F. (40° C), allowing from one to two quarts (liters) to flow by gravity through the hypodermic needle. Enterodysis often produces excellent results. From two to four quarts of a 2-per-cent solution of tannic acid at a temperature of 110° F. (43 ^^ C.) should be injected, preferably through the long rectal tube. Both these measures are useful in overcoming the anuria. Antitoxin Treatment. — Better results have been reported from the use of this method as a prophylactic measure than in treatment. The inocu- lation is made first with a weak culture, and five days later with a stronger one. Immunity develops in five days after the second inocu- lation. YELLOW FEVER. BLACK JACK, THE BLACK VOMIT. Yellow fever is endemic in the tropics, Guiteras has given us the foJlowing useful classification of the areas of infection : i. The focal zone, from which the disease is never absent, including Havana, Vera Cruz, Rio, and other Spanish-American ports. 2. Peri- focal zones, or regions of periodic epidemics, including the ports of the tropical Atlantic in America and Africa. 3. The zone of accidental epidemics, between the parallels of 45° N. and 35° S. latitude. It is noteworthy, however, that under the supervision of the United States authorities, Havana has been removed from the first to the second or third of these classes. Definition.— Axi acute infectious disease probably caused by the ba- cillus icteroides, and having as its most distinguishing features a peculiar jaundiced, congested facies, fever with slow pulse, hematemesis (black vomit), and albuminuria or total suppression of the urine. Etiology.— The bacillus icteroides, of Sanarelli, is now generally ac- cepted as the cause. It is a slender, motile, facultative, anaerobic ba- 90 PRACTICE OF MEDICINE cillus from 2 to 4/^ in length. Its etiological relation is supported : (i) by its frequent presence in the blood and viscera of the dead, (2) by a serum test in which the bacilli become agglutinated and motionless after the manner of typhoid bacilH in the Widal test, and (3) by the production of the disease in man through inoculation experiments con- ducted by Sanarelli and others. The disease is not directly contagious, and recent investigations apparently disprove the old behef that the poison is carried by fomites. If the investigations made by the Com- mittee of the Pan-American Medical Congress be correct, the disease is produced only by inoculation, and the only known mode of its trans- mission from one individual to another is by the mosquito (^Stegomyia fasciata). This discovery supports the old theories that the disease is most infectious at night and in low-lying districts, and that it may be carried to some distance by air-currents. The same investigations seem to show that the bacillus remains in the body of the mosquito from 12 to 18 days, the length of time depending upon the temper- ature of the air, before it can be inoculated into a human being. The recent investigation in regard to the transportation of mosquitoes on shipboard, taken in connection with these probable facts, seems to explain the sudden outbreak of the disease in places remote from a known center of infection, as in Galveston, in 1897, after an absence of 30 years, an occurrence which occasioned much discussion and no little criticism of the physicians who recognized the character of the disease. Season.— Tht disease is favored by high temperature, from 72° F. (22° C.) and upward, and by a high degree of humidity. It is quickly a-rrested by frost, which kills the mosquito, but freezing does not entirely devitalize the bacillus. In tropical countries it may prevail the year round. It usually reaches our shores in the autumn. Age and Sex.— The. disease attacks people of all ages, but is less fre- quent toward either extreme of life. Children appear more susceptible than adults. Infants have the disease, if at all, in a mild form. The negro is to a certain extent immune and usually recovers. During an epidemic such influences as fatigue, heat prostration, worry, fear of the disease, alcoholism, and debauchery increase susceptibility. Immunity. — One attack generally confers immunity, but second attacks have been observed. Protracted residence in the North and long absence of the disease from a locality are thought to overcome immunity. The question arises, may not the immunity be sustained by repeated inocu- lation of the disease by the mosquito? Morbid Anatomy. — The skin is jaundiced, and ecchymoses are fre- quently seen in it. The icteric hue is said to deepen after death. The urine and other fluids are yellow. The blood shows little change in cases of moderate severity. The bacillus is occasionally found in it. In severe cases free hemoglobin is found in the blood-serum as a result of destruction of the red corpuscles, and these corpuscles usually show degenerative changes. Fatty or other degeneration is more or less con- stantly found in the heart, liver, and kidneys. The liver in early cases is congested, but in cases of longer duration it is pale. The hepatic cells show fatty degeneration and necrosis, and the small bile-ducts are gorged with desquamated, degenerated epithelium. The bile in the gall-bladder is thick and dark. The brain and meninges are congested. YELLOW FEVER 91 Hemorrhagic infarcts are sometimes found in the lungs and elsewhere. The mucous membranes, particularly of the stomach, show ecchymoses and erosions, and similar changes are found in the serous membranes. The black, tarry matter which constitutes the black vomit is found in the stomach and intestines of hemorrhagic cases. Symptoms.— The incubation period is from iS hours to a week, usually three or four days, being shorter in proportion to the severity of the disease. Prodromes are usually absent. The invasion is sudden and generally occurs in the morning hours. The clinical history is divided into three stages : J^trsf Stage. — Chilly sensations, sometimes a rigor, or in children a convulsion, with headache, severe pains in the back and calves of the legs, are almost constant symptoms. The temperature rises during the chill to 103*^ or 105° F. (39.5" — 40.5° C). The cheeks and conjunc- tivae immediately become bright red with capillary dilatation. The eyes are watery and staring. The lips and eyelids are generally puffy, and a slightly icteric tinge may be detected in the conjunctivae and skin of the face on careful examination, often on the first day. These ap- pearances are characteristic of the disease. Vomiting begins on the first day, as a rule; the vomitus consists first of the contents of the stomach, then of a thin, grayish mucus, and finally, in severe cases, of blood. The pulse is seldom over 100, full and soft, in the beginning, and becomes slower and more feeble as the disease progresses, until it is perhaps 50 or less. The epigastrium is so sensitive that slight pres- sure causes vomiting. The tongue is dry and pointed, the gums swollen and red, often bleeding. The skin is at first dry; it sometimes becomes moist and then has a peculiarly offensive odor. The urine is scant,- highly acid, and albuminous, particularly in the evening. By the second or third day the jaundice deepens to a saffron color. The temperature, as a rule, remains high until the third or fourth day, then subsides and often becomes subnormal. Second Stage. — This is known also as the ''calm" or "remission." With the decline of the temperature the other symptoms abate and the patient experiences a relief. In children this may occur as early as the second day. In mild cases it is permanent and marks the beginning of convalescence. In another group of cases destined to recover, the convalescence is delayed by recrudescence of two or three days, with irregular reactionary fever. In severe cases, however, the calm lasts but a few hours, possibly 3 6, 'and the patient rapidly declines into a collapse. Third Stage, or Collapse. — This is marked by suppression of urine and hemorrhages from the mucous membranes, particularly of the stomach. Fever may be present, but the temperature sometimes remains normal. In fatal cases it often rises to 108° or 110° F. (43° C.) before death. The disease is of short duration, not usually exceeding a week. Re- lapses occasionally occur. Special Symptoms. — Fades. — Even on the morning of the first day the face is flushed more than in any other acute infection, and the eye- lids and lips are swollen. The superficial capillaries of the face and those of the conjunctivae are dilated, and on close examination slight icterus can be recognized. The eyes have a peculiar stare and a distinc- tive "alertness." 92 PRACTICE OF MEDICINE ■. Fever. — The temperature may be only moderately high in an ordinary case. After the initial rise it often subsides on the second day to 102^ or 103° F. (39.0° — 39.5° C). It is then irregular in its course and may terminate by lysis. A rapid fall below normal often precedes collapse, and a rapid rise a fatal termination. The pulse is slow and out of normal ratio (4:1) to the temperature from the beginning, and, although the temperature may be still rising, it becomes progressively slower. It sometimes reaches a rate of only 35 to 50 during defervescence. Occasionally it becomes rapid and irreg- ular, reaching 120 or more. At first full, it becomes extremely feeble in fatal cases. Respiration is usually accelerated, sometimes irregular; dyspnea may be extreme in the later stages. Black Vomit. — Extreme irritability of the stomach is a constant symp- tom from the beginning. Black vomit occurs in about one-third of the cases. When the blood is copious there is usually severe pain in the stomach and esophagus. Hemorrhages from the gums, nose, eyes, kidneys, and uterus frequently occur, and petechiae may appear in the skin. The bowels are usually constipated. The stools have not the clay color of jaundice ; they are frequently black, from the presence of blood. Albumiiiuria generally appears not later than the evening of the third day even in the mildest cases. An intense nephritis, with much albumin and casts, develops in severe cases; complete suppression may occur and lead to fatal uremia. ■■ Mental Condition.— \vl mild cases the mind remains clear and the patient watches all that transpires. Delirium and coma develop when the disease is severe. i Clinical Varieties.— With regard to the severity of the manifestations, different types of the disease have been recognized. There are mild cases with moderate fever, slight or no jaundice, and early recovery. A transitory albuminuria may be present. "Walking" cases are not uncommon. A comatose type is recognized in which, without fever, the patient passes into a stupor on the first or second day, with great prostration, feeble pulse, and albuminuria. Death often ocours on the third day. Another class of cases is distinguished by violent delirium from the beginning. Complications and Seque/ce. — These are not common and are generally of the same character as are encountered in other acute infections, as phlebitis and thrombosis of the femoi"al veins, acute nephritis, and sup- purative parotitis. Fatal hematemesis has followed an error in diet several weeks after recovery. Pregnant women generally abort. Diagnosis. — The three distinguishing features of the disease, as em- phasized by Guiteras, are : the facies, albuminuria, and the slowing pulse, with maintenance or elevation of temperature. The urine should be examined in the evening. The headache, pain in the calves, gastric irritability, epigastric tenderness, and the black vomit are valuable fac- tors in diagnosis. The agglutination test may be applied as early as the second day. Dengue. — This is probably the most difficult disease to distinguish, since it so frequently occurs in the same localities and at the same seasons and is similar in onset and symptoms. It is not, however, YELLOW FEVER 93 accompanied by so great weakness, gastric irritability, jaundice, albu- minuria on the first or second evening, or hemorrhages. The pulse is rapid and the temperature rises more slowly. An eruption often appears. The blood would probably not agglutinate the bacillus icteroides. Malaria, especially the irregular remittent, estivo-autumnal type, when accompanied by vomiting and slight jaundice, is often difficult of distinction. But the icterus does not appear so early, the face is usually dull, not alert; the tongue is broad, flat, and pale, not dry and pointed. The discovery of the plasmodium in the blood is distinctive. Relapsing fever is readily recognized by the discovery of the spirilla in the blood, as well as by the slower onset, more rapid pulse, enlarge- ment of the spleen, and the absence of black vomit and extreme gas- tric irritability. Acute yellow atrophy of the liver is accompanied by gradual elevation of temperature, without pain or so great gastric irritability. The urine contains large quantities of bile pigments, leucin, and tyrosin. Acute febrile jaundice (Weil's disease) is characterized by less severity of onset and less prostration ; black vomit, albuminuria, and suppression are absent. Prognosis.— The death-rate in epidemics is very different. It may be as low as 10 to 20 per cent or as high as 80 to 90 per cent. The prognosis is rendered less favorable by previous debility, anxiety or fear, alcoholism, pregnancy, or the puerperal state. Suppression of urine is an unfavorable symptom, and when this is accompanied by black vomit recovery rarely follows. Black vomit alone is not, however, ex- tremely dangerous. The virulence of an epidemic appears to be greater in proportion to the length of time that has elapsed since the last pre- ceding outbreak. Much depends upon the promptness with which treat- ment is instituted. Prophylaxis consists less in the inspection and quarantine of ships from infected ports than in the isolation of the sick, with especial refer- ence to the exclusion of mosquitoes. By the systematic warfare that has been waged upon these pests and their larvae during the last two or three years, Havana has been freed from yellow fever for the first time in 150 years. Stress has always been laid upon the importance of burning all fomites, but if recent investigations prove to be correct this is not necessary. Susceptible persons have slept in the midst of infected Hnen for 28 days without infection so long as mosquitoes were excluded. Sanarelli has used horse serum, Freire and others that of immune persons, with some success. Treatment. — Good ventilation and absolute rest are important. The patient should not be disturbed, the bedpan must be used, and nourish- ment and drink must be given through a tube. Removal of the patient to other quarters is harmful. Food should be administered by the rectum during the period of gastric irritabihty. This irritability calls for the administration of cracked ice, or, better, iced champagne. Dilute hydrocyanic acid may be given in 3-drop doses. Sternberg highly recom- mends the following mixture: Sodium bicarbonate, grs. cl (10. o); hydrargyri bichlorid, gr. Y^ (0.02); pure water, Oij (1000), to be given in doses of three tablespoonfuls every hour. It has been found to reduce the gastric irritability, to maintain the urinary secretion, and in other 94 PRACTICE OF MEDICINE ways to reduce the mortality. Nunez has had good results from potas- sium bitartrate and salol. Quinin in 20-grain (1.30) doses was formerly much employed. The cardiac weakness, particularly in the second stage, should be met by stimulation with brandy and strychnin hypodermically or by rectum. The pains may be in a measure relieved by applications of heat and sinapisms ; some patients prefer the ice-bag. Morphin should be used cautiously, if at all, since it has proved a dangerous remedy (Sternberg). For cerebral congestion ice-bags should be applied to the head and sinapisms to the feet. The tendency to hemorrhage often resists treatment; the acetate of lead and opium may be employed with caution. Good results have been obtained from hypodermic injections of ergotin. Sanarelli's serum treatment is reporte'd to have proved successful in a considerable number of cases. During convalescence the greatest care must be exercised in order not to overtax the stomach. Alimentation must be begun cautiously; the food should be of the most delicate character and administered in small quantity. Such tonics as iron, quinin, and strychnin, separately or combined, hasten recovery. THE PLAGUE. BUBONIC PLAGUE, MALIGNANT ADENITIS, BLACK DEATH. The plague is a disease of the Orient, where it has prevailed from antiquity. Its fre- quent prevalence in the Philippine Islands, its outbreak in Hawaii in 1899, importation to San Francisco in 1900, and continued presence in Mexico as late as the spring of 1903 have given it an importance to American physicians which it did not before pos- sess. Dsfiniiion.—A. virulent acute infectious disease caused by the bacillus pestis of Kitasato, running a rapid febrile course with bubonic swellings in different parts of the body, and often accompanied by hemorrhages from the mucous membranes. Three clinical forms are usually recognized, the glandular, the pneumonic, and the septicemic. EHology. — The bacillus pestis has been proved the cause of the dis- ease by inoculation experiments in animals, as well as by its uniform presence in the body after death, particularly in the blood and enlarged glands. The bacillus is a short, thick rod with rounded ends. It is obtained with least difficulty from the bloody sputum of pneumonic cases, and may be cultivated on an alkaline agar medium. It is believed to have an independent existence outside of the body, in the ground. The avenues of its entrance into the body, it is generally believed, are the mucous membranes of the respiratory passages and the cutaneous surface after injury. The tonsil is also believed to be a possible portal of entrance. The poison is thought to be carried on clothing, bedding, and oth^r articles, and to cling tenaciously to houses and localities. Epidemics have followed the opening of the graves of plague victims. Rats, cats, dogs, and other animals become infected. Rats especially are regarded as carriers of infection, even to distant lands, by gaining entrance into ships. They often die in great numbers before and during an epidemic. Flies, bugs, lice, and especially fleas are also capable of THE PLAGUE 95 conveying infection to man. The chief predisposing causes are over- crowding, filth, and deficient ventilation. Season. — The disease is favored by warm weather and humidity, but outbreaks sometimes occur in winter. It is somewhat more frequent between the ages of 20 and 30; persons over 50 are seldom attacked. Both sexes are about equally susceptible. It is believed to be only mildly contagious. Morbid Anatomy. — The lymph-glands of the inguinal or the femoral region, less frequently those of the axillse or neck, are enlarged and firm, or in a state of suppuration. The overlying skin is edematous and much thickened. After death in the most rapidly fatal cases, the primary bubo, or lymph-gland nearest the site of inoculation, may be so small as to be found with difficulty. In it the parenchyma is destroyed. Necrotic or hemorrhagic areas appear, or suppuration may have oc- curred. Pyogenic cocci are frequently found in addition to the bacillus pestis. Ecchymoses and petechia are found on the surface of various parts of the body. The secondary buboes are intensely hyperemic and occasionally contain hemorrhages. The various hemorrhagic lesions are believed to be the direct result of the bacteria, and not due to the toxins. Parenchymatous and fatty degenerations of the heart, liver, and kidneys are common. The spleen is much enlarged and soft, being distended with blood rich in polymorphonuclear cells. In the pyemic form of the disease, metastatic foci of suppuration are found in the lungs, liver, spleen, and muscles, often surrounded by extravasated blood. The lung lesions in the pneumonic form are primarily lobular, but they may be so ex- tensive as to cause the solidification of an entire lobe. Bronchitis is always found and the bronchial glands have the appearance of primary buboes. Clinical Forms. — With reference to its severity, three forms of the disease are recognized. These are : ( i ) Pestis siderans, a rapidly fatal septicemic form; (2) pestis major, the usual form; and (3) pestis minor, a mild form characterized by glandular enlargements without pronounced constitutional disturbances. The last form is seen particularly in the beginning of an epidemic. A more useful classification, perhaps, is based upon the character of the pathological lesions : ( i ) a glandular type, (2) a pneumonic type, and (3) a septicemic type. Symptoms. — Glandiclar Type. — The incubation period is usually from two to five days. Headache, pain in the back and limbs, vertigo with a staggering gait, languor, nausea, vomiting, and epistaxis are some- times complained of during the last day or two of this period, A more or less distinct chill follows, with rapid rise of temperature, usually to 103° or 105° F. (39.5° — 40-5° C.), sometimes even above 108° F. (42° C). The pulse ranges from 120 to 150 and the breathing is quickened. As the disease progresses, the headache, nausea, and vomit- ing become more severe, extreme thirst develops, and the lymph-glands rapidly enlarge. The face is intensely flushed, the conjunctivae are con- gested. The patient may fall into a stupor, but in some cases delirium develops. After three or four days the glandular swelling becomes ex- treme. By the involvement of a group of glands large buboes are formed, the apparent size being increased by the edema of the overlying tissues. These are found especially in the groin or along the femoral groove of one or both legs, less frequently in the axillae or neck. The tonsils are 96 PRACTICE OF MEDICINE tsometimes similarly involved. The primary bubo is usually larger and in a later stage of- development than the secondary buboes. The skin over the affected glands becomes stretched and glossy. The swellings are generally extremel}^ painful and exquisitely sensitive to touch. Sup- puration frequently occurs and is considered a favorable change. When the cervical glands are involved, dyspnea and venous obstruction are produced. Carbuncles often form on the back of the neck. The frequent appearance of petechiae over the body has given the name "black death" to the disease. Leucocytosis is usually present. The urine shows the usual febrile changes. The acute, febrile, period of the disease lasts from 3 or 4 to lo days. Convalescence is generally rapid, unless it be retarded by the suppuration of the glands. 2. Pneumonic Type.—T\\\s begins with a chill, pain in the side, severe headache, high fever, and rapid breathing, with signs of pulmonary con- solidation. Extreme dyspnea and cyanosis are often present. The sputum is bloody, not " rusty" as in lobar pneumonia. This form of the dis- ease is nearly always fatal in from one to five days. Broncho-pneu- monia sometimes occurs as a compHcation of the glandular type of the disease, causing it to resemble the pneumonic. 3. Septicemic Type. — Cases of a septicemic character (pestis siderans) are not infrequently encountered during an epidemic. The indications all point to a severe and rapidly fatal sepsis. They usually terminate within three days, often within a few hours, and before glandular en- largement has become recognizable. Even in these cases, however, there is marked sensitiveness over the regions of the lymph-glands, possibly over the entire body, and frequently there are hemorrhages into the skin and from the various mucous membranes. Diagnosis. — The frequent occurrence of mild cases in the beginning of an epidemic often prevents the immediate recognition of the disease. Septic cases at this time are seldom recognized. In ordinary cases the mode of invasion, with the early tumefaction, pain, and tenderness of the lymph-glands, is distinctive after the prevalence of the disease has been recognized. Tubercular and venereal buboes, when accompanied by fever, may cause temporary uncertainty during an epidemic, but not otherwise. Other diseases are sometimes difficult of exclusion. Typhus fever is accompanied by an eruption, usually petechial in char- acter, but the glandular swellings or pneumonic symptoms are absent. Malaria and relapsing fever are usually distinguished, if not by the absence of glandular involvement, by the recognition of the specific micro-organism of each in the blood. Cases are occasionally observed, however, in which one or the other of these affections has been coin- cident with the plague. Prophylaxis.— This consists in the most rigid measures of sanita- tion in the infected districts, absolute quarantine, and a general clean- ing up of adjacent territory. The extermination of rats is essential. The houses that have been occupied by the patients and all articles that have come into contact with them must be thoroughly disinfected or destroyed. No measure was ever more appropriate or more effective than the total destruction of the infected district by fire practiced by our Government at Honolulu a few years ago. For individual protec- tion, Haffkine's serum may be used. It is a sterilized, attenuated bouil- MALTA FEVER 97 Ion culture of the bacillus pestis. Although it does not always afford complete immunity, the disease has proved less virulent after its use. Treatment. — The general treatment is wholly supportive and symp- tomatic. The strength should be supported by nourishing liquid food and brandy. The heart's action may be maintained by frequent full doses of strychnin, gr. 1-60 to 1-20 (o.ooi — 0.003), ^^d ammonium carbonate. Since suppuration is considered favorable, it may be encour- aged by the application of hot poultices to the buboes. The Yersin- Roux serum, obtained from immunized horses, has been used with re- ported benefit in some cases. CLIMATIC BUBO. Under the names chmatic bubo and malarial bubo, various authors have described a nonvenereal enlargement of the inguinal glands which attacks by preference young adult Europeans after a residence of three months or more in tropical countries. The disease occurs chiefly at the end of the rainy season and in persons who are suffering from fatigue or those run down and anemic. It is apparently independent of any relation to malaria. The only recognizable cause is the entrance of micrococci through slight wounds of the integument of the lower extremities or the bites of such insects as fleas and mosquitoes. The affection has followed the dhobi itch and other skin lesions. The blood- count shows anemia and leucocytosis. Fever is usually present, but it rarely exceeds 101° F. (38° C). On account of the adenitis and fever the condition has been mistaken for the pestis minor, or mild form of bubonic plague. The treatment consists in the removal of the glands, which promptly arrests all symptoms. MALTA FEVER. MEDITERRANEAN FEVER, GIBRALTAR FEVER, NEAPOLITAN FEVER, UNDU- LANT FEVER. The disease is endemic at Malta and occasionally spreads in epidemic form along the shore of the Mediterranean. It is also met with in the East and West Indies. Definition. — An infectious disease caused by the micrococcus Melitensis of Bruce and characterized by a series of febrile attacks with profuse sweating and painful swelling of the joints. Etiology. — The disease is not contagious. The infectious agent prob- ably originates in small foci, often, apparently, in the rooms occupied by a previous patient, but the means of its transmission is not known. June, July, and August are the months of greatest prevalence at Malta. Epidemics sometimes occur. The most susceptible age is from 6 to 30 years. Infants and the aged generally escape. Immunity is thought to be conferred by one attack. Symptoms. — The incubation varies from 6 to 17 days. The onset is often much like that of typhoid fever, with anorexia, thirst, pain in the head, back, and extremities, and a gradual rise of temperature. The tongue becomes coated and the pharynx congested; the epigastrium is 98 PRACTICE OF MEDICINE tender. Constipation is the rule. Delirium sometimes occurs at night. The fever may reach 103° or 104° F. (39.5° — 40° C.) and is usually of a remittent type, occasionally distinctly intermittent. The character- istic curve is a gradual ascent for a week or ten days, followed by a decline of about the same duration. A profuse sweat occurs toward morning, when the temperature is low. During the fever the joints swell in rapid succession, and become painful, as in acute rheumatism. After from one to three weeks, the symptoms subside for three or four days. A relapse then occurs; the former symptoms return, often with increased severity. Another interval occurs after three or four weeks, and thus the disease progresses, sometimes for several months. In mild cases, recovery may follow the first relapse, but another relapse may occur after several months. A malignant form of the disease is recognized which is usually fatal in about 10 days. Complications and Sequelce. — The chief of these are pneumonia, neural- gia, and anemia. Orchitis sometimes occurs without other infection. Diagnosis. — Typhoid Fever. — During the first rise of temperature, the differentiation may be difficult. The" absence of roseola after the eighth day and failure of the VVidal test are important. A similar agglutina- tion reaction may be obtained with a culture of the micrococcus Meliten- sis and the serum of the patient. Malaria may be distinguished by the latter test and by the finding of the Plasmodium in the blood. Prognosis. — The mortality is about 2 per cent. Death is usually the result of sudden hyperpyrexia, exhaustion, or complications. Treatment. — No specific treatment has been discovered. The indi- cations are in all respects the same as those of typhoid fever. BERIBERI. KAKKI, ENDEMIC NEURITIS. This disease prevails endemically in many isolated regions of the tropics, especially in China, Japan, the Philippine Islands, Hawaii, South America, and the West Indies. Cases are occasionally carried by ship to the United States. In 1895 a disease believed to be beriberi broke out among the inmates of the State insane as3iums of Ala- bama and Arkansas. It has appeared also among the fishermen of Newfoundland and Cape Cod. Definition. — An acute or chronic disease of tropical and subtropical countries characterized by multiple neuritis with motor and sensory disturbances, edema, and visceral lesions of greater or less severity. Etiology. — Two theories are maintained in regard to the character of the disease : First, that it is an infection due to an unrecognized micro-organism; second, that it is due to a toxemia from food. 1. The principal argument in favor of the theory of infection is that a micrococcus has been found which, by inoculation, produces peripheral neuritis. Ogata, however, attributes it to a bacillus. The disease occurs at a definite season and attacks young, robust individu- als. It is a place disease, clinging to houses and more particularly to isolated localities, as does malaria. There is some evidence that it is contagious. 2. The theory of food toxemia is held especially in Japan and Java, BERIBERI 99 where the disease is attributed to the excessive consumption of white (hulled) rice. It is said to have been repeatedly checked by the adop- tion of European food. Visitors to Japan do not become aiTected so long as they do not adopt the rice diet. The fermentation of rice is regarded by several writers as the more direct cause. Capt. E. R. Rost, I. M.S., asserts that in Rangoon, where the disease is epidemic, it is caused chiefly by drinking rice-water liquor made by the Chinese from damaged rice. The disease is not seen in children there, seldom in women, and it is not infectious or contagious. Males from i6 to 25 are most frequently attacked, but it may af- fect either sex at any age. Hot, moist atmosphere and overcrowding favor its development. Morbid Anaiomy. — Peripheral neuritis is the essential lesion. The va- gus and phrenic arc sometimes involved. Hypertrophy of the right ventricle, with degeneration of the myocardium, is usually present. The skeletal muscles may be also degenerated. Symptoms. — The incubation probably lasts a month. The initial symptoms are generally catarrhal. These are followed by pain and weakness in the legs, and paresthesia and edema gradually invading the entire body. The muscles become soft and sensitive. The heart's action is weak and irregular; palpitation may be felt and dyspnea is produced. The urine is scant, but not albuminous. Recovery may oc- cur after a few weeks or after several months. Relapses often occur at the same season for many successive years. Three forms of the disease are described : 1. Diy, Atrophic, or Paretir Form. — This is characterized by a pain- ful atrophy, with more or less complete paralysis of the muscles of the arms and legs, sometimes involving also those of the face. The tendon reflexes are abolished. Edema is not usually present. 2. Wet, or Dropsical Form. — Edema is the most marked feature. The subcutaneous tissue and serous cavities of the entire body are often invaded. The degenerative changes in the muscles may not be prominent. Cardiac weakness and dyspnea are seldom absent. 3. Acute, Cardiac or Fertiicious Form. — Cardiac weakness is the pre- dominant symptom. Death from heart-failure may take place within the first few days, before the development of other symptoms. V\Tien the vagus is involved, the larynx may be paralyzed, and vomiting is a prominent symptom. When the phrenic nerve is affected, death may result through paralysis of the diaphragm. Diagnosis. — This is seldom difficult in tropical regions. The ordi- nary form of peripheral neuritis does not involve the vasomotor and vis- ceral nerves, and it is not attended with so great dyspnea or edema. Prognosis. — The mortality ranges from 2 to 50 per cent. Much de- pends upon the character of the epidemic, the strength of the patient, and the hygienic conditions. The greatest mortality has been among coolies. Vomiting is regarded by the Japanese as of fatal import. Prophylaxis. — This consists in proper diet and hygienic measures, particularly the prevention of overcrowding. Visitors to localities where the disease prevails should not adopt the exclusively farinaceous diet. Treatment. — The patient should be immediately removed to a high loo PRACTICE OF MEDICINE and dry locality, when his condition will permit. This is regarded by Manson as important in order to avoid reinfection. The treatment should be begun with free purgation. Following this the salicylates should be given in 20-grain (1.30) doses four or five times a day. Stimulation must be practiced when the heart becomes weak. Strychnin should be given in doses of gr. 1-40 (0.0016). If the arterial tension is high, glonoin, gr. i-ioo (0.0006) every half-hour, is indicated until the heart's action becomes normal. Blood-letting has been practiced with benefit in some cases, and inhalations of amyl nitrite have been recommended when there is danger of cardiac failure. Nitrogenous food should constitute the principal part of the diet; and if rice is eaten, it should be the unhulled or red variety. SCARLET FEVER. SCARLATINA, SCARLET RASH. Definiiion. — An acute infectious disease manifested by severe angina and an erythematous exanthem, with constitutional symptoms of vari- able severity. Etiology. — The disease may be either sporadic or epidemic. It is ex- tremely contagious and frequently spreads with great rapidity among the inmates of schools and asylums. -Forchheimer has shown that it is probably not capable of transmission to any great distance through the atmosphere. Mediate contagion is the rule. No specific organism has been discovered. Streptococci and other germs have been found in the blood, urine, skin, and in various organs in fatal cases, but their relation to the disease has not been proved. Inoculation has been suc- cessfully performed with the blood, serum, nasal and pharyngeal secre- tions. Contagion is generally believed to take place directly from the patient, through the exhalations, but by far the most dangerous source of infection is found in the desquamated epithelium. Clothing, books, toys, anything that has been handled by the patient, furniture, carpets, even the dust from the sick-chamber, retains the poison and may con- vey it to others. The contagium has been retained for several years in articles of clothing protected from the air, longer than is known to be possible in any other disease. Physicians and nurses have carried the infection, and it is not infrequent for those coming into contact with the patient to contract a severe angina, although they may have had the disease in childhood. Pets, birds, cats, and dogs, probably be- come carriers of the infection in some instances. Food, especially milk, is readily contaminated. Defective house-drainage has been held re- sponsible for the disease in some instances. The mucous membrane of the throat is probably the usual avenue of infection. Age. — Scarlatina is typically a disease of infancy and early childhood. Half the cases appear before the fifth year, and go per cent before the tenth. Nurslings are seldom attacked. Infants, although born during the illness of the mother, may escape, but sometimes they are born with the disease. Adults arc occasionally affected. Sex does not modify the susceptibility to it. Season. — Sporadic cases are seen at all seasons; epidemics generally prevail during the autumn and winter. SCARLET FEVER loi The immunity conferred by one attack is generally permanent, but second and third attacks are not extremely rare. So far as known, the Japanese alone possess natural immunity. The susceptibility of all individuals is not equal, for it is not uncommon to see different degrees of severity manifested by the disease among the children of the same family, or for one or two members of a family to escape. Some families are much more susceptible than others. The virulence of the disease is much greater in some epidemics than in others. Morbid Anatomy. — The cutaneous and pharyngeal lesions are alike hyperemic in character and promptly disappear after death, except in the hemorrhagic form of the disease. A section of the skin shows only capillary dilatation, without the changes of inflammation. There are no characteristic lesions; those found in the organs after death are the result of high temperature or of pyogenic infection. The serous mem- branes are more generally involved than the mucous. The most impor- tant complication is on the part of the kidneys, an acute nephritis being found in a large proportion of fatal cases. As a result of the throat lesions, sometimes pseudomembranous in character, the cervical lymph-glands are often greatly enlarged and in a state of suppuration. Gangrenous sloughs are sometimes found. Lobular pneumonia may be the immediate cause of death in such cases. The lesions of endocar- ditis, pericarditis, pleurisy, and peritonitis are sometimes found. Gastro- intestinal congestion may be present. The spleen shows the usual febrile enlargement, and interstitial changes have been seen in the liver. Symptoms. — T/ie incubation is from one to ten days. There are gen- erally no prodromes, but slight indisposition may be noticed during the last day or two. The invasion is usually sudden and may be severe. Vomiting, sore throat, and chilliness, rarely a distinct chill, are commonly present. One or more convulsions may announce the onset in young children. The patient becomes restless and delirium may develop within the first 24 hours. Thirst and dryness of the throat are complained of. The tongue is at first white with red edges, and the papillse often protrude through the coating, producing the characteristic " strawberry tongue." A few days later, the fur is cast off", and with it the surface epithelium, leaving the tongue intensely red and the denuded papillae prominent, an appearance which has been called the " raspberry tongue." Leucocy- tosis generally develops early in the disease and may be extreme in severe cases. The Eruption. — A scarlet erythema invades the skin, generally on the second day, sometimes within the first 24 hours. It is seen first on the sides of the neck, upper part of the chest and back, in the form of mi- nute pale red papules, v/hich rapidly coalesce to form an intensely scarlet flush, that spreads within a few hours to the surface of the entire body. A punctate eruption sometimes appears first in the mucous membrane of the mouth and throat. Petechiae are rarely seen, except in hemor- rhagic cases. Papillary elevations are occasionally noticeable, and minute yellowish vesicles, probably sudamina, sometimes appear (scarlatina miliaris). The face is livid, except around the mouth, where the skin remains normal, but appears excessively white by contrast. The eyelids become edematous in severe cases, particularly when nephritis develops. PRACTICE OF MEDICINE The eruption is occasionally limited to regions or appears in isolated patches. Burning and itching are often complained of, and the skin may be hyperesthetic. In malignant cases extreme cellulitis of the neck is frequently encountered, and a false membrane may develop on the ton- sils and spread rapidly to adjacent surfaces. True Klebs-Loefifier diph- theria is sometimes present as a complication. The eruption begins to subside, as a rule, by the third day. The temperatu7-e remains high, often 104° or 105° F. (40° — 40.5° C), with slight morning remissions, until the fading of the eruption. Delirium not infrequently persists throughout the febrile stage, particularly at night. In mild cases the temperature may not reach 103° F. (39.5° C), but in the malignant type it often exceeds 108° F. (42.2° C.) shortly before death. The iit'ine shows the ordinary febrile changes, diminution of quantity with increase of solids, particularly the urates. The frequency of renal complications renders daily examination of the urine imperative. Desquamation usually begins within two or three days after the sub- sidence of the eruption, but may be delayed for nearly a week. It never fails to occur. It follows the same course of progression as the eruption, beginning on the neck and chest. It may be fur- furaceous or membranous in char- acter, the epidermis separating in scales or in sheets. More or less complete molds are sometimes obtained from the hands and feet. The denuded skin is for a time red and tender. Desquamation usual- ly lasts from three to five weeks. Several coats are sometimes shed, and the progress may be pro- tracted to 7 or 8 weeks. The danger of communicating the in- fection does not end until the skin has become quite normal. In rare cases the hair and nails are also cast off. The itching accompany- ing desquamation is often intense. The character of the desquamation does not always conform to the severity of the disease, but, as a rule, it is less extensive in the milder cases. Forms of Scarlatina. — Great difference is manifested in the severity of symptoms. The disease may be so mild as to readily escape notice or to render the diagnosis difficult. The fever may not exceed 100° F. (38° C), and may last but a few hours. The throat s3nTiptoms are mild and only a trace of albumin may appear in the urine. Desqua- mation may, however, be abundant. Cases have been reported in which the eruption was absent (scarlatina sine eruptione). Occasionally the rash does not appear until the fourth or fifth day. Malignant Scarlatina.— i. Cases occur in which the symptoms of toxemia predominate. The temperature reaches 106° F. (41° C.) or higher on the first evening, and profound prostration, delirium, and gastrointestinal disturbances are predominant. In some cases the fever continues for 10 to 14 days and subsides by a slow lysis. FAHR. 105.8 104.0 103.3 100.4 98.6 C. 41 40 39 38 37 2 3 * 5 6 1 8 9 A r / / A 1 ^ 1 \ V ' \ 1 A y l\ K J ' \ - - ^ Y ; \ \ Y \ A V \ f{ y / s ^ s \ , Fig. 9. — Temperature chart of mild scarlatina. SCARLET FEVER 103 2. Foudroyant cases are encountered. The invasion is extremely severe, with repeated convulsions, immediate rise of temperature to 107° or 108° F. (41.5° — 42.0° C), intense delirium, profound stupor or coma, and projectile vomiting. The pulse is feeble and dyspnea urgent. Death may occur within the first 24 hours, before the appearance of the eruption. 3. A hemorrhagic type is rarely met with. It usually terminates fatally in the first few days. Blood is extravasated into the skin and mucous membranes, and there is bleeding from the nose, stomach, and bowels. The temperature may be moderate. 4. Angmose Type. — In this form the throat symptoms predominate. A false membrane usually develops upon the intensely swollen tonsils and pharynx and quickly spreads into the nose and larynx, often through the trachea into the bronchi. Gangrenous sloughs form in the throat, and suppurative otitis media results from extension of the in- ilammation along the Eustachian tube. A suppurative cellulitis of the neck follows the adenitis, and a general septic infection usually leads to a fatal issue, if, as is generally the rule, death has not occurred earlier in the disease. Puerperal and Surgical Scarlatina.— It is now generally believed that most of the cases which were formerly regarded as of this char- acter are in reality cases of septicemia. The view is well supported by the remarkable decrease in the number of these cases since the adoption of methods for the prevention of sepsis. Scarlet fever may, however, attack the surgical patient or puerperal woman. Complicaiions and Sequelae. — (^i') Nephritis is the most serious of the complications. Three forms occur. They probably result from toxemia, although micro-organisms have been repeatedly found in the kidneys. They usually develop during desquamation, in the second or third week of the disease, and may occur in either mild or severe cases : (a) Acute Degenerative Nephritis. — This is a mild form in which the lesions are not inflammatory in character and are, in most cases, con- fined to the parenchyma of the tubules. It is indicated by a reduction in the quantity of urine, a moderate quantity of albumin, a few hyalin, epithelial, or granular casts. The constitutional disturbances are slight, the edema moderate. Recovery is the rule. (^) Glomerulonephritis, or Exudative Nephritis. — In this form the glomerulus, to which the involvement is chiefly limited, is compressed by an abundant exudation of serum, red and white blood-cells, and epi- thelium within the capsule. The condition is announced by an almost complete suppression of urine. That voided contains blood, a large quantity of albumin, and increased urates. The microscope reveals dif- ferent kinds of casts, blood-cells, and pigment. The constitutional symp- toms are severe and may appear early. They are : edema of the face, hands, and feet, headache, nausea, vomiting, dyspnea, muscular twitch- ings, and sometimes delirium. The fever and rapid pulse continue with high arterial tension and irregular action of the heart. The dropsy may become extreme and it may involve the lungs. Under careful man- agement, recovery generally occurs in from four to six weeks. The con- dition may become chronic, however, or a fatal uremia may super- vene. (f) Acute Diffuse Nephritis. — This is the most severe form of the I04 PRACTICE OF MEDICINE disease, affecting both parenchyma and interstitial substance of the glo- raeruH and tubules. It usually arises in the third week, either suddenly or gradually. Vomiting, marked anemia, and more or less complete suppression of the urine are the constant symptoms. Convulsions often occur. Blood and albumin are abundant in the urine. Death usually occurs early from uremia. (2) The Heart. — Acute endocarditis is not uncommon, and frequently leaves permanent lesions of the valves, often to be recognized in after- life. The malignant form of endocarditis is rare. Pericarditis with serofibrinous or purulent exudation may occur, and myocarditis some- times develops. (3) Serous Membranes. — Pleurisy is frequent and may lead to em- pyema. Peritonitis may also be encountered. (4) Nervous System. — Chorea and hemiplegia develop, especially in cases complicated with arthritis and endocarditis, and are probably a result of embolism. Mania sometimes occurs. Progressive paralyses have been noted. Thrombosis may affect the lateral sinus or the cere- bral veins. Meningitis and abscess of the brain have been observed. (5) The Ear. — Suppurative otitis media, due to extension of the throat inflammation, is so frequent and so severe as to render scarlatina one of the most common causes of deafness. The suppuration generally extends to the labyrinth and may involve the mastoid cells. (6) Suppurative cellulitis of the neck, with gangrenous sloughing, is an occasional result of the throat inflammation. (7) The Glands. — The adenitis, although extreme, usually subsides in a few weeks, but in some cases it persists indefinitely. Suppuration may develop and it may extensively involve the surrounding tissues. (8) The Joints. — Painful swelling of the joints sometimes occurs dur- ing the height of the fever, but more frequently during its decline. It is regarded by some writers as a form of rheumatism, by others as a septic infection analogous to gonorrheal rheumatism. Suppuration some- times develops in the affected joints. (9) Rare Complications. — Among these ma}' be mentioned blindness from iritis or neuroretinitis, S3^mmetrical grangrene, noma, furunculosis, and purpura hemorrhagica. The association of scarlatina with other diseases, notably measles, variola, varicella, and pertussis, is occasionally observed. Diagnosis. — The sudden onset with vomiting, rapid rise of temperature, the angina with enlargement of the cervical glands, the early appear- ance of the eruption, and the strawberry tongue seldom leave the di- agnosis long in doubt. Cases arise, however, in which much difficulty is experienced. 1. Acute Exfoliative Dermatitis. — This affection closely simulates scar- latina in its sudden febrile onset and uniform red rash. The throat symptoms are usually absent, the tongue is not typical, the eruption appears first on the trunk and has not faded away until desquamation has begun. The hair and nails are usually involved in the exfoliation. Repeated attacks are common, even within short intervals of time, a fact which doubtless explains many instances of supposed recurrent attacks of scarlatina. 2. Measles.~~\xv this disease we have prodromal catarrh, a less violent SCARLET FEVER 105 invasion, subsidence of temperature before the appearance of the erup- tion on the third or fourth day. The eruption is papular, more abun- dant on the face, and often shows crescentic arrangement. The throat symptoms are mild or absent and the leucocytes are not increased. 3. Rotheln. — This disease is usually excluded by the mild invasion, slight febrile disturbance, and the paleness and mottled character of the rash, which appears first on the face. 4. Diphtheria. — In most cases the absence of the Klebs-Ldfifler bacillus is sufficient to distinguish scalatina with membranous throat formation from true diphtheria. When, however, this bacillus is present, it is often difficult to decide whether the case is one of diphtheria with erythematous eruption or a double infection. The diphtheria rash is usually dark red and confined to the trunk. 5. Septicemia. — The more uniform and prolonged febrile course of this condition may suffice for differentiation. It is not always possible to distinguish the two affections in the puerperal period. 6. Drug Rashes. — Belladonna and quinin, less frequently potassium bromid and iodid, chloral, acetanilid, and other drugs produce rashes resembling that of scarlet fever. The other symptoms are lacking. Prognosis. — The disease is most fatal in young children and among the poor. Some epidemics are much more fatal than others. High fever, delirium, membranous angina, and hemorrhages are exceedingly unfavorable symptoms. Even in the mildest cases a serious nephritis may develop at a time when recovery seems certain. Nephritis is not necessarily a fatal complication; most cases recover. The total mor- tality of the disease ranges from 5 to i o per cent in the milder epidemics and from 20 to 30 in the more severe. Prophylaxis. — The patient should be isolated and the house quar- antined. The other children of the family should be kept from school and prevented from associating with their playmates long enough to determine that they have not also contracted the disease. The same precautions should be taken with reference to the apartments and the conduct of the physician and nurse as are recommended under the prophylaxis of smallpox. The patient need not be confined to bed longer than a week or ten days after the fever has subsided, in the absence of other contraindications ; but care should be exercised to avoid exposure to cold for three or four weeks longer. The quarantine should last six, or, better, eight weeks, or in any case until the last indication' of desquamation has disappeared. Treatment. — The room should be well ventilated, and a uniform tem- perature of 68° F. (20° C.) should be maintained. The patient should wear a flannel gown, but the bedclothing should be light. The diet should be liquid during the febrile stage, preferably milk, in addition to which gruels, broths, and tgg albumen may be allowed. Ice cream is nourishing and soothing to the throat. An abundance of water should be given. Solid food may be allowed after the fever has subsided in a mild case, but a continuance of the milk diet reduces the Hability to nephritis. Medication is unnecessary in mild cases. An antiseptic, as sodium sulphocarbolate or salicylate, should be given with a view to reducing the liability to complications. For high temperature, restless- ness, or delirium the bath of 90° F. (32° C), gradually reduced, cool io6 PRACTICE OF MEDICINE sponging, or the wet pack should be employed, and the bromids may be administered. The ice-cap is often useful. The bowels should be regu- lated with magnesium citrate, compound licorice powder, or other aperi- ent. The action of the kidneys must be favored by a plentiful supply of pure cold water, lemonade, or other drink. Irrigation of the bowel every six or eight hours with a pint or more of water at iio° F. (43° C.) is recommended for the restoration of the renal secretion and for the relief of convulsions. The throat, nose, ears, heart, and urine should be examined daily, and the examinations of the urine should be continued periodically dur- ing convalescence. For weak heart, stimulants should be given. Peri- carditis requires special treatment described under that disease. For the throat and nose, a spray of 5 per cent menthol and camphor in liquid albolin or 10 per cent hydrozon is beneficial. Otitis requires puncture of the drum membrane as soon as tension becomes prominent. Renal complications are to be treated according to the methods given under Nephritis. As soon as desquamation has commenced, the patient should be given a warm bath morning and evening, followed by thorough in- unction of the entire body with sweet oil or carbolated vaselin in order to limit the dissemination of the scales. MEASLES. RUBEOLA, MORBILLI. Definition. — An acute infectious disease running a febrile course and exhibiting a papulomacular exanthem. Eiiology. — The bacterial cause of the disease is unknown. Measles is the most infectious of the exanthemata, and immunity is exceedingly rare. It is highly contagious during its entire course, including the last days of the incubation. It occurs endemically in cities at all sea- sons, and epidemically about every second winter. Age has probably little influence on susceptibility, but few persons escape the disease dur- ing their childhood. Infants under six months are seldom attacked. The disease is by no means infrequent in adults. Second, third, and even fourth attacks have occasionally been reported. The contagium is com- municated by the breath and secretions of the patient, particularly by the nasal mucus, saliva, and tears. It may be carried by a third person, by fomites, or by the air, but the poison is not so virulent or so reten- tive of life as that of scarlatina. Inoculation has been performed. Morbid Anatomy. — The lesions of the mucous membranes are the same as those of other catarrhal conditions. The mortality is due chiefly to complications, especially to bronchopneumonia. The bronchial glands are always enlarged. The gastrointestinal mucous membrane is fre- quently hyperemic and the solitary and agminated follicles are often greatly enlarged. Leucocytosis is absent. Demme found during the height of the fever a diminution of the red blood-corpuscles, numerous microcytes and free nuclei, and a diminution in the quantity of fibrin in the blood. MEASLES 107 Symptoms. — The period of incubation generally lasts from 7 to 14 days. Fretfulness and slight fever may be noticed during this time. The invasion is often announced by chilly sensations, occasionally by vomiting; rigors and convulsions are rare. The first symptoms are usually those of coryza, generally accompanied by hyperemia of the pharynx and larynx and conjunctival congestion, with lachrymation and photophobia. Sneezing, cough, and hoarseness develop and the child becomes fretful and cross. The tongue is furred; the edges may remain red and the papillae prominent. The temperature may rise abruptly on the first day to 103° or 104° F. (39.5 — 40.0° C), but it sometimes pursues a more gradual elevation until the appearance of the eruption. Nausea and vomiting are occa- sionally persistent. In mild cases the symptoms of invasion may be so trifling as to escape observation. KopUk''s Spots. — Peculiar spots, first described by Koplik, can be seen on the mucous membrane of the lips and cheeks with the aid of strong daylight, in most cases 24 to 48 hours, sometimes four or five days, before the appearance of the eruption. They are small, bright red spots, each of which shows in its center a minute, bluish white speck. The speck can be picked off with a forceps or removed by rubbing. The spots coalesce, and, when fully developed, the labial and buccal mucous membranes appear uni- formly rose-red, with a studding of myriads of bluish white specks. Stage of Eruption. — On the evening of the third day the child gen- erally appears more fretful and its sleep is more restless. The morning of the fourth day, the eruption can generally be detected upon the face, and it becomes distinctly visible during the day. It appears first on the forehead, chin, and sides of the neck, in the form of slightly elevated, round or lenticular papules of variable size. The papules enlarge and are often so numerous on the face as to cover its entire surface with dark red blotches which can often be distinctly felt with the finger. On the chest, arms, and back they usually coalesce into crescentic figures. Petechiae are sometimes seen, especially in the more malignant cases, and miliary vesicles are sometimes observed. From the face and neck the eruption gradually invades the entire surface of the body, reaching the lower extremities by the evening of the fifth or sixth day of the disease. It remains two or three days in each locality, then rapidly fades. A fine, bran-like, furfuraceous desquamation, often scarcely notice- able, follows its disappearance. The mucous membranes of the mouth, throat, and larynx are often invaded by the eruption. With the appearance of the exanthem, the catarrhal symptoms be- come aggravated and the bronchial mucous membrane becomes involved. The temperature often reaches 105° or 106° F. (40.5° — 41.0° C.) on the < < !5 Q 1 2 3 4 5 6 7 8 9 10 10 — — — — — — — — — lol zz — — — ^ — zz — — — ^Z. zz. 3: — zz. TT zz zz zz ^ ^ zz ~ 39J. — — — — — d — — — ~ — — — — ~ — — — — — — — — — — -Q" — — — — — — — — 3; H — — J. -_ — — — — n ~ ^ ^ E/l -'- = = — 38. 5 ^ 3 — = q ^ E — E = — — — — — ' — — zz. ~ — ~ ZZ — — — — ZZ\ ~ [ — ~ zz 38 — q — — — — — — — — — r — B § E E E — = E — ^ 37.5 — ^ -0 ^ — — — - -A- — — -zr — — — — co- — 7- fe >^ 5j — -T^ — — ■^; — — — — — — — — = 0- = = Tjr = = = = — = = = Fig. 10. — Temperature chart of measles. io8 PRACTICE OF MEDICINE evening of the fourth day; the pulse is rapid, 120 to 150, and bounding. Epistaxis sometimes occurs. The cough is often distressing. The rest- lessness is greatly added to in some cases by persistent vomiting, thirst, irritability of the bladder, diarrhea, intense burning of the skin, and insomnia. Delirium develops in severe cases. There is more or less general, though moderate, enlargement of the lymphatic glands. The urine frequently contains albumin, pepton, and aceton and gives the diazo reaction. All the symptoms promptly sub- side as the eruption fades, with the exception of those due to the bron- chial catarrh, which frequently persists. Atypical Cases.— (i) In epidemics, it is not unusual to meet with cases in which the eruption appears on the second or third day, and others in which it is delayed as long as the sixth day or later, (2) Cases occur in which the catarrhal symptoms are prominent, but the eruption absent, and others in which the eruption appears without the usual catarrh. (3) Hemorrhagic or Black Measles.— This form of the disease is characterized by hemorrhages into the skin and mucous membranes, great prostration, hyperpyrexia, and violent delirium or profound stupor. It is encountered especially in prisons and asylums or among the ab- origines of a country in which the disease has not previously prevailed. The mortality may exceed 25 per cent. (4) Malignant cases occur with the same symptoms of profound intoxication as in black measles, but without the hemorrhages. Death may occur before the appearance of the eruption. Complications and ^e^t/e/ce.— Bronchopneumonia is a frequent and often fatal complication, particularly in debilitated children and amid bad hygienic surroundings. The enlarged bronchial glands often become tubercular and may thus become the nidus for the development of acute miliary tuberculosis. Although the laryngeal catarrh is often severe, edema seldom develops. A fatal pseudomembranous growth sometimes, spreads over the pharynx and larynx. In some cases it is due to diph- theritic infection. Corneal ulcers and blepharitis not infrequently occur and optic neuritis may develop. Otitis is sometimes a sequel. Noma of the cheek or vulva often owes its origin to this disease. Entero- colitis, with profuse diarrhea, is an occasional complication. Diphtheria^ whooping cough, and other affections are occasionally associated with the disease. Tuberculosis is the most serious of the possible sequelae. Such affections as paralysis, generally due to neuritis or myelitis, pleurisy,, pericarditis, nephritis, and arthritis are seldom seen. Diagnosis. — Measles is generally differentiated by the character of the prodromal symptoms, particularly the cough, sneezing, congestion and suffusion of the eyes, and the presence of Kophk's spots. A febrile period of four days associated with these symptoms and followed by a papular eruption on the face serves to distinguish it from other aff"ections. Scarlatina is much more acute in its onset; the diffuse eruption ap- pears on the second day, and the strawberry tongue is characteristic. Rothehi is distinguished by the mildness of the invasion, brighter color of the efflorescence, the absence of crescentic figures, and the greater enlargement of the cervical lymph glands. Copaiba, quinin, and anti- GERMAN MEASLES 109 pyrin occasionally produce rashes resembling measles, but the fever and catarrhal symptoms are absent. Treatment. — As prophylactic measures the patient should be isolated for two weeks from the onset. After recovery, he should receive an antiseptic bath; the clothing and bed-linen should be thoroughly dis- infected by boiling, and the room with formaldehyd vapor. In a mild case confinement to bed and daily sponging are often all that are necessary. The room should be well ventilated, moderately dark, and of uniform temperature. The diet should be liquid during the height of the fever. Medication is often necessary. The restlessness, insomnia, and delirium, when present, call for the administration of the bromids and cool baths. The cough should be kept under control by a mixture of camphorated tincture of opium and ipecacuanha, squill, or ammonium chlorid. The danger of the tubercular infection requires that the treat- ment be continued until recovery is complete and the cough has entirely ceased. The eyes should be cleansed several times a day with a 2 per . cent boric acid solution, and a little pure vaselin should be ap- plied to the edges of the lids. The throat and ear should be occasion- ally examined and antiseptic sprays used when indicated. If otitis develops the membrane must be promptly incised. During desquamation the skin should be anointed once a day after bathing, with oil or vaselin. GERMAN MEASLES. RUBELLA, ROTHELN, RUBEOLA NOTHA. Definition . — An acute infectious disease of mild type, characterized by a macular cutaneous eruption and enlargement of the cervical lymph- glands. Etiology. — Rotheln is a highly contagious disease, prevailing mostly in the winter and spring months, among children, and often assum- ing epidemic proportions. Old age is not exempt, and congenital cases have been observed. It is entirely distinct from measles and scar- let fever. One attack usually confers immunity. The specific cause is unknown. Symptoms. — Incubation lasts from 10 to 20 days. The invasion is like that of a very mild case of measles, with slight headache, coryza, sore throat, pain in the back and extremities, chilliness in some cases, and an elevation of temperature seldom reaching 102° F. (39.0° C). The cervical lymph-glands are distinctly enlarged, sometimes for sev- eral days before the development of other symptoms. The eruption appears on the first or second day, sometimes, it is stated, as late as the third. It comes out first on the face and palate, then on the chest, and extends within 24 hours to the entire surface of the body, including the palms and soles. Cases have been reported in which the rash was confined to limited areas. In character it may be macular or papular, slightly elevated, round, rose-colored spots, distinct except on the but- tocks and inner sides of the thighs, where the maculae frequently coalesce. The spots vary in size as do those of measles, but are often larger. The efflorescence is brighter than that of measles and does not usually no PRACTICE OF MEDICINE form crescents. The intervening skin is often hyperemic, without the punctate appearance of scarlatina. A few small vesicles or pustules have been observed in connection with the rash. Itching is sometimes present. The eruption begins to fade in two or three days. The disease runs its course in about live or six days. It is followed by a fine, flaky desquamation. Slightly pigmented spots are frequently left. Sometimes it is more severe, resembling measles except in the character of the eruption. Albuminuria has been noted in some instances. Diagnosis. — The disease is to be differentiated chiefly from measles and scarlet fever; erythema and urticaria may enter into the consider- ation. Measles.— T\\G eruption is paler, less elevated, and appears earlier than that of measles and does not form crescentic figures. The symp- toms are in every respect milder. Scarlatina. — The spotty character of the eruption, appearing first on the face, the less intensity of the throat symptoms, the slower, milder invasion without vomiting, and the absence of the strawberry tongue generally distinguish it from scarlatina. In the absence of an epidemic it may be extremely difficult to distinguish a severe case from a mild attack of either measles or scarlatina. Erythema appears for the most part on the hands and feet, is gener- ally accompanied by burning pain, and is not attended with coryza. Urticaria is characterized by the appearance of "wheels," with intense itching, chiefly on the extremities. There is no coryza. Treatmeni. — The treatment is that of a miild case of measles. In most cases medication is superfluous; it is generally difficult to confine the patient to the house. RUBELLA SCARLATINOSA. The provisional name of "Fourth Disease" was given by Dukes, of England, in 1900, to a train of symptoms which he regards as belong- ing to a distinct infection not heretofore differentiated from scarlatina and rubella. He studied it in 19 cases in the school at Rugby. A more extensive study is that of Curtis and Shaw, of Albany, in 1902, compris- ing 147 cases, of whom 81 were adults. Symptoms. — Incubation lasts about 19 days. During this stage the malaise is so slight as to readily escape observation. Vomiting does not occur. The eruption is generally the first symptom to attract at- tention. It envelops the entire body in a diffuse erythema without the punctate features of scarlatina. Pressure causes only the most transient blanching. The throat is red and swollen, and an exudate sometimes forms on the tonsils, but in many cases it occasions little discomfort. The Klebs-Loffler bacillus is not found. The tongue is furred throughout, but "cleans as all furred tongues do." Desquamation sometimes lasts six or seven weeks. In some cases the skin becomes merely rough, while in others the epidermis comes off in strips or lamellae as extensive as any seen in scarlet fever. It bears no relation to the intensity of the eruption. The lymph-glands are uniformly enlarged, hard, and tender, but less so than in rotheln. The temperature is moderate, averaging 101° F. (38.3° C), and usually subsides on the third or fourth day. CEREBROSPINAL MENINGITIS in The pulse ranges from loo to 120. Albuminuria is absent. Treat- ment is not usually required. There is much doubt as to the pro- priety of admitting the disease as an entity and not merely as a form of rubella. CEREBROSPINAL MENINGITIS. CEREBROSPINAL FEVER, SPOTTED FEVER, EPIDEMIC LEPTOMENINGITIS. Definition. — A severe infectious fever caused by the diplococcus in- tracellularis meningitidis, occurring epidemically or sporadically and char- acterized by an inflammation of the cerebrospinal meninges and a great diversity of clinical manifestations. Etiology. — The diplococcus intracellularis meningitidis is recognized as the specific cause of the disease. It resembles the gonococcus in form, but not in its behavior on culture media. It is found chiefly in the polynuclear leucocytes, both in the tissues and in the cerebro-spinal fluid, sometimes in the fluids of the joints. From the fact that it is found in the secretions of the nose, Striimpell and Weigert be- lieve that infection takes place through this channel, and it has been suggested that the meninges are reached by way of the Eustachian tube and ear. Weichselbaum calls attention to the possibility of its occurring through the auditory canal. Its transmission from place to place is not understood. The frequent occurrence of the disease among soldiers in crowded barracks and among prisoners suggests con- tagion, but is probably due rather to unhygienic surroundings, for it often occurs sporadically in populous tenements, and epidemics have been more frequent in rural districts than in the cities. It occurs most fre- quently in children and young adults, but no age is exempt. Over- exertion, lack of ventilation, uncleanliness, and crowding are impor- tant predisposing influences. A second attack has been reported in five instances (Councilman). Morbid Anatomy. — In the early fatal cases death is probably due to the intense action of the toxin. No lesions are usually found beyond intense hyperemia of the meninges. In less rapidly fatal cases, a fibrino- plastic exudation is found, especially at the base of the brain and along the fissures and sulci of the cortex ; the pia is opaque. The membranes at the base may be much thickened. In more protracted cases there is still more marked thickening of the meninges, the ventricles are distended with a fibrinopurulent fluid, a fluid consisting of serum, fibrin, pus-cells, and diplococci. The posterior cornua often contain pure pus. The brain substance is softened and has a pinkish tinge; areas of encephalitis and hemorrhagic foci are frequently found. The cranial nerves, especially the second, fifth, seventh, and eighth, are frequently involved, and the spinal nerve roots are embedded in the exudate and their axis cylinders are swollen. A chronic hydrocephalus is sometimes developed, particu- larly in children. Congestion, with granular and fatty degeneration of the heart, liver, or kidneys and other organs, is often found. The spleen is enlarged and soft. Hemorrhages may be found in the skin, serous membranes, particularly the pleura and pericardium, or in the viscera. Congestion or edema of the lungs and bronchopneumonia occur, and a lobar pneumonia, due either to the pneumococcus or the diplococcus 112 PRACTICE OF MEDICINE intracellularis, is by no means infrequent. The larger joints often become distended with a seropurulent exudate, and the muscles show granular or fatty degeneration. Symptoms. — The incubation period, probably lasting a week or ten days, is not usually accompanied by prodromal symptoms. Headache, pain in the back, loss of appetite, and slight nasal catarrh are sometimes observed. The onset is generally abrupt, with intense headache, a chill or convulsions, rise of temperature to 102° or 103° F. (39.0° — 39.5° C), and projectile vomiting. The muscles of the neck and spine soon become sensitive, painful, and rigid, the pain and rigidity often extend- ing also to the muscles of the extremities. In extreme cases the head is drawn far back and in some cases the entire spine is bowed (opisthot- onos). Motion of the head is painful or may be impossible, on account of the rigidity. Unconsciousness or delirium early supervenes. Photo- phobia, sluggish reaction or unequal dilatation of the pupils, are com- monly observed, and strabismus, nystagmus, or ptosis, with conjunc- tivitis, is not infrequently present. Hypersensitiveness to sound is observed in almost all cases, and swallowing is often painful. The face has a drawn appearance expressive of pain. The temperature range is exceedingly variable, sometimes rising suddenly to 104° or 105° F. (40° — 40.5° C), and then declining nearly or quite to the normal, only to rise again, without apparent cause for the fluctuation. A fatal termination is generally preceded by a sudden rise, perhaps to 110° F. (43.3° C.),or by a decline to a subnormal degree. The pulse may be rapid or slow. Respi- ration is usually accelerated. Slow respiration, with dyspnea, due to pres- sure on the respiratory centers, is sometimes noted in a late stage of the disease. A sighing or a Cheyne-Stokes respiration is sometimes ob- served. The nervous manifestations are usually prominent features of the case. After the first delirium the patient may arouse with apparent promise of improvement, but the delirium soon returns and often becomes mani- acal. It usually gives place in a few days to a stupor, which may deepen into coma. The face is usually dull and expressionless, except at ir- regular intervals, when it is drawn into a distressing grimace, and the patient, if a child, utters a shrill, piercing, characteristic cry (the hydro- cephalic cry). A spasm of the muscles is not infrequent, when the fea- tures remain constantly drawn into a peculiarly ghastly grin (the risus sardonicus). Twitching is frequently observed in the muscles of the extremities ; the forearms are flexed upon the chest, and the thighs and legs are flexed in many cases and often rotated to one side. Later the limbs may become fixed in these positions. Herpes of the lips is seen in about half the cases; petechige or pur- puric spots sometimes occur, especially in malignant cases, general pur- pura is seldom encountered, although it gave the name " spotted fever" to the disease. Dusky erythematous spots are occasionally seen over the course of the peripheral nerves. Rose-spots like those of typhoid fever have been observed, and urticaria, ecthyma, pemphigus, and very rarely gangrene of the skin have been recorded. The vomiting generally subsides after the first day or two, but it is sometimes a distressing symptom throughout the disease. Diarrhea occurs in some cases; constipation is a more general condition. The CEREBROSPINAL MENINGITIS 113 urine sometimes contains albumin, less frequently sugar; hematuria is a frequent feature of malignant cases. Lumbar puncture shows an increase of pressure within the spinal ca- nal, and the fluid obtained is turbid, often purulent, and when examined microscopically reveals polynuclear leucocytes and numerous diplococci. Leucocytosis is usually, but not invariably, observed in the blood-count. Varieties of the Disease. — The types of the disease generally recog- nized are the following : 1. The ordinary form that has been described. 2. Unusually mild cases, in which headache, vertigo, vomiting, and moderate fever are observed, possibly hyperesthesia and stiffness of the extremities, but the disease pursues a moderate course and recovery is usually complete. 3. Abortive cases in which the onset is sudden and often severe, but the symptoms rapidly subside, sometimes with profuse sweating or epistaxis, as if by crisis. Convalescence is established often within the first week. 4. A malignant form in which the nervous manifestations are of extreme severity, although the temperature may not be high. The pulse is often below 60 and feeble. A purpuric eruption is usuallj^^ observed. Death often occurs within 24 hours. 5. An hitermittent type is recognized, in v/hich the temperature pur- sues a course more characteristic of pyemia, rising more or less abruptly every day or every second day, falling nearly or quite to the normal in the interval of remission. 6. A chro7iic form, which often lasts five or six months, to be followed even then by incomplete recovery or a fatal issue. A condition of ex- treme emaciation (marasmus) and various sensory and psychical dis- turbances, with contractures of the limbs, is generally produced. The protracted course of the disease is marked by occasional recurrences of fever and other symptoms. Osier looks upon these protracted cases as probably due to chronic hydrocephalus or abscesses of the brain. Complications and SequeloB. — Lobar and bronchopneumonia, pleurisy, endocarditis, and pericarditis are not infrequent complications. Per- sistent headache, and various affections of the eye or ear resulting in blindness or deafness, are only too commonly encountered. Deaf-mutism, aphasia, chronic hydrocephalus, imbecility, and various paralyses fre- quently remain. Arthritis of variable severity is almost always present. In the worst cases the exudation into the joint becomes purulent, and per- manent contractures and deformities result. Even after convalescence has progressed favorably for weeks there is no assurance of ultimate complete recovery. Emaciation, anemia, feeble digestion, and general debility often remain for months. Diagnosis. — The sudden invasion with chill, the intense headache, pains in the neck, back, and extremities, but more particularly the cervical rigidity, explosive vomiting, constipation, photophobia, sensi- tiveness to sound, and hyperesthesia are always suggestive of the disease, especially if other cases have occurred in the vicinity. Later, the irregu- lar temperature, rapid or abnormally slow and weak pulse, peculiar facial expression, emaciation, muscular tremor, soreness and rigidity, the cry, and other phenomena already reviewed, establish the diagnosis. Ker- nig's sign is a valuable aid to diagnosis in many cases in which it is 114 PRACTICE OF MEDICINE present, but unfortunately it is occasionally absent. It consists in a peculiar flexion of the knees when the patient sits up in bed. When the patient lies upon his back the legs can be flexed or extended by the hand of the examiner, but, if the patient is raised into a sitting posture, his knees become partially fl.exed and cannot be fully extended on ac- count of contraction of the flexor muscles. The extreme limit of flexure is usually under 135° it may be as low as 90°. The sign indicates simply that the meninges are involved and is not peculiar to this form of meningitis. Unfortunately, cases of pneumonia, typhoid fever, and other affections occur in which the symptoms are suggestive of meningeal involvement, and other forms of meningitis must be excluded. Simple meningitis is often difficult to differentiate in the absence of an epidemic. As a rule, the onset is less severe, the tremor, contrac- tures, and joint-involvement are less prominent features; the sardonic grin and hydrocephalic cry are not typical, if present. Tubercular mefiingitis is generally more insidious in its invasion and appears, as a rule, in persons already suffering from tubercular infection. If this be located in the lung, the bacillus may be found in the sputum. Lumbar puncture proves a valuable aid in the differentiation, since Pfaundler has shown that the pressure of the fluid is often greater in tubercular meningitis than in any other condition, while the fluid may remain nearly or quite clear, a condition never found in the acute disease. Pneumonia may be complicated by meningeal irritation or inflamma- tion and is then with some difiiculty distinguished from a complication of cerebrospinal meningitis, especially if the latter disease be prevalent at the time. In pneumonia the symptoms point more distinctively to an involvement of the cerebral meninges alone. It may, however, re- quire the lumbar puncture and examination of the spinal fluid to de- termine the real condition. Typhoid Fever. — In this disease symptoms referable to irritation of the meninges do not usually appear until the second week. The history of the invasion is different. The rose-spots, greater enlargement and firmness of the spleen, the absence of leucocytosis, and positive reaction to the VVidal test are usually sufficient to determine the condition. Typhus fever can usually be excluded by the character of the epidemic prevailing. Both diseases are, however, peculiarly prone to occur in bar- racks and jails and may be differentiated with difficulty in the start. The extremely high temperature, dusky hue of the face, and less pro- nounced manifestations on the part of the spinal muscles are often the most valuable symptoms. Prognosis. — The course of the disease is so variable that the prog- nosis is made with difficulty. The mortality in different epidemics has ranged from 20 to 80 per cent. In mild cases convalescence begins within the first week; malignant cases generally terminate fatally within the same period ; in the ordinary form it begins in from two to three weeks. Park tells us that about 40 per cent of the cases in which the diplococci are found in the fluid removed by lumbar puncture recover, while nearly all those due to the pneumococcus and streptococcus die. The com- pleteness of recovery can rarely be prognosticated. Treatment — The patient should be isolated in a quiet, moderately darkened room. All excitement should be avoided. Rest must be secured. PNEUMONIA IIS if by the administration of opium. The headache, delirium, restlessness and cervical pains may be moderated by the application of ice-bags to the head and spine, but morphin or other opiate must be resorted to in severe cases. The bromids in large doses may be sufificient in the case of a child, and when it is found necessary to administer opium it should be the camphorated tincture or deodorized tincture, beginning with a small dose. Urethane in 30-grain (2.0) doses is recommended for the relief of the muscular twitchings in an adult; warm baths and cannabis indica for the rigidity. The high temperature is best combated by cool sponging or the wet pack whenever the temperature reaches 103° F. (39.5° C). The use of the coal-tar antipyretics in this case is generally condemned on account of the weakness of the heart and consequent danger of greater depression. The heart may be strengthened by the free administration of stimulants, which are usually well borne. If the res- piration becomes irregular, atropin may be judiciously administered with the morphin. Ergot and belladonna are thought, by some writers, to exert a beneficial influence on the meningeal congestion, but are re- garded as of doubtful service by others. Blisters and other irritants to the nape of the neck should be used, if at all, only in the early stage on account of the tendency to bedsores. This tendency should be further guarded against by proper bathing. Wet cups applied to the nape of the neck in the beginning of the disease are sometimes found of benefit. The diet should receive careful attention. During the acute stage it should be restricted to milk, broths, and beef-juice. Water should be plentifully given. If swallowing becomes difficult, resort to rectal ali- mentation is necessary. The milk should then be predigested. The bowels should be kept freely open by the saline cathartics, perhaps with an occasional dose of calomel. After the more acute manifestations have subsided, the iodids may be administered with a view to hastening the absorption of the exuda- tions ; the sirup of the iodid of iron is especially indicated on account of the anemia also present. During the convalescence, codliver oil, malt, strychnin, iron, and arsenic are indicated. Massage and electricity may hasten the restoration of tone to the muscles after motion has become established. PNEUMONIA. LOBAR PNEUMONIA, FIBRINOUS PNEUMONIA, CROUPOUS PNEUMONIA, PNEU- MONITIS, LUNG FEVER. Pneumonia occurs in all parts of the world, and ranks as one of the most fatal of the acute infections. In the United States the mortality attributed to it is second only to that of tuberculosis, and in many of the cities it outranks the latter disease. Definition.— An acute infection caused by the micrococcus lanceolatus and characterized by inflammation of the lungs, with fever and other evidences of toxemia. Etiology.— Bacteriology.— T\\Q micrococcus lanceolatus, the recognized cause of the disease, is known also as the pneumococcus. It is found in about 90 per cent of all cases in the pulmonary exudate, but has been repeatedly found in the mouths of healthy persons. It is seen in the rusty sputum, sometimes in the blood, and almost always in the ii6 PRACTICE OF MEDICINE smaller blood-vessels after death. It can be demonstrated without difficulty, since it takes up the usual stains and is identified by its fairly lancet or elliptical shape and encapsulation in pairs, particularly when found in the sputum. The usual avenue of infection is doubtless the respiratory passages, probably the lung itself, although Menzer believes that it may occur through the tonsil. The viability, virulence, and other characteristics of the micrococcus are so different under different circumstances that the existence of more than one species has been suggested. Eyre and Washburn distinguish several types, notably a parasitic, the most virulent and including the pneumococcus, and a saprophytic, almost devoid of virulence and including the species so often found in the respiratory passages of healthy individuals. Other Organisms. — The Friedlander bacillus pneumoniae is also found in the lungs, but not so uniformly as the pneumococcus. This is a larger organism, a short rod inclosed in a capsule, and it exhibits very ..different vital phenomena from those of the diplococcus. The staphylo- coccus and streptococcus pyogenes are also found in some cases usually associated with the pneumococcus, but they may be found alone, partic- ularly in the pneumonia of children. The bacilli of influenza, diphtheria, and typhoid fever have each been encountered in pneumonia. The mode of transmission of the disease is not understood. The possibility of direct contagion has been too little regarded in the past, for recent investigations reveal a comparatively frequent occurrence of successive cases in the same locality, as in the house referred to by Schroder, which furnished 32 cases to the clinic of Kiel in 15 years, 6 of them in one year. Endemics including many cases in rapid succession have been repeatedly observed in prisons, camps, and on ships. Tyson refers to 410 cases among a ship's crew of 815. Age. — The disease occurs at all ages. In childhood it is more frequent before the sixth year. Holt's table of 500 cases in children under 14 shows 15 per cent of cases in the first year, 62 per cent between the second and sixth, 21 per cent from the seventh to the eleventh, and only 2 per cent after the twelfth year. Netter observed a case in which the disease was transmitted from the mother to the fetus, and two in- stances in which the blood from the uterine vessels of the patient con- tained pneumococci. After puberty, from decade to decade, there is probably not much difference which cannot be better attributed to other influences than age. Sex. — Men are oftener attacked than women, probably on account of greater exposure. Race. — The negro in our country is highly susceptible. Physical Condition. — The disease is so common among robust working- men that it was once thought to have an affinity for persons in full vigor. In many, if not in a majority, of cases, however, there has been a previous impairment of health. This may have been induced by fatigue, alcoholism, a chronic disease, or a catarrhal condition of the respiratory passages. A previous attack affords only temporary immunity and it seems to render the individual more liable to the disease in the future. Some of the other acute infections are more or less frequently followed by lobar pneumonia ; among them, typhoid fever, erysipelas, dysentery, and cerebro-spinal meningitis. Tuberculosis does not notably increase PNEUMONIA 117 the susceptibility to it; asthma, emphysema, and valvular diseases of the heart are thought to lessen it. Excessive indulgence in alcohol is one of the most universally recognized predisposing causes of the disease. In the large proportion of the cases admitted to hospitals the disease follows a debauch. Many cases follow exposure to cold and wet. Climate is not an important factor, since the disease prevails almost everywhere, in warm climates as well as in cold. In some countries, as in Switzerland, it is met with especially in the higher altitudes. Winter and spring are the seasons of greatest prevalence in our country. Trauma in which the lung has been injured, with or without fracture of the ribs, has been followed by pneumonia in some instances, and it is possible that such injury favors the entrance of the pneumococcus. Morbid A nafotny.— Three distinct stages are recognized in the inflam- matory process m the lungs : Engorgement, red hepatization, and gray hepatization. Engorgement.— T\ve first stage is one of hyperemia or congestion. The vessels are distended with blood. The affected portion of the lung is dark red, heavier than normal, though it still contains air, crepitates on pressure, and floats in water. When it is incised, bloody serum flows from the cut surface. The alveolar spaces are diminished in size by the thickening of their walls, but they contain as yet no exudate. With the occurrence of exudation the condition passes into one of solidification or red hepatization. Red Hepatization. — In this stage the exudation soon becomes com- pletely coagulated within the alveoli. The walls show less evidence of congestion than in the first stage. The lung is as firm as liver, contains no air, and is increased in volume to such an extent that it usually shows the indentations of the ribs. It is also friable, so that it can easily be crushed between the fingers. The surface of a section is com- paratively dry, has a reddish brown color, and appears granular, owing to the projection of minute fibrinous casts from the alveoli. The ex- udation consists principally of fibrin, in the meshes of which are numer- ous red blood-corpuscles, polynuclear leucocytes, and epithelial cells. The diplococci can also be seen in stained preparations. Gray Hepatization. — The conditions found at this stage are the result of degenerative changes in the exudate of the previous stage. The lung is still firm and even more friable, , but has a gray or yellowish gray or mottled color. The cut surface has the same color and is smooth and moist. The fibrin and erythrocytes have disappeared, and the exudate is composed chiefly of leucocytes, epithelial cells, and pus-cor- puscles. This stage merges into the resolution, or perhaps it would be proper to say that it is a part of the latter process, having for its object the removal of the exudation. This is accomplished chiefly by absorption into the blood current; in part also by expectoration. The pathological process of pneumonia probably begins b}' a de- struction and desquamation of the epithelium of the finer bronchi and air-cells by the micrococci, and, as in other croupous inflammations, a coagulable exudate forms on the injured surfaces. (See p. 30). Later the white corpuscles migrate from the vessels into the exudate, and the red corpuscles and fibrin are dissolved by a chemical process sometimes regarded as a form of peptonization. After the absorption ii8 PRACTICE OF MEDICINE of the exudate the epithelium is regenerated. The entire process usually runs its course within ten days. When this reaches the periphery of the lung, the pleura invariably becomes involved in a fibrinous inflammation. Sometimes the process of resolution passes into suppuration and abscess- formation, occasionally terminating in gangrene of the lung. The extent to which the lungs are involved in the disease is very different in diff'erent cases. It may be confined to a single lobe, or it may be more extensive. The lower lobes are most frequently involved; the upper lobes rank next. The corresponding lobes of both lungs are sometimes aff"ected (double pneumonia). The right middle lobe is seldom independently involved. Striimpell, in 244 cases, saw the right lung affected in 137, the left in 86, and both lungs in 21. Involvement of the lower lobe of one lung simultaneously with the upper lobe of the other lung is a condition rarely met with (crossed pneumonia). It is not unusual to find red hepatization in one lobe and gray in another in the same patient. Less often they are found side by side in the same lobe, and occasionally all three stages are simultaneously present. These phenomena result from the successive involvement of diff^erent areas. Symptoms. — Typical Case. — The incubation is probably short, only a day or two, for the initial chill frequently occurs within a few hours after some unusual exposure. Prodromal symptoms are often absent; there may be a catarrh of the upper respiratory passages for a day or two; sometimes headache, pains in the limbs, and anorexia are com- plained of. The onset is almost always abrupt with a chill which often lasts from fifteen to thirty minutes or longer. The chill may, however, be slight, it is occasionally absent, seldom repeated. It may seize the individual in the midst of his work; it often comes on at' night during sleep. While the patient still shivers, the temperature rises, and within a few hours it reaches 104° or 105° F. (40° — 40.5° C). Its course is high throughout the disease, the diurnal fluctuation often amounting to but 1° F. It almost always terminates by crisis. The pulse be- comes rapid, generally no to 120, full and bounding, seldom becoming dicrotic at any time. Shortly after the chill, sometimes before it, the patient is seized with a sudden, often agonizing pain in the affected side of the chest. At the same time, and partly as a result of the pain, the respiratory movements increase in frequency, and the movements are shallow, particularly on the"affected side. A dry, painful, suppressed cough is also present, but in a day or two this becomes moist, and the characteristic bloody, "rusty" sputum is expectorated. The dyspnea is sometimes distressing, and the expirations are frequently accompanied by moans. The patient's position and appearance are often typical of the disease. He lies at first on his back ; but as soon as solidification has occurred he turns upon the affected side and assumes an attitude of. restraint, avoiding motion on account of the pain it occasions. The face is flushed, often dusky, and in the center of each cheek, or frequently only in that of the side corresponding to the affected lung, there is a bright red spot. The expression is that of anxiety and pain. The tongue is furred and often becomes dry and brown. Vomiting sometimes occurs, especially in children; the bowels are generally constipated. A herpetic eruption PNEUMONIA 119 appears in about a third of the cases, on the Kps, about the angles of the mouth, on the chin or nose, occasionally about the eyes, or on the helix of the ear, rarely on the genital or anal region. Sleep is usually restless, or insomnia may prevail. Delirium not infrequently develops; it is especially frequent and severe in alcoholic subjects. The disease runs its course in from three to ten days ; then, as a rule, terminates by crisis. The temperature falls within a few hours to the normal or lower, the pulse and respiration become slow, pain and dyspnea vanish, and the patient falls into his first peaceful slum- ber. For a few hours he is usually bathed in a profuse sweat ; diarrhea sometimes occurs, but soon ceases after the crisis is over. The cough may continue for a few days, but the blood disappears from the sputum and the quantity of the expectora- tion rapidly diminishes. Convalescence is usually rapid, and recovery may be complete within a week or ten days. Special Synrzfoms. — T//e CJiilL — There is no other disease in which the inva- sion is so constantly an- nounced by chill or in which the chill is uniformly so severe. It is a pronounced rigor, often lasting more than a half-hour; it is sel- dom repeated. Chills may, however, occur during the course of the disease, and then generally signify an involvement of an additional area of the lung. The chill is absent, according to some observers, in about 20 to 30 per cent of the cases. The Fever. — The distinc- tive features of the fever are the sudden rise of temperature, often to 104° or 105° F. (40°— 4o.5°C.) within 12 hours; its uniform course frequently not varying more than 1° or 1.5° F. during two or three days, audits termination by crisis. The surface temperature often shows comparatively little increase ; hence the rectal temperature may be several degrees higher than that of the axilla. F. 106' 105° 104 103 102 101 100° 99 98 DAY OF DISEASE M I E j M E : M E 1 M E M E M E M E i 1 1 1 1 1 ! 1 — JU A ! /\ /I n ' \/y , / j / ^ / y 1^ / /i \\ A / \ / ' Vl \ /\! 1 \_i \i v! I / V ' \ / \ \/ ^ V i ;\ 1 ! l\ ' ! t\ ! 1 i ) ! ! I i 1 ! 1 1 1 1 ! 1 1 I 1 lit 1 1 i \ 1 1 1 1 1 i 1 I 1 1 1 ■| 1 1/ 1 1 \ / / J • 1 1 2 1 3 4 5 « 1 7 1 Fig. 1 1 .—Temperature chart of pneumonia, termi- nating by crisis on the sixth day. (Ziegter.) 120 PRACTICE OF MEDICINE Irregular types of fever are sometimes observed, as when the tempera- ture, alone or along with the other symptoms, more or less completely subsides before the crisis. A drop to normal, with amelioration of the other symptoms, sometimes occurs, and is then followed by a hyperpyrexia which in turn ushers in the crisis. A convulsion or vomiting sometimes takes the place of the chill in children, in whom the rise of temperature is also more gradual and the daily fluctuation may be greater. The same conditions are sometimes observed in adult cases beginning without a chill. In very old persons the temperature may be but slightly elevated, and the termination is often by lysis. Hyperpyrexia is not uncommon. The temperature may reach 107° or 108° F. (41.6°— 42.2° C), even 109.5° F. (43.0° C), as in a case reported by Ironside. The crisis may occur at any time from the third to the tenth or twelfth day. A peculiar frequency of its occurrence on odd days, as on the seventh, ninth, or eleventh, has been repeatedly noted, but it not infrequently occurs as early as the end of the sixth day. The fall of temperature is often very abrupt, and it may amount to 5° or 6° F. (^2.7°— 3.3° C.) within from three to eight hours, sometimes becoming from I ° to 3 ° F. subnormal. The temperature sometimes rises one or two degrees just before the crisis, and it may rise to 102° or 103° F. (x<^.Q° — 39.5° C.) in 24 hours after the crisis and remain elevated for two or three days. A pseudoc/'isis is sometimes observed in which, particularly on the fifth or sixth day of the disease, the temperature falls to 101° or 102° F. (38-5°— 39-o° C), but immediately rises again to its former height. It is usually indicative of the involvement of additional lung space. The crisis may still occur, but lysis is the usual termination in protracted cases. Fain is constantly present at the beginning. It may subside to a great extent after complete solidification of the lung. It is often ex- cruciating, and is greatly increased by coughing or efforts at full in- spiration. In a double pneumonia the moans of the patient can often be heard at a great distance, notwithstanding the restricted breathing. The pain is confined to the affected side of the chest and is usually referred to the lower axillary space or to the region of the nipple. The pain is probably due almost solely to the accompanying pleurisy, for it is often shght in a central pneumonia. The dyspnea varies in severity with the extent of lung involved, the degree of temperature, the amount of pain, and probably in a great measure with the extent to which the toxemia affects the respiratory centers. It is always a prominent symptom. The respiratory movements are usually increased to 30 or 40, often to 50 or 60 a minute. In children they may reach 80 or 100. They are shallow, but regular, as a rule. The dyspnea is accompanied by the usual signs, movement of the alse nasi, and a sense of suffocation or of constriction beneath the sternum. But, as Grisolle remarks, the most rapid respiratory movements in some patients may be only a manifestation of nervous irritation at the pain and may not denote so great dyspnea as is often indicated by 24 or 28 respirations a minute in other cases. The disturb- ance of the ratio of respiration to pulse-rate is a striking and charac- teristic feature of pneumonia. Instead of the normal ratio of i 14, it is PNEUMONIA ^ 121 often 1:2 or i :i.5, for the pulse may be only 120 when the respira- tions are 60 or more. Pulse and Heart. — The acceleration of the pulse is moderate in most cases, being strikingly out of proportion to the respiration as stated in the last paragraph. The pulse is usually full and bounding in the beginning; it may become weak after a iesff days and occasionally di- crotic. In alcoholic cases and old persons, it is frequently feeble and rapid from the beginning. The second sound of the heart is accentuated owing to the increased tension in the pulmonary circulation, and a temporary systolic murmur is often heard over the pulmonary valve; sometimes also over the mitral. A fatal cardiac distention or paralysis sometimes results from trifling exertion in the presence of profound toxemia. The cough is an early symptom, rarely absent except in infants and very aged or feeble persons, but it may be suppressed on account of the agonizing pain which is occasioned by it. It is at first short, sharp, and dry, but by the second or third day it is attended with expectora- tion. The sputum is at first mucous in character, but after 24 to 48 hours it becomes tinged with bright arterial blood. The color soon changes to an orange-yellow, iron-rust color, which has given it the name of rusty sputum. Free hemoptysis occasionall}^ occurs at the onset of the disease. The sputum is often so tenacious and viscid that it clings to the tongue and lips and is wiped away with difficulty; the cup can often be inverted without spilling it. In some cases, however, particularly in asthenic cases, the sputum is more fluid and has the dark brown color of prune-juice, a name often applied to it. The quan- tity of the expectoration is exceedingly variable. Occasionally there is no expectoration, or the sputum may pass into the esophagus and escape observation, particularly in women and children or in the presence of extreme prostration. Microscopic examination of the sputum reveals numerous degenerated bronchial,, probably also alveolar, epithelial cells, normal and degenerated erythrocytes and leucocytes. The micrococcus lanceolatus and other bacteria are often present in great numbers. Cerebral Disturbances. — Headache is a common symptom. Convulsions rarely occur except at the beginning of the disease in children. In some cases of so-called cerebral pneumonia in children, the rigidity and re- traction of the neck, and the muscular twitching form a picture very suggestive of cerebrospinal meningitis. Delirium is a not unusual symp- tom, especially in alcohohc subjects, children, and the aged. It is often mild in character, but it may become maniacal, particularly in the drunkard. Typical delirium tremens not infrequently develops on the third or fourth day in these cases. Such patients often show a propen- sity for getting out of bed, and have jumped out of windows in the absence of the attendant. Delirium is frequently absent, however, even in fatal cases among alcoholic patients. Exceptionally, the delirium, instead of ceasing at the crisis, becomes more violent for a itw^ hours, and in another class of cases it makes its first appearance at this time, but it is then usually of short duration. Other cerebral disturbances continuing after the crisis usually terminate favorably. Toxefnia.— Casts are now and then observed in which toxemia resem- bling uremia is present. Chill, pain, and cough may all be absent in the 122 PRACTICE OF MEDICINE beginning, and the fever slight, but in a few days the temperature rises and the patient passes into a low, muttering dehrium, or a coma which proves rapidly fatal. The Blood.— The most characteristic feature of the blood is simple leucocytosis, developing early, continuing to the crisis and sometimes reaching the extent of from 30,000 to 60,000 per c.mm., or from three to eleven times the normal limit. Polynuclear corpuscles are most abun- dant in the beginning, but eosinophiles become numerous later. Absence of leucocytosis is an unfavorable sign usually seen in protracted cases. Stockton, however, reports the case of a httle girl with two relapses and ultimate recovery, in which there were only 4,000 leucocytes to the c.mm. during the first relapse. As is remarked by Thompson, the theory that the leucocytes are active agents in the production of immunity receives much support from this clinical fact. It may be applied thus : " The toxin formed by the pneumococci is active for a few days until sufficient leucocytes accumulate to manufacture antitoxin to destroy it, producing a crisis. Absence of leucocytosis gives free scope to the toxin in severe cases. Insufficient leucocytosis ' postpones the crisis and resolution." The micrococci are recognized in the blood with difficulty. The urine is high in color, specific gravity, and solids, particularly in uric acid, and a trace of albumin is often present. As in other fevers the chlorids are generally, though not always, diminished, a phenomenon which is perhaps best explained by Koranyi's theory of molecular inter- change in the kidney. F. Pick calls attention to the fact that in from 24 to 48 hours after the crisis the urine often becomes neutral or alka- line for a period of 24 to 36 hours, after which the acidity returns. Sternberg regards secondary infection of the uriniferous tubules by the pneumococcus as probably not infrequent. The toxicity of the urine has been found greatly reduced during the disease. Physical Examination.— i. During the stage of congestion, inspection shows a diminution of the movement of the affected side, and in double pneumonia the breathing is chiefly abdominal. By palpation, an in- creased fremitus is generally noticed over the affected area. Percussion reveals dullness or a high-pitched tympanitic note over the region in- volved and a tympanitic note over the surrounding region of the lung. On auscultation, the breathing is found to be bronchovesicular in char- acter and it is reduced in amplitude. An exaggerated respiratory mur- mur may be heard over the other regions of the chest. Subcrepitant rales are usually present, or the crepitant rale may be heard at the end of a forced inspiration. 2. S^a^e of Hepatizatio7i.—Inspectio7i.—T\v^ respiratory movement of the affected side is much limited if an entire lobe is involved, and a corresponding increase in that of the opposite side is observed. The healthy side of the chest may appear larger than the affected side. The tactile fremitus is generally increased. A pleuritic friction fremitus may be felt. On percussion the note varies from a tympanitic dullness to flatness; occasionally a metallic quality can be detected. In central pneumonia the dullness may be almost unrecognizable, although the sense of resistance imparted to the finger may be increased. In children, careful, light percussion is always required to elicit dullness. Ausculta- tion reveals typical tubular breathing and bronchophony in most cases; PNEUMONIA 123 rarely egophony, over the afifected area. Subcrepitant rales are not infrequently heard. All sounds may cease when the bronchi become completely closed by the exudate. 3. Resolution. — During this period the respiratory movements become less restricted and percussion resonance gradually increases. The sub- ' crepitant soon give place to coarser moist rales, which may continue throughout the week or more of absorption of the exudate. The res- piration again becomes bronchovesicular and finally returns to its normal quality. Varieties of Pneumonia. — This term is employed, not to designate different types of the disease, but rather the different features presented in different cases. The affection is, so far as is known, the same in all cases, and the variations probably result from differences in the age, vulnerability or susceptibility of the patient, or from accidental or unrecognizable influences. The terms apical and basal are sometimes ap- plied to the disease to indicate that the apex or the base is involved. Frank pneumotiia is merely a synonym for the ordinary type of the disease. Epidemic pneumonia is usually a virulent type, often occurring in individuals previously debilitated by influenza or other infection. Migratory pneimioiiia is a frequently fatal form in which one area after another is iuA/olved until the vitality of the patient has been exhausted. Massive pneumonia is that condition in which an unusually large area of the lung is solidified and the bronchi are completely filled with the exudate. Expectoration may be absent. Central pneicmonia is a rather frequent form, at least in the beginning of the attack. In it the exudation is often confined to the center of a lobe or to the base of the lung and does not reach the periphery during the first two or three days of the disease. Both the subjective and objective signs may be very indefinite during this time. Secondary pneumonia is a term sometimes used when the disease has developed as a complication of other infectious diseases. The base of the lung is usually affected and the diagnosis may be difficult, particu- larly when other micro-organisms than the pneumococcus are present. Bacelli describes a form of pneumonia which follows pleurisy. The signs of pleurisy are distinct on the first day. On the fourth or fifth, symptoms of intense pulmonary edema appear, dyspnea, serous sputum, blood-stained or hemorrhagic. The disease runs a rapid, often fatal course. Terminal pneumonia signifies that the disease has developed in an aged person or one who is the subject of a chronic disease. In other words, it becomes the fatal termination of senile debility, tuberculosis, cancer, cardiac or renal disease. This part is more frequently played, however, by bronchopneumonia or hypostatic congestion. Alcoholic pneumonia is often masked by the predominance of the acute symptoms of intoxication. It should be recognized, however, upon ex- amination, the necessity of which is indicated by high temperature, rapid respiration, dyspnea, often with cyanosis. Typhoid pneumonia is a term without much to recommend it. It is used to designate either pneumonia complicating typhoid fever, or a 124 PRACTICE OF MEDICINE condition of stupor like that of typhoid fever supervening upon a lobar pneumonia. Either condition is grave. Pneumonia in infants usually begins wdth a convulsion and runs an irregular course, often affecting the apex, attended with delirium, and terminating by lysis, occasionally by crisis. (Fig. 12). Pneui7i07iia in the Aged. — The peculiarities of the disease in old people have already been stated. Bronchopneumonia is more common in them, as also in children. ^ .^ __l __ 1— _- _. — 1 P-> ■^ — • — ■ _ >— « p-i — 1 •— 1 1^ — 1 1— 1 ■— 1 r* •— ^ ^- MM 105° 104 •> — , — — — — — — — ' — — — — — — - — 1 — — — - — ~ — — _ — — — — —■ j— — - -- - -- s E - = J -; I I ^ 1 — t 1 1 ^ ^ 1 1 V 3 I j - \ z p j = £ z - E z _ z z z E E z E E 103° 102° 101° 100° 99° S8» S7° DaU. - j 1 ~ '- - E E ~ r: t -_ z t = E 1 : : z - E z E E E ! E 1^ = E E E = E r-' - I ; = E E i - = Eh — r z: -_ E E E z z ~ _ Z E z E = z ^ ^ z z E _ z; E E - ^ z z z it ZZ z ^ =t 1 •I [_ ^ _ _ _ .^ L _ — - — — _ — — — — — . — _J — !_ _: — 4r- 1_ d ~ — ~_ ~r r - - = -, ~ z z - - = - - - p - - - - - - - - - - - -r ^ z f- - ^P -^ th i^= ~ - - - ■^ — - - - r - - - - r - ' - z z - = - = z z z z - z z n ~ — ~ — ^i^ ^ X ^ = E - E E; :z E E E E E E E E E E z \ E E E E E E E \ E E E E z - z E E z zz i 1 \ S ^ \ ^ z E E = Ei l^ ~ E E = E E z z z z z E E E E E z r r = E E E z E E I it E E Efe zt E - =1= ^ z FEB so s\. f -£. 2 _^ a_ z 4. z k_ -^ i_ g kJ 4 s__ ^« U > > I 5 ^ ^' 1 Fig. 12. — Temperature chart of a case of pneumonia, terminating b}- crisis, in an infant of nine months. Pseudocrises are shown also upon the sixth and ninth days. Apyretic pneumonia has been described. Guider attributes the ab- sence of fever to exhaustion of the economy, functional disturbance of the nervous system, and the action of infectious agents. Pneu7no7iia after Surgical Operations. — The occurrence of lobar pneumonia after surgical operations is probably purely accidental and is very infrequent. Ether pneumonia and respiration pneumonia are both bronchopneumonias and should not be confounded with this disease. Delayed Resolution. — In a typical case of pneumonia, resolution does not occupy more than a week or ten days. The cough ceases, and physical examination reveals no abnormal condition further than slight dullness due to thickening of the pleura. This dullness some- times persists for a month or more. The resolution is sometimes de- layed beyond the usual limit, particularly in debilitated subjects, but sometimes also in robust individuals in whom the slow recovery is unac- countable. In some cases the consolidation of lung continues, with or without fever. In other cases, after the temperature has subsided by crisis or lysis, it returns again at intervals, or runs an irregular course for several weeks. There may be intense b-onchial breathing, but there is usually no cough or expectoration. In other cases, again, the moist rales and expectoration continue. The temperature curve and frequent sweating in some cases suggest the possibility of sepsis. Tuberculosis PNEUMONIA 125 rarely follows lobar pneumonia, but a latent pulmonary tuberculosis may be awakened by it. Relapse. — A true relapse of pneumonia is seldom seen. In some cases, however, there is an apparent recrudescence due to delayed resolution or to the development of complications. In other cases the apparent relapse is due to the invasion of additional lung space, with return of the S3-mptoms, at a time when the crisis is being looked for, but the condition can hardly be regarded as a relapse. Recurrence is not infrequent. There have been well-authenticated in- stances in which the same person passed through eight or ten attacks. Complications and Sequelae. — Pleurisy is so constantly an accom- paniment of pneumonia that it may well be looked upon as a part of the disease, rather than as a complication. It is absent only in central pneumonia before the inflammation has reached the surface. In some cases, again, the pleural inflammation predominates to such a degree that the condition is frequently spoken of as a pleuro-pneumonia. The fibrinous exudation is always unusually abundant in these cases and interposes a thick cushion between the consolidated lung and the chest wall, greatly interfering with the transmission of the respiratory sounds. A serofibrinous form of pleurisy is not infrequently encountered in long- continued cases. Occasionally it becomes suppurative and an empyema may be developed. In such cases it is the rule to find both the pneu- mococcus and streptococcus in the fluid. The condition is recognized by a continuance of the fever, usually with a remittent or intermittent course, and persistence of the leucocytosis, frequently with sweating and other signs of pyothorax. The diagnosis is established by the with- drawal of pus through the aspirator needle. Endocarditis is a comparatively frequent complication, especially in the presence of an old valvular lesion, and perhaps for that reason it is more frequent in the left heart. It may follow the crisis. Its develop- ment is often concealed, there being no murmur even in severe cases; and, as already stated, a murmur may be present for a time without lesion of the valves. In other cases, a rough diastolic murmur is heard. A malignant endocarditis is to be suspected, however, when chills, ir- regular fever, and sweating continue to occur, and particularly when embolic infarctions develop in any of the organs. The pneumococcus is sometimes found in the cardiac vegetations after death. Meningitis is not infrequently associated with a malignant endocarditis of this character. Pericarditis is seldom met with in adults and is more frequent in the left-sided pneumonia of young children. It is a result of an extension of the inflammation from the left pleura to the pericardium. It may be recognized early, before eff'usion has taken place, by the friction sound, or if this be absent, by the precordial pain, increased heart dullness, intense dyspnea, indistinct heart sounds, and the feeble pulse. Embolism has been found in the larger arteries ; thrombi occasionally form in the veins. Aphasia, with or without hemiplegia, has been ob- served in a few instances, probably as a result of embolism. Meningitis, attributed to the migration of the pneumococcus, is en- countered during the height of the fever in some cases. It usually affects the cerebral cortex, but is much more easily recognized when it attacks the base. It is then indicated by severe headache, sluggish response or 126 PRACTICE OF MEDICINE unequal dilatation of the pupils, rigidity and retraction of the neck, with a tendency to delirium or stupor. Croupous colitis occasionally develops late in the disease. Jaundice appears early in some cases. It is seldom severe in char- acter. The mode of its production is not understood. Some writers regard it as a true hematogenous icterus. Acute articular rheumatism may precede, accompany, or follow pneu- monia, and it is frequently accompanied by endocarditis or pleurisy. Among the rarest complications are acute nephritis, otitis media, croupous gastritis, parotitis, peritonitis, and peripheral nueritis. Ab- scess and gangrene of the lung sometimes follow imperfect resolution. Diagnosis. — Pneumonia is seldom difficult of recognition except in children and very old or feeble patients, too weak to expand the chest and bring out the auscultatory signs. It may be readily overlooked when it develops insidiously during the course of another affection. The attitude in bed, the anxious expression, flushed face with bright red cheek, the chill, fever, pain, rapid pulse with disproportionately rapid breathing, the cough and expectoration of rusty sputum, leave little chance for error in a typical case. When there are added to this the physical signs, particularly the bronchial breathing and the crepitant rale, the picture is complete. In children the diagnosis is often difficult either on account of the predominance of meningeal irritation or the absence of characteristic features. Percussion must always be performed with delicacy in a child in order to elicit the dullness, for a resonant tone may be transmitted from the viscera beyond the area of consolidation, on forcible percussion. An agglutinative reaction has been obtained upon the pneumococcus with the serum of individuals suffering from pneumococcus infection, but its utility as a test for the disease has not yet been demonstrated. Pleurisy and Empyema. — A pleuritic effusion, especially if purulent^ may cause confusion unless the exploratory needle is used. In pneu- monia, however, there is no displacement of the heart or other viscera, as in hydrothorax. The presence of vocal and tactile fremitus cannot be relied upon in the exclusion of pyothorax. Acute pneumonic phthisis runs a slower course, as a rule. The sputum has the prune-juice appearance rather than the rusty color, and the sweating, rapid emaciation, and irregular temperature are distinctive. The delirium is often more constant and more severe than that of pneu- monia. Typhoid fever may begin with rapid respiration and other symptoms suggesting pneumonia, and, on the other hand, the pneumonia patient may sink into a typhoid stupor. The temperature curves are quite different, and the absence of the rusty sputum, the presence of rose- spots, pea-soup stools, a positive Widal reaction, and the absence of leucocytosis in the former disease render the distinction positive in most cases. Prognosis. — Pneumonia is one of the most fatal of the acute infec- tious diseases. The prognosis is modified, however, by the age, sex, and vigor of the patient, and to a very marked extent by his habit as to indulgence in alcohol. In private practice the mortality is usually from lo to 15 per cent, in hospitals from 20 to 30 per cent. In epi- PNEUMONIA 127 demies it often exceeds 50 per cent. The death-rate is very different in different localities, at different seasons, and in different classes • of patients. It is more fatal in the extremes of life. Infants under one year and adults over 65 seldom recover. Alcoholic subjects and the victims of chronic disease are especially liable to succumb. Children almost invariably recover, and the prognosis is generally favorable in robust adults of middle age. Much depends in any case upon the degree of the toxemia, as manifested by high fever, delirium, prostration, and feeble circulation. Diffuse bronchitis adds gravity to the case. Absence or deficiency of leucocytosis indicates feeble resistance on the part of the economy; and increased heart action, cyanosis, or disappearance of the second sound over the pulmonary valve late in the disease are of evil import, indicating a failure on the part of the heart. Death is usually due to an intense action of the toxin upon the heart or central nervous system, or a sudden, fatal dilatation of the right heart, seldom solely from interference with the respiration, even in extreme cases of double pneumonia. A complicating endocarditis is not necessarily fatal, but a meningitis is almost always so. The pulse is not always a safe guide to the prognosis, for a slow, full, compressible pulse often ac- companies the failure of the circulation which precedes death by only a few hours. Prophylaxis. — Comparatively little is known on this subject. Prob- ably too little attention has been given to the danger of communi- cating the disease through careless disposal of the sputum. The fact that in a few instances the nurse has become infected while waiting upon the pneumonic patient suggests the advisability of adopting measures of thorough antisepsis, including destruction of the sputum by fire or steam and thorough disinfection of the apartments after the re- covery of the patient. N. S. Davis, Jr., recommends the use of anti- septic mouth-washes several times a day. Treatment — General. — The treatment of a case is chiefly symptomatic. We have no means of cutting short an attack, and probably none of greatly modifying its course. As Osier remarks, '" Patients are more frequently damaged than helped by the promiscuous drugging which is still too prevalent." Good nursing and the amelioration of symptoms are, however, requisite. The patient should be placed in a quiet, sunlit, well-ventilated room kept at a temperature between 65° and 70° F. (18° — 20° C). Visitors should be excluded. Ordinary ventilation is not enough. The patient should be placed in the open air or directly at an open window when the weather will permit. The relief experienced in a severe case by this treatment is remarkable. Frequent sponging is beneficial for stimulation and for the reduction of temperature. The Brand method, however, has not given good results. The cold pack may be employed, and the warm plunge of 90° F. (32.0° C.) is beneficial to children. The diet should be liquid; milk, broths, gruels, and soft eggs may be given. Plenty of water, plain or carbonated, or lemonade should be given at regular intervals. The patient should under no cir- cumstances be permitted to raise even his head. Food should be adminis- tered through a tube. The bowels should be kept open. A dose of calomel may be given in the beginning, and a saline laxative at intervals during the disease. Tympanites must be immediately relieved by the application 128 PRACTICE OF MEDICINE of turpentine stupes or the adminstration of 5 to 10 drops of turpentine every hour or two, on account of its interference with respiration. The rectal tube will sometimes remove the flatus. Local applications of heat or cold, especially the application of the con- tinuous ice-bag, to the affected side afford great relief. Counter-irritants are still employed by some, blisters are rarely used. The pneumonia jacket, consisting of a thick layer of cotton covered with oil silk, is em- ployed by some physicians, but it is generally better to leave the chest accessible. Bleeding at the beginning of the disease has been found highly beneficial in robust individuals with full, bounding pulse, prom- inent arteries, and high fever. Dry cups, over the affected area, and wet cups afford marked relief when applied early in cases beginning with severe pleurisy and edema of the lungs. Drugs. — The most important of these are the cardiac stimulants, especially strychnin, digitalis, nitroglycerin, and alcohol. Each should be given with reference to the effect obtained, and not by rote. Strychnin should be given hypodermically in doses of gr. 1-60 to 1-20 (o.ooi — 0.003) every three hours unless muscular twitching is produced. Nitro- glycerin, gr. i-ioo to 1-50 (0.0005 — o.ooi), may be given when dyspnea or other symptoms indicate a disproportion between the heart's action and the arterial tension. Digitalis should be given in full doses of the infusion, an active tincture, or fluid extract. Ammonium carbonate, gr. V — X (0.3 — 0.6), and citrated caffein, gr. ij — iij (o.i — 0.2), are often bene- ficial. Veratrum viride, once much in vogue, is employed by some phy- sicians, but should be used with great caution, in 2 to 5 drop doses of the tincture only until the heart's action has become normal. Diaphoretics should not, as a rule, be employed, although they have been thought to reduce sweating and prostration during the crisis if administered before it. Alcohol is highly regarded by some writers. As a rule, its use is unnecessary, if not injurious, and it is inferior to strych- nin, even in alcoholic cases. Quinin is the safest antipyretic. The coal- tar antipyretics are unsafe, as a rule. Creosot carbonate has recently been employed in many cases, with results which apparently justify the claim that it is a specific. It im- mediately reduces the temperature, quiets the cough, and often produces an early termination by lysis or by crisis free from weakness and pros- tration. It should be given in doses of gr. v (0.3), increasing rapidly to gr. XV (i.o), every two or three hours, from the beginning. Tneaiment of Special Symptoms. — Pain must be relieved at the onset, often by morphin hypodermically, and followed with codein at frequent intervals. But the action of an opiate must be watched, lest it produce cardiac depression. Holt regards phenacetin as better than opium for restlessness and cough in children. A single dose in 24 hours is often sufficient. Inhalations of oxygen often assist the patient to reach the crisis. It is administered pure for 1 5 minutes at a time, or, diluted with atmos- pheric air, for longer periods. It must be pure and fresh. Edema of the lungs may be checked by cupping and the administration of atropin, gr. i-ioo (0.0005), with each dose of strychnin, to check secretion. Delirium may be modified by the administration of the bromids in DIPHTHERIA 129 full doses, but morphin, gr. ^ to %, may be required. Stimulation and cold sponging often have a beneficial influence upon it. Saline injections have been employed in severe cases, and apparently with benefit, in carrying the patient over a critical period. From one to two pints of a 7 per cent solution are allowed to flow by gravity through a large hypodermic needle into the subcutaneous tissue. Serum Treatment. — If the theory be true that the crisis announces the victory of the antitoxin produced by the system over the toxin of the disease, there is much reason to hope for a successful serumtherapy. The results obtained in this direction have been encouraging. The serum of Pane, obtained from the larger animals, is injected into the subcu- taneous tissue in the quantity of from 40 to 120 c.c. in 24 hours. In- travenous injections have been made in a few instances. The serum of convalescents has also been employed. DIPHTHERIA. DIPHTHERITIS, ANGINA MALIGNA,, PUTRID SORE-THROAT. Definition. — An acute infectious disease occurring sporadically or epi- demically, caused by the Klebs-Loffier bacillus, and attended with a fibrinous exudate on the mucous membrane of the pharynx and upper respiratory passages and symptoms of toxemia. Etiology. — The Klebs-Loffler bacillus is constantly found in the pseu- domembranous deposit on the throat, and is recognized as the spe- cific cause of the disease. Diphtheria is endemic in most of the cities and towns of the United States and frequently becomes epidemic during the winter season. Sporadic cases occur and are often virulent in char- acter. The disease is encountered in all climates and its spread is favored by the cold of winter and spring. It is highly contagious and may be contracted by direct contact. It has frequently been conveyed by kissing, and physicians have been repeatedl}^ inoculated by injudicious attempts to clear by suction an obstructed trecheotomy tube, or by having the membrane coughed into their faces while examining or treating the throat. The infectious agent may be carried b)^ clothing, bedding, hand- kerchiefs, drinking-cups, hair, shoes, pencils, and other articles from the sick-room, but probably not by the air or by sewer-gases. So far as known, it is carried by pet animals onl)^ in their fur. The so-called diphtheria of animals and birds is generall}^ due to other bacteria than the diphtheria bacillus. The bacillus is so tenacious of life when protected from light and air that it has been known to retain its virulence for several months, and to remain alive in the throat for almost a year. It grows freely in milk, and cases have been traced to this source. It may be carried in the throat of a healthy individual without producing any disturbance for days or weeks. As W. H. Park remarks, " W^en we consider that it is only the severe cases of diphtheria that remain isolated during their actual illness, the wonder is not that so many, but that so few, persons contract the disease." The bacilli are believed to enter the system only through inhalation, by being conveyed in some other manner to the mouth, or b}'^ the inoculation of an abraded surface in some other part of the body. 9 130 PRACTICE OF MEDICINE Age is an important factor in susceptibility. A large majority of cases occur between two and fifteen ; the period of greatest susceptibility appears to be between the third and tenth years. The disease seldom occurs in infants or in adults after the thirtieth year, but A. Jacobi has seen it in the new-born and in a man of 86 years. Some individuals and some families are undoubtedly more susceptible to infection than others. Epidemics vary greatly in severity. Caille emphasizes the im- portance of enlarged tonsils, chronic nasopharyngeal catarrh, carious teeth, and an unhealthy condition of the mucous membrane of the mouth and throat as predisposing causes. Immunity.— ^oraQ degree of natural immunity is probably possessed by many persons, else the disease would be much more prevalent than it is. It probably depends upon the inability of the bacillus to pene- trate into a healthy mucous membrane. An attack of the disease confers immunity for an indefinite, but probably short, space of time. Second attacks have frequently been seen after a few months. Golay reports a case in which the bacilli were constantly present in the throat of an individual for 362 days, during which time he had three acute attacks. Bacteriology. — The diphtheria bacilli, as they are usually found in the false membrane of diphtheria, are straight or slightly curved, nonmotile rods from 1.5 to 6.0/i in length and from 0.5 to 0.8/i in thickness, with rounded or clubbed extremities. They are not usually uniformly cylin- drical, but are thicker at one end, or swollen in the middle and more slender at the ends. They are sometimes found in pairs, rarely in chains. What appear to be branching forms are sometimes seen. The bacillus is an aerobe, but varies greatly in morphology and other qualities under different methods of cultivation. It is very resistant to extrem.e cold, but readily succumbs to a temperature of 58° C. The usual stain for it is Loffler's methylene-blue solution. Neisser's differential stain should be employed to distinguish the true bacillus from the pseudobacillus. It is almost the rule to find in the false membrane also streptococci, staphylococci, or pneumococci. The streptococcus pyogenes is usually found in suppurating glands when they occur in this disease. False JDiphtheria.—Ot\iGr bacteria besides the Klebs-Loffler bacillus are capable of producing pseudomembranous inflammation. Some of these are almost constantly to be found in the secretions of the throat, and only under favorable circumstances produce lesions similar to those of diphtheria. The streptococcus and pneumococcus most frequently act in this capacity. In false diphtheria, these forms are sometimes found, but in many cases a pseudodiphtheria or diphtheroid bacillus occurs which is different in morphology and culture from the Klebs-Loffier ba- cillus. Morbid Anatomy. — The distinctive lesion of the disease is the pseudo- membrane, which consists of a fibrin reticulum inclosing in its meshes leucocytes in a state of hyalin degeneration, degenerated epithelial cells, and occasionally a few erythrocytes. The membrane dips deeply into the epithelial layers of the mucous membrane, but does not invade the submucosa. The mucosa undergoes rapid degenerative changes and necrosis. A change occurs in the deeper tissues, also, which is in part due to degeneration, in part to infiltration; necrosis may occur in them. The bacilli are usually found in the membrane, and they alone are charac- DIPHTHERIA 131 teristic of the diphtheritic membrane. Other cocci are generally present. The false membrane is more frequently found upon the tonsils. It is rarely confined to them, but in more than half the cases it is limited to the tonsils and uvula. It often spreads from these to adjacent surfaces. It may invade, primarily or secondarily, the pharynx, nasal chambers, larynx, trachea, and bronchi, involving the entire surface, or pass for- ward over the soft palate and pillars to the mucous membrane of the entire mouth ; occasionally even over the lips to the face. The membrane has rarely been found in the esophagus, stomach, rectum, bladder, va- gina and puerperal uterus, and on the external genitals of both sexes. Its character varies. It is, as a rule, thick, tough, and elastic, usually laminated, rarely thin, but always firmly adherent except in the larynx. It may be an eighth-inch thick. After death it becomes soft and friable. The capillaries and smaller blood-vessels in the vicinity show hyalin degeneration. The heart is usually flabby, the right ventricle or both dilated. The myocardium generally shows fatty or other degeneration. There may be also degeneration or necrosis of the endocardium, and thrombi may be found in the chambers. ^ The Lungs. — Bronchopneumonia is commonly found. There may be also marked congestion, edema, and atelectasis. Thrombi are sometimes found, and there may be gangrene of the lung. The bronchi are generally involved and may contain a membranous exudate. The bacilli are often found in greater numbers here than in any other region affected. Dilatation of the lymph-vessels is also common; they may be densely filled with lymph and plasma cells. The cervical glands are enlarged to some extent in almost all cases, but markedly in only about a third of the cases which involve the throat. The tissues about the glands are sometimes edematous, and the submaxillary gland may be swollen. The liver and spleen show the usual changes arising from toxemia. Kidney changes varying from slight degeneration to intense acute ne- phritis are found in all fatal cases. The lesions are most pronounced in the rapidly fatal cases. Nervous System. — It is in the nervous system that the most prom- inent results of toxemia are usually found, and more particularly in the nerve-trunks of the central system. The change begins in the myelin sheath at some point near the axis cylinder, and gradually extends around and along it. The lesions are essentially those of neuritis and may be found anywhere in the nervous system. Symptoms. — General. — The period of incubation varies from two days to a week, but is seldom more than four days. The initial symptoms vary remarkably in severity. The onset is seldom marked by more than slight indisposition. Vomiting, rarely a convulsion, may occur in young children, and the prostration is often out of proportion to the other indications of illness. General muscular soreness and stiffness of the neck are occasionally observed. The symptoms are generally proportion- ate to the extent of surface invaded by the membrane, but the rule is not without many exceptions. In some cases the constitutional symp- toms are intense without recognizable membrane-formation, and in some of the most extensively membranous cases the systemic disturb- ances are exceptionally sHght. The patient is generally pale, the face 132 PRACTICE OF MEDICINE often has an ashen hue. If a child, it becomes languid or fretful and restless and it may complain of headache, loss of appetite, and nausea. It may later pass into a stupor or become delirious. In many cases, however, the mind remains clear throughout the disease, although se- vere. The tongue has a white coat and the breath is offensive. There is usually an urgent thirst. The constitutional symptoms are generally more pronounced in adults than in children, although the membrane- formation is usually less extensive. They become more prominent as the disease reaches its height, and are especially severe when necrosis and sloughing occur. The temperature is not usually high. In the majority of uncomplicated cases it does not reach 102° F. (39.0° C.) at any time, very often it does not exceed 101° F. (38.5° C.) and the fever may subside in 48 to 7 2 hours. Instances of subnormal temperature are not infrequent. The pulse is accelerated out of proportion to the temperature and frequently reaches 150 or 160 in children. It may reach 180. In cases character- ized by great cardiac weakness, however, it often becomes as slow as 40 or 50. In some cases the disease begins with early elevation of temperature, marked nervous manifestations, and it may terminate fatally within a few days from the intensity of the toxemia. Dyspnea is present in many cases, particularly when the larynx is involved ; it may, however, result from disintegration of the red blood-corpuscles by the toxins, from degenerative changes in the heart, or from a sudden spasm or paralysis of the vocal cords. " The heart is probabl}^ affected in every case of diphtheria" (Jacobi). Either tachycardia or bradycardia is a feature of almost all severe cases. A systolic murmur is heard in about 10 per cent of cases, usually at the apex, and the pulmonic second sound is often accentuated. Since endocarditis is not common, this sound is probably due to relaxation. Cardiac dilatation frequently precedes a fatal issue. The nervous system is profoundly affected by the toxins. This is shown, not only by the frequency of psychical depression, but also by the development of paralysis in about 10 per cent of cases. These are more fully considered under the head of Complications. Moderate albuminuria, due to the irritation of the kidneys by the toxins, appears frequently on the second day of the disease, or later, in a majority of cases. Hyalin and granular casts are often present, usually appearing later as a result of the obstruction of respiration. The cervical glands usually become enlarged, and the tissues about them are edematous. The voice becomes nasal. The blood-count reveals moderate leucocytosis in all cases. The count of polynuclears and mononuclears is shown to be characteristic and important by Besredka. In all but the most fatal cases the former type of cells is much increased, while a decrease in the mononuclears is always observed. There is a deficiency of red cells amounting to from 500,000 to 2,000,000 in the c.mm. and the hemoglobin is reduced from 12 to 25 per cent. The membrane usually remains attached for 5 or 6 days, and, grad- ually becoming detached around the edges, soon separates, leaving a de- nuded surface or superficial ulceration. The swelling and glandular en- DIPHTHERIA 133 largement rapidly subside, but the convalescence is often slow and may be markedly interrupted by the most distressing complications. In fatal cases the temperature may subside while the pulse becomes more rapid, irregular, and feeble or extremely slow, 50 or less. The action of the kidneys may fail; the urine becomes scant and highly albuminous, and uremia develops. Other cases terminate fatally on account of pulmonary edema, collapse, or bronchopneumonia. Sudden death from paralysis of the heart has been repeatedly observed, partic- ularly as a result of excitement or exertion during convalescence. Varieties of Diphtheria. — In addition to the symptoms just enumer- ated, others occur which depend, for the most part, upon the location of the disease. Tonsillar or Pharyngeal Diphtheria. — The first complaint is usually of soreness or dryness of the throat upon swallowing or speaking. When the tonsils are first affected there is usually a slight rise of temperature, rarely exceeding 101° F. (38.5° C). The tonsils at first appear slightly enlarged, intensely hyperemic, and on the surface of one or both there is one or more small patches of a gi-ayish membrane. The uvula, the pillars, and the pharynx are usually congested. If an examination is made only a few hours later, the membrane may be found to have spread over the entire surface of the tonsils, and new patches may have developed on adjacent surfaces. Swallowing and speaking rapidly become more difficult and painful, and the symptoms of prostration more pronounced. The cervical glands are enlarged and sensitive, but less so than in ton- silitis. In other cases the exudate remains confined to the tonsils or spreads to but a limited area of the adjacent mucous membrane; little or no pain is complained of and the adenitis is slight. Maligjtant cases not infrequently occur in which the extension of the membrane is extremely rapid and the constitutional disturbance most profound. Within the first 24 hours the entire surface of the tonsils, the sides of the pharynx, the uvula, and soft palate are covered with a heavy exudate, and the glands of the neck become enormously enlarged. The temperature may be but slightly elevated; it may even be sub- normal, but the heart's action is rapid and feeble or slow and irregular. Stupor develops and the case terminates fatally within three or four days from toxemia. In other malignant cases the membrane, although not extensive in its invasion, has a foul, necrotic appearance, giving the breath a sweetish, fetid odor. The adjacent tissues for a consider- able distance may be involved in the necrosis, and symptoms of sepsis often supervene. The tongue becomes dry, the temperature runs up to 104° or 105 °F. (40°— 40.5° C), the pulse is rapid and feeble, the ex- tremities become cold. Death may result from exhaustion or from the supervention of bronchopneumonia. Atypical cases are not infrequent, in which: (i) The mucous mem- branes of the throat are intensely hj^peremic and edematous, but no pseudomembrane is formed. (2) The membrane may be punctate in form, remaining confined to small, isolated areas. In either of these forms the exudation may rapidly form or suddenly assume an active growth and spread with great rapidity into the nares or larynx. (3) The exudate may be soft and creamy or pultaceous in character. Laryngeal Diphtheria. — WTien primarily affecting the larynx the dis- 134 PRACTICE OF MEDICINE ease begins with hoarseness and a harsh, croupy cough. By the second or third day there may be complete aphonia, stridulous respiration, a shrill, whistling cough, and the most alarming dyspnea, and cyanosis, with great restlessness. When the laryngeal involvement is a result of the extension of the disease from the pharynx, these symptoms are added to those already described. As the disease advances, the signs of ste- nosis become extreme. The accessory muscles of respiration are called into play. Rigidity of the sternomastoid muscle is an early indication of it (McCollom). The nostrils vibrate, the supraclavicular and inter- costal spaces sink with each inspiration, cyanosis becomes extreme. The child sits up and gasps for breath until exhausted or overcome by the suffocation, then falls back, possibly to doze for a moment, but not to find relief. The detachment of a fragment of the membrane by cough- ing affords a short respite, but the membrane is soon replaced and the dyspnea returns. The constitutional symptoms soon become intensified. The temperature often rises to 103° F. (39.5° C.) and the action of the heart may suddenly cease. The patient may sink into a coma or die of exhaustion. Bronchopneumonia follows this type of the disease oftener than any other. Fortunately, under present methods of treat- ment these extreme cases are seldom encountered. Nasal diphtheria may develop primarily or as an extension from the disease of the pharynx. It is much more frequent in children than in adults. It is usually characterized by mixed infection. The initial sympn toms may be those of an acute nasal catarrh. The nostrils become obstructed and a thin, mucopurulent, sometimes sanguinolent, irritating fluid flows from them. Sneezing is caused by the irritation, and the lips become excoriated. Distinct enlargement of the glands at the angle of the jaw and of the submaxillary glands is developed early. In one group of cases the nostrils become completely filled with a thick membranous formation (fibrinous rhinitis), while in another class they are obstructed by the intense hyperemia and swelling, without an ex- udate. In the former class the constitutional disturbances are often slight and recovery occurs in the usual time, while in the other class the system may become charged with the toxins and the disease may assume a malignant character. The bacilli are usually numerous in the membrane or discharge, and great numbers of other micro-organisms are also found, particularly streptococci and staphylococci; sometimes the yellow sarcina, the bacilli subtilis and proteus are present. The inflammation frequently extends to the Eustachian tube and middle ear or to the antrum, occasionally through the lachrymal ducts to the con- junctivae. Diphtheria of Other Parts. — Primary diphtheria very rarely attacks the conjunctiva, producing a catarrhal or membranous inflammation. The globe is sometimes perforated in a single day. The presence of the Klebs-Loffler bacillus establishes the identity of the disease. This organ- ism may alone be present, or the infection may be of a mixed character. The external auditory meatus is sometimes the seat of the disease, which is generally a secondary involvement from the middle ear. Diphtheria of the skin is generally confined to the regions about the mouth, but it may be conveyed by the fingers of the child to more remote parts, particularly to the external genitalia and the anal region. DIPHTHERIA 135 Wounds are occasionally infected, producing either a superficial inflam- mation, occasionally accompanied by necrosis, or the formation of a false membrane. Thee onstitutional symptoms of wound diphtheria are usually slight, but paralysis sometimes follows it. Complicaiions and SequelcB. — Hemorrhage sometimes occurs as a re- sult of ulceration in the nose or throat, especially in the nasal form of the disease. It is encountered also in malignant cases, probably as a result of profound blood changes, in the nature of toxemia. Pneumonia. — Bronchitis frequently develops as early as the first or second day of the disease, especially in laryngeal cases. It may be delayed until after the beginning of convalescence. Pulmonary collapse or bronchopneumonia sometimes results from it. The diagnosis is often difficult, for all of the usual signs may be obscured by the great restriction of respiration, deficient expansion of the chest, and the loud noises produced in the larynx. Aii increase of temperature, accompanied by marked rapidity of breathing, usually indicates the condition. Lo- bar pneumonia is rare. An aspiration pneumonia, which may ter- minate in gangrene of the lung, may be induced in cases attended with extensive sloughing or a soft pultaceous membrane. Heart-failure is one of the most dangerous complications. It is most likely to develop after the membrane has become detached, and the danger continues great from the third to the fifth week. Cases in which the appearance is most indicative of anemia are most liable to it. The asthenic condition of the heart may be recognized by the slowness, irregularity, and weakness of the pulse, as well as by cyanosis and oc- casional attacks of syncope. In some cases apparently progressing favorably such slight exertion as sitting up or vomiting or the excite- ment occasioned by the visit of a friend causes the heart to become extremely erratic in its action or to suddenly stop. Similar accidents may happen even during the first week. Hibbard found degenerative changes in the vagus in all fatal cases of heart-failure. Paralyses (postdiphtheritic paralyses), due to toxic neuritis, occur in about i o per cent of cases. They generally develop during the second or third week, but may occur as early as the seventh day or as late as the sixth week. They may be either local or multiple, unilateral or symmetrical. They follow the mildest attacks with apparently as much certainty as the most severe, but are more frequent in adults than in children. The symptoms produced in the multiple form are exceed- ingly variable in character, depending upon the nerves aff"ected. One of the most common local paralyses is that of the uvula. This is attended with difficulty in swallowing, regurgitation of food through the nose, and a nasal tone of the voice. The palate is relaxed, and the uvula appears elongated and dependent. The constrictor muscles of the phar- ynx are sometimes involved in the paralysis. Either the extrinsic or the intrinsic muscles of the eye may be paralyzed, causing ptosis, stra- bismus, or a loss of the power of accommodation. Facial paralysis sometimes occurs and may prove to be persistent. In some of these cases a paraplegia or a paralysis of the arms is associated with that of the muscles of the eye or of the throat. The termination is usually in recovery, except when the heart or the muscles of respiration become involved. One or both of either the upper or lower extremities may 136 PRACTICE OF MEDICINE become partially or completely paralyzed, without the involvement of other parts. A solitary paralysis of the bladder has been recorded in one instance. Nephritis. — Albuminuria is a constant feature of severe cases. The quantity of albumin present may be a mere trace and is probably due to the irritation of the kidneys by the toxins or to the fever. Actual nephritis is not a frequent complication. When present, it is indicated by a marked reduction in the quantity of urine voided, rarely by total suppression, a large percentage of albumin, and epithelial and blood casts. Edema is seldom a feature of diphtheritic nephritis. The prognosis is generally favorable. Septic infection not infrequently occurs in the more malignant cases, as a result of extensive necrosis and sloughing of tissues. A septic in- fection of the joints and other parts is sometimes observed. Cutaneous eruptio?ts are sometimes observed. Erythema and urticaria are the more frequent types. Several cases of gangrenous stomatitis and vulvitis (noma) have been reported in which the diphtheria bacillus was found. Diagnosis. — The discovery of the Klebs-L5ffler bacillus is the only means of making an absolutely positive diagnosis of the disease. When this is found in a throat that is inflamed, whether or not a membranous formation is present, it indicates in almost every case that the individual is suffering from diphtheria, and even more positively that he may prove a source of infection to other persons. Diphtheria does not exist without the bacilli, but these may be overlooked for a time, and it should be borne in mind that the bacilli have been repeatedly found in the throats of healthy children and adults. There is no other disease in which bacteriological examination is so important. The health de- partments of all the larger cities and of many villages recognize this fact and provide for the examination free of charge of all specimens submitted. In most places an examination of the secretions from the throats of all suspicious cases, by an official bacteriologist, is required by law. The examination may be made directly from the throat, but it is ordinarily so diflEicult and requires so much experience and skill that it is customary to make it from a culture. The throat appearances in diphtheria are more or less typical and are usually sufficient to establish a tentative diagnosis when accom- panied by the usual symptoms, and more particularly when the disease is epidemic in the locality. The diphtheritic membrane is gray or yel- lowish gray in color. It does not rest lightly upon the surface, but has the appearance of having grown from the mucous membrane. It cannot be detached by ordinary rubbing with a swab, while the mem- branous formations produced by other bacteria, with the exception of Vincent's bacillus, are generally removed without much difficulty. (For- cible removal should not be attempted, on account of the danger of increasing the infection.) The extent to which the surfaces are ihvaded by the disease is also of value. As a rule, the more extensive its for- mation, particularly if it cover the entire surface of the tonsils and begin to invade other regions, the more positive is the diagnosis of diphtheria. The appearance of membrane in the nose is almost invariably due to this disease. DIPHTHERIA 137 The hyperemia of the tissues surrounding a membrane-formation is seldom, if ever, so intense in any other condition as it is in diphtheria. An intense hyperemia of the throat without discoverable membrane should be regarded as diphtheritic until the presence or absence of the bacillus can be determined. The absence of such hyperemia strongly indicates the nondiphtheritic character of a membranous formation, but should not be too implicitly relied upon. Paralysis following an inflam- matory condition of the throat, with or without membrane, is usually proof that the case was one of diphtheria, although cases have occurred in which the Klebs-Loffler bacillus had not been discovered. The symptoms presented by the patient are also of value. In many cases the mild fever, rapid pulse, and great prostration, taken in con- nection with the throat symptoms, leave no justifiable doubt of the diagnosis. A history of exposure may be of great value in making an early diagnosis. It is very often expedient and sometimes imperative to make a positive diagnosis from the clinical manifestations, and not to delay the treatment until a bacteriological examination can be made. Prognosis. — The physician is never justified in pronouncing an un- qualifiedly favorable prognosis in this disease. The mortality has been reduced since the introduction of the serum treatment from over 40 per cent to less than i o per cent, but epidemics diff'er greatly in severity, and there is no means of foretelling the course of an individual case. The disease is not always less severe in robust children, but convalescence is usually more rapid and more complete. The younger the child, as a rule, the more unfavorable is the outlook. The highest mortality is seen between the second and sixth years. Unusually extensive membrane- formation reduces the chances of recovery. Laryngeal diphtheria is al- ways extremely dangerous. In the nasal form the cases accompanied by a sanguinolent discharge without membrane are the most unfavorable. Extreme adenitis is unfavorable. The presence of a mixed infection always increases the gravity of the case. Streptococci are particularly dangerous, by increasing the liability to sepsis. Absence of polynuclear leucocytosis was noted by Besredka only in fatal cases. Weakness and irregularity of the pulse are of evil import. A rapid pulse with low tem.perature is equally grave. The fatal termination of a case may be due to paralysis of the heart, pulmonary collapse, bronchopneumonia, general sepsis, or toxemia. The mortality independently of such complications depends almost as much on the promptness with which the serum treatment is instituted as upon the type of the disease. Malignant cases are now and then encountered, however, which run a rapidly fatal course under the most careful and skillful treatment. Serious, even fatal, accidents may occur as late as the fifth or sixth week. The danger of paralysis is not passed for at least two months, but paralysis usually ends in com- plete recovery. Prophylaxis. — The patient should be isolated in a room from which all unnecessary furniture, carpets, and hangings have been removed. Thorough ventilation and a uniform temperature of about 70° F. (21° C.) should be maintained. The atmosphere should be kept moist by steam generated from a suitable vessel in the room. The vapor of turpentine, carbolic acid, or benzoin is thought to be beneficial. A special nurse should be in charge, and she should neither mingle with the other X3S PRACTICE OF MEDICINE members of the family nor permit them to enter the sick-chamber. The physician should exercise the same precautions in his visits as in other contagious diseases, wearing a gown and cap and disinfecting his hands and face after leaving the room. The child should expectorate into a vessel containing a strong disinfectant solution (corrosive sublimate I :5oo) or upon patches of muslin that can be immediately burned. Infection from the secretions of the throat is possible for a month or longer in some cases, hence isolation should be maintained until bacteri- ological examination no longer shows the presence of bacilli. It is no less important to isolate mild cases and those in which the diagnosis is for the time uncertain. It is good practice to separate all cases of sore throat from the other members of the family, even when the case is not regarded as diphtheritic. The members of the family who have been ex- posed to the contagion should be kept at home, and, together with those who will come into contact with the case, may be still further protected by the administration of a prophylactic injection of from 200 to 1,000 units of antitoxin. This will protect for about two weeks, when it should be repeated. The nurse and attendants should gargle their throats several times a day with an antiseptic solution, preferably one containing i : 10,000 of corrosive sublimate. After the recovery of the patient the premises should be thoroughly disinfected, as after other infectious diseases. Treatment — General Management. — The diet of the patient should be liquid in character — milk, broths, soups, albumen-water, and ice-cream, with an abundance of cold water. Holt recommends that nursing infants be fed the milk obtained from the mother's breast by means of a breast-pump; they should not be put to the breast. Forced feed- ing by means of a soft tube passed through the mouth or nose must be practiced when, in the later stages of the disease, the patient refuses nourishment or when the muscles of deglutition have been paralyzed. Every measure for the support of the patient's strength should be adopted in the beginning. Brandy (from i to 6 ounces in 24 hours) and strychnin, gr. i-ioo to 1-40 (0.0006 — 0.0016), t. i. d. or oftener, should be administered as soon as asthenia becomes apparent. When the heart's action is rapid, and when it becomes weak or irregular, cafifein or digitalis in small doses should be given in addition to the strychnin. The tincture of strophanthus (gtt. ij to v) probably acts more promptly than digitalis. When syncope develops, ammonium car- bonate and camphor or musk are indicated. When heart-failure threatens, the patient should be kept absolutely quiet. It is safer in this con- dition to secure rest by the hypodermic administration of morphin every few hours, in sufficiently large doses to keep the patient drowsy. Paral- ysis of respiration may be so sudden in its onset that nothing can be done, but in a few instances several days of persistent treatment, con- sisting of the administration of strychnin in full doses for the age, at short intervals, the application of the galvanic and faradic currents, and artificial respiration when occasion required, have been rewarded with the recovery of the patient. The internal administration of remedies for the purpose of antag- onizing the disease is of doubtful utility. A. Jacobi and others highly recommend the administration of mercury, preferably the bichlorid in DIPHTHERIA 139 small doses, gr. 1-60 (o.ooi), often repeated. It should be given in a small quantity of water. Some writers prefer calomel, gr. y^ (0.008), dropped upon the tongue without water. Pilocarpin is thought to hasten the elimination of the toxins, but is seldom employed. Large doses of the tincture of the chlorid of iron, quinin, and a host of other probably useless remedies are employed by many physicians. Emetics are sometimes given to strong, vigorous children to assist in the re- moval of the membrane, particularly in laryngeal cases, when a flapping sound indicates that it has become partially detached, or when suffoca- tion threatens. Antipyretics are seldom required, and those of the coal- tar group should not, as a rule, be employed. The temperature may be more safely reduced by cold sponging. The complications are treated in the same manner as if they were independent affections in a debilitated patient ; special methods are there- fore to be adopted for bronchitis, pneumonia, nephritis, otitis, and other affections. Local Treatment. — Local measures are less relied upon than they were before the introduction of antitoxin ; possibly they are too much neglected. They should be employed with a view to cleanliness and the prevention of such complications as aspiration pneumonia or involvement of the larynx, rather than with a view to overcoming the disease. In very young or nervous children, when it is apparent that more worry and exhaustion is produced by persistence in local applications than is com- pensated for by any possible benefit, it is often wise to omit all local applications. Numerous antiseptic solutions have been recommended for use by means of a cotton swab, spray, or irrigation. The last method is usually preferred in nasal diphtheria. For swabbing, the solutions most used are : Mercuric chlorid (i :iooo), hydrogen peroxid (i 15), and Loffler*s solution (menthol, 10 grams, dissolved in sufficient toluol to make 36 c.c. ; liquor ferri sesquichloratis, 4 c.c. ; and absolute alcohol, 60 c.c). For irrigation the solutions should be much diluted, or less irritating so- lutions, as Seller's alkaline antiseptic solution or boric acid, may be employed in large quantity. Nasal hemorrhage sometimes prevents ir- rigation for a time, or astringent solutions of alum or of the chlorid or subsulphate of iron (Monsel's solution) may be employed. It is claimed for aqueous solutions of the various preparations of papaya and trypsin that they dissolve the diphtheritic membrane. A solution of lactic acid is still employed by some physicians, although it proba- bly has no specific action. Antitoxin Treatment— The diphtheria antitoxin should be adminis- tered at the earliest possible moment, for the results are better in pro- portion to the promptness with which the treatment is instituted. Statistics show that the mortality is three times as great when the treatment is begun on the third day, and five times as great when it is begun on the fifth day, as when on the first. It should be given in all forms of the disease, and in sufficient quantity to subdue the action of the toxin. It is only in the mildest cases that the physician is justi- fied in waiting for the result of the bacteriological examination. If the case appears at all severe, the injection should be given at once, for it is better to err on the safe side, and no harm can be done if the disease I40 PRACTICE OF MEDICINE proves not to be diphtheria. Unfortunately, a time is reached in every severe case after which the use of the serum is of comparatively httle benefit. This time limit may be three or four days, or it may be only six or eight hours, and we have no means of determining which it will be in any case. The dose of antitoxin is measured in units. Each unit represents the quantity required to counteract ten times the minimum dose of diphtheria toxin necessary to kill a guinea-pig weighing 250 grams. It is not possible to determine the quantity of toxin that is to be antagonized in a case of diphtheria affecting a human being, hence the quantity to be administered must be determined by the effect that is produced. The syringe should be large enough to hold the entire quantity for one injection, and it should be so constructed that it can be thoroughly sterilized by boiling in a 5 per cent solution of carbolic acid before each injection. The serum is usually injected into the cellular tissue of the loin or gluteal region. From 1,500 to 2,000 units are gener- ally given as the first dose in an ordinary case, except in an infant, when from 500 to 1,000 units may be sufficient. If the case is one of unusual severity, or if it be accom.panied by signs of laryngeal stenosis, from 3,000 to 5,000 should be given at the outset. The beneficial effects— an amelioration of all the symptoms, including a reduction of tempera- ture and pulse-rate— are usually apparent within a few hours. If after ten or twelve hours there is no distinct improvement, or if the membrane is found to have invaded new areas, the injection should be repeated, and as many subsequent doses may be given as the case demands. It is seldom that more than three injections are required in a case in which the treatment has been instituted early. The serum treatment is never more imperative!}- demanded at the earliest moment than in laryngeal diphtheria. Here it should be em- ployed at the first evidence of inspiratory or expiratory obstruction, even when no membrane can be seen. The only outward effects of the antitoxin treatment are : an immediate rise of the temperature in a few cases, a cutaneous eruption, or the formation of an abscess at the point of injection. In from 5 to 20 per cent of cases there is an eruption of urticaria affecting the skin immedi- ately around the needle wound, or rarely spreading more or less generally over the entire body. This disappears within a few days. Sometimes, when the eruption is general, it resembles that of scarlatina or measles. It may appear as early as the second day or as late as the fifteenth ; it may be accompanied with fever and pain in the joints for two or three days, and is often followed by a profuse desquamation. The antitoxin treatment is of benefit only in true diphtheria. Its action is limited to the neutrahzing or antagonizing of the toxin pro- duced by the Klebs-Loffier bacillus, and it is absolutely useless in strep- tococcous or other forms of infection. If after the first injection the bacteriological examination proves to be negative, the dose should not ordinarily be repeated. But in a severe case, and particularly if benefit has followed the first dose, it is better to repeat the dose on the sup- position that some unavoidable accident has prevented the discovery of the bacillus, a supposition that not infrequently proves correct. Treatment of Laryngeal Diphtheria. — In addition to the methods that have been described, some writers advocate the inhalation of the fumes DIPHTHERIA i^i of subliming calomel, produced by dropping about 20 grains of the drug on hot coals if a special apparatus is not at hand. Inhalations of steam, alone or with the addition of such volatile substances as ben-^ zoin, turpentine, carbolic acid, or eucalyptol, are undoubtedly beneficial. They are administered by erecting an improvised tent, for which a sheet or blanket will answer, over the child. Steam may be generated by slowly pouring water on a heated brick or iron at the side of the tent. The calomel fumes are not thought to exert any action upon the bacillus, but only to favor the detachment of the membrane, and should not be used too freely. Intubation. — If the methods that have been described do not aliford relief, intubation of the larynx may become necessary. It should not be too long delayed, but, on the other hand, it should not be too readily resorted to, for the introduction of the tube in no way limits the ex- tension of the disease, and if in any manner an abrasion is produced by the introduction of the tube, an additional point for infection is es- tablished. As a rule, frequent or persistent attacks of cyanosis indicate the necessity for a resort to intubation. The intubation outfit consists of a set of gold-plated or hard-rubber tubes of different sizes, a holder for their insertion, and an extractor. The mouth of the child is held open by a small gag and the tube, grasped with the holder, is guided back over the epiglottis by the finger of the operator and gently passed into the larynx. The instrument may sometimes be worn for several days. If no accident happen, it should be allowed to remain for five or seven days from the beginning of the stenosis; but if it becomes ob- structed, it must be immediately withdrawn, cleansed and replaced with as little delay as possible. The tube is sometimes coughed out of place and may pass into the esophagus. It must then be withdrawn by means of a thread which is always attached to it. Some children are able to take fluid, or, better, semi-fluid nourishment, while the tube is in place. To attempt this, they should be held face downward, or with the body inverted. Occasionally a child can drink in the ordinary way, but it is generally safer to use a tube. This failing, the food must be introduced through a small, soft stomach-tube passed through the mouth or nose. McCollom objects to nasal feeding, on the ground that it favors infection of the middle ear. The atmosphere of the room should be heavily im- pregnated with moisture while the child wears the tube. Tracheotomy is now seldom resorted to until intubation has failed to afford relief, or until the membrane has extended into the trachea and relief is no longer to be expected from intubation. In country prac- tice, where the physician cannot respond promptly in the event of an obstructed tube, the operation may be deemed a safer procedure. Un- fortunately, the benefit to be hoped for from tracheotomy in many of these cases is but temporary, on account of the extreme growth of mem- brane or the development of such complications as edema of the lungs or bronchopneumonia. DIPHTHEROID. PSEUDODIPHTHERIA, MEMBRANOUS CROUP, StREPTOCOCCOUS DIPHTHERIA. Definiiion. — An acute infection, or group of infections, closely resem- bhng diphtheria in local and general symptomatology, but distinguished from it by the absence of the Klebs-Loffler bacillus. 142 PRACTICE OF MEDICINE Etiology. — The afifection is generally caused by the streptococcus py- ogenes alone or in association with other bacteria. The pseudo-diph- theria bacillus may be present, but it is not of known etiological im- portance. One of the most important, perhaps, is the bacillus of sputum septicemia. The affection most frequently occurs as a compli- cation of the acute infectious diseases, notably scarlet fever, measles, erysipelas, typhoid fever, or whooping-cough, but it is occasionally pri- mary. It is sometimes incited by the inhalation of hot steam, the fumes of ammonia, arsenic, corrosive sublimate, or other irritating substances. Morbid Anatomy. — A membrane is formed which is identical with that of diphtheria, except that the specific bacillus is absent. The ex- udate is most frequently found in the larynx, but it is sometimes con- fined to the tonsil, or it may affect all the surfaces usually involved in diphtheria. The membrane is, however, more loosely attached to the mucous membrane. In some cases, too, just as in diphtheria, membrane- formation is wanting, and there is only an intensely hyperemic surface; and in other cases, again, there is a soft, pultaceous formation. General streptococcous infection of a severe type sometimes follows the local phenomena. The symptoms are those of diphtheria, but they are generally less severe in character. Severe attacks are occasionally met with, however, and death has repeatedly occurred in cases regarded as of this char- acter. The affection usually lasts about a week. Albuminuria is sel- dom present, and other complications are infrequent. The treatment is that of diphtheria affecting the same region, but without antitoxin. In laryngeal cases inhalations of steam are of the greatest value. Intubation may become necessary in severe cases. The antitoxin of diphtheria is entirely without beneficial influence, but should be employed in a severe case if there is the possibility of an error in diagnosis. WHOOPING-COUGH. PERTUSSIS, TUSSIS CONVULSIVA. Definition. — ^An acute infection characterized by paroxysms of a convulsive cough followed by a long-drawn sonorous inspiration or whoop. Etiology. — The disease is usually conveyed by contagion. It may be contracted by brief contact with a patient. It is seldom conveyed by a third person, but clothing and houses apparently become infected. The poison is much less virulent than that of measles or scarlet fever. The sputum and probably the breath convey the contagion. Bacteria have been found in the sputum by different investigators. Koplik found a short, slender, facultative, anaerobic, motile bacillus, probably first described by Afanassieff, in 13 of 16 cases, and Czaplewski and Hensel found one which they regarded as the same in all of 44 cases examined. Absolute immunity is usually conveyed by an attack; natural immunity is rare. Sporadic cases occur at all seasons, but epidemics are more frequent in winter and spring. They frequently precede an outbreak of measles, less frequently that of scarlatina. Epidemics last two or WHOOPING-COUGH 1 43 three months. About 50 per cent of the cases occur during the first two years of Hfe. It sometimes attacks infants of only a few weeks, or adults up to advanced age. Girls are slightly more susceptible than boys; and weak children, particularly those affected with catarrh, more readily contract the disease. Morbid Anaiomy.—Tht morbid changes are rather those of the com- plications, of which pulmonary collapse and bronchopneumonia are the most frequently found in fatal cases. Enlargement of the tracheal and bronchial glands is constant. Symptoms. — The course of the disease is generally divided into a catarrhal and a paroxysmal stage. The incubation varies from a few days to two weeks. The catarrhal stage lasts from one to two weeks and is characterized by slight indisposition, fever at night, and evi- dences of laryngeal or bronchial catarrh, as in an ordinary cold. The cough is usually hoarse and becomes peculiarly sonorous, and finally paroxysmal. The face becomes swollen and the lower eyelids puffy. The paroxysmal stage begins with the first appearance of the whoop. The cough becomes distinctly spasmodic. It is of a rapid staccato character and ceases only after the air in the lungs has been exhausted; and it is followed by a long audible inspiration, the air being drawn through the glottis while the vocal cords are approximated. Several paroxysms frequently occur in succession until a mass of tenacious mucus is expelled. From four or five to eighty spells occur in a day; they are often more frequent at night. They are brought on by any slight irritation of the throat, as by the inhalation of dust or cold air; and the child soon learns to refrain from laughing or talking, even from eating, particularly when it feels the aura-like inclination to cough which generally precedes the attack. As the spell comes on, the child generally runs to its mother or seizes any near object for support. Dur- ing a severe paroxysm the face becomes cyanotic, the thorax is con- tracted, the eyeballs protrude, the conjunctivse become injected, often remaining blood-shot, and hemorrhages frequently occur from the mouth and nose. Hemoptysis has been observed. Convulsions may occur in nervous children. Vomiting very generally follows a paroxysm, par- ticularly just after a meal. The sphincters sometimes give way. A small ulcer generally forms under the tongue during the disease. Examination of the chest during an attack reveals dullness from de- ficiency of air in the lungs; during the intervals, the signs are those of emphysema and bronchitis, mucous rales and absence of the vesicu- lar murmur. The paroxysms begin to diminish in frequency and severity in three or four weeks, but the cough continues to be spasmodic in char- acter until the last. The contraction of a cold renews the peculiar cough for months after recovery. Comp/icaf/'ons and Seque/ce. — The repeated vomiting and subsequent inanition induce anemia. Hemiplegia has been induced by a severe paroxysm, and sudden death has occurred from subdural hemorrhage. The pulmonary complications are the most frequent and most important.' The bronchitis, enlargement of the bronchial glands, and emphysema may persist. Bronchopneumonia sometimes proves a fatal complication,; or tuberculosis may be engrafted upon it. Pleurisy is frequent, l6bar' pneumonia infrequent. Pericarditis and lesions of the valves have been 144 PRACTICE OF MEDICINE attributed to the great strain thrown upon the heart during the par- oxysms. Hernia has been produced by the violent coughing. Nephritis sometimes occurs. Anders found it in 20 per cent of cases, but Blumen- thal found only increase of the uric acid, with high specific gravity. Leucocytosis develops early. Diagnosis. — The whoop is pathognomonic, but in young infants it is often absent. A dry cough with an occasional short whoop sometimes occurs in other catarrhal affections of the nose and throat. Prognosis. — The frequency and severity of the complications always warrant the giving of a guarded prognosis. The bronchopneumonia is almost always fatal. The younger the child, the greater is the danger. The mortality is very high among the children of the poor, probably owing to neglect. Cases among all classes of people are too often al- lowed to run their course without treatment, owing to the popular fallacy that nothing can be done for the disease. Treatment. — Isolation should always be insisted upon, and in severe cases the patient should be confined to bed in a well-ventilated room. Milder cases, in warm weather, will do better in the open air. The diet should be light, easily digested, consisting largely of milk, and it would best be given in small quantities at short intervals on account of the vomiting. Removal of the patient from the city to the country is im- mediately beneficial' in most cases. Local Treatment. — Various methods of local treatment have been recommended. These are applied by insufflation, with a brush, in the form of spray, or by inhalation. Quinin with bicarbonate of soda and powdered gum acacia, or a mixture of quinin and resorcin, has been extensively employed by insufflation three times a day. Boric acid, benzoin, salicylic acid, iodoform, and other powders have also been used. For application with the brush or swab, a 2 per cent solution of re- sorcin or carbolic acid has been recommended. In the form of spray the same solutions may be used, and equal parts of h3^drogen peroxid and glycerin are highly recommended. For inhalation, the vapor of creosot, naphthalin, or bromoform and ozone has been recommended. Internal Medication.-— Qviinin and belladonna are most relied upon. The former is given in doses of i to 2 grains for each year of age, up to 5, three times daily, and the belladonna should be pushed until the face flushes after each dose. They may be given together. Bromoform in I to 5 minim doses has been highly recommended, but should be used with caution, commencing with the minimum dose, owing to its tendency to depress the heart. MUMPS. EPIDEMIC PAROTITIS. Definition. — An acute infectious disease whose chief symptom is in- flammation of the parotid gland. Etiology. — The specific cause of infection is not known. The disease prevails sporadically, endemically, and sometimes epidemically. It is highly infectious to persons coming into close contact with those aff'ected, and the contagium may be carried on clothing. It frequently attacks MUMPS 145 more than 90 per cent of the inmates of schools and barracks. It is most prevalent during springtime and autumn. Childhood and youth are the ages of greatest susceptibility. Infants under 2 years and adults over 25 are seldom attacked. Boys are more frequently affected than girls. One attack, including possible relapse, generally produces permanent immunity. Morbid Anaiomy.—A. serous exudation into the glandular and peri- glandular tissues of the parotid, and catarrhal inflammation of the ducts, constitute the usual lesions of the disease. Suppuration rarely occurs. The affection is limited to one gland in some instances. The submaxillary glands may be affected, alone or in conjunction with the parotids. In boys the disease is not infrequently accompanied by in- flammation of the testes, and in girls by inflammation of the ovaries, vulva, or mammary glands. Symptoms. — The incubation is about 14 days, without symptoms. The invasion is usually announced by a slight elevation of temperature, seldom beyond 101° F. (38.3° C). Nausea, vomiting, headache, and rest- lessness may be present. In about 24 hours after the onset, slight pain and a sense of fullness in the region of the parotid gland are experienced. Swelling is soon noticeable and by the third day forms a prominent protrusion which interferes with speech and deglutition by restricting the opening of the mouth. Slight deafness, tinnitus, earache, pharyn- gitis, and epistaxis occasionally add to the discomfort. After a day or two the other parotid gland usually becomes affected ; it is seldom that both are affected in the beginning. When the submaxillary glands alone are involved, the swelling is confined to the region beneath the chin, but may extend far down the neck. The secretion of saliva may be either increased or diminished. The more severe symptoms generally abate in two or three days, and the swelling slowly subsides after a week or ten days, but one or more relapses not infrequently occur. In the most severe cases the temperature runs high, 103° or 104° F. (39.5° — 40° C), and nervous symptoms develop, notably delirium or stupor, occasionally mania; rarely, the patient passes into a typhoid state. Orchitis is not usually seen before puberty. It may occur during the height of the disease, seldom earlier, but more frequently develops during convalescence and is accompanied by a renewal of the former constitutional disturbances. It is generally unilateral, but it may in- volve both testes simultaneously or in succession, and sometimes lasts longer than the original parotitis. Effusion of serum into the tunica vaginalis, edema of the scrotum, and slight urethral discharge often ac- company the condition. The epididymis is not usually involved. Atro- phy of one or both glands may result. Vulvovaginitis sometimes occurs in girls; ovaritis is rare. The mammary glands are occasionally in- volved in boys, though not so frequently as in girls. The complications and sequeloB are few. The most important are those on the part of the nervous system — meningitis, peripheral neuritis, and paralyses (hemiplegia and facial paralysis), or edema of the brain from compression of the jugular vein. Acute mania and insanity have followed the disease. Stomatitis, laryngitis, and otitis media are oc- casionally encountered, and deafness and atrophy of the optic nerve have been attributed to the disease. 146 PRACTICE OF MEDICINE Diagnosis. — The peculiar character of the swelHng, free from redness of the skin or special tenderness, and passing around the lobule of the ear, with the more or less marked constitutional disturbance, serves, as a rule, to distinguish parotitis from other inflammatory affections of this region. Idiopathic parotitis is rare in childhood. Treatment. — The patient should be isolated and confined to bed during the acute stage. Hot applications, preferably a wad of absorbent cot- ton wrung out of hot water and covered with oil silk, soothe the pain and probably reduce the inflammation. Cold applications are preferred by some patients. Medicine is seldom required except for the relief of nervous manifestations. Two to 5 grain (0.15 — 0.30) doses of phenacetin, according to age, relieve the headache and reduce the fever. The bowels should be kept open with saline laxatives. If orchitis develop, the testicles should be elevated and treated with hot or cold applications. Thompson recommends the application of equal parts of guaiacol and glycerin or 30 per cent ichthyol in lanolin. SEPTICEMIA. SEPSIS, BACTEREMIA, BLOOD-POISONING. Definition. — A general disease, caused by the entrance of pyogenic mi- cro-organisms or their toxins into the blood, and characterized by chills, irregular fever, sweating, and great prostration. Etiology. — The phenomena of septicemia are commonly preceded by suppuration, but the location of the suppuration is not always recognized before the development of the septic condition. The pyogenic micro- organisms become localized at one or more points within the body or on an abraded cutaneous or mucous surface, and there set up a suppurative or putrefactive process. From this the bacteria or their toxins, or both bacteria and toxins, gain entrance to the general system through the blood or lymph circulation or through both these channels. It is an essential feature of septicemia that no secondary foci of suppuration are developed. In this regard it is distinguished from pyemia. Any disease or condition attended by suppuration may become a cause of septicemia. Among these are abscesses of the breast, lymph-glands, liver or other organs, empyema, suppurative peritonitis, chronic otitis, malignant endocarditis, and pyelitis. Sepsis is a common termination of chronic tuberculosis. Bacteriology. — The bacteria most frequently causing the disease are : (i) The Streptococcus pyogenes, (2) Staphylococcus pyogenes aureus, (3) Gonococcus, (4) Micrococcus lanceolatus, (5) Bacillus pyocya- neus, (6) Bacillus proteus, (7) Bacillus influenzte, (8) Bacillus typhosus, (9) Bacillus coli communis, and (10) the Bacillus aerogenes capsulatus. Of these the most important are the first and second. Klebs and Koch attribute the disease to a specific microbe which is smaller than the pus-forming organisms. The term septicemia is sometimes applied to conditions in which the blood becomes highly charged with the toxins of other bacteria, but toxemia is a better designation for these. Conditions closely resembling septicemia have been induce by Bergmann, Angerer, and others through the injecting into the blood of pepsin, pancreatin, and trypsin. SEPTICEMIA 147 Infection may occur through an incised wound, as in surgical septi- cemia, or through accidental wounds or abrasions. In puerperal sepsis it is taken up from the uterine canal. The serous membranes, especially the pleura and peritoneum, or the mucous membranes of the respiratory or alimentary canal, not infrequently admit the poison, and suppuration of bone is often the source of infection. Suppurating lymph-glands in any part of the body may act as hidden foci of infection in the so- called cryptogenic form of the disease. Motbid Anatomy. — In sapremia and fermentation fever there are usually no lesions. In true septicemia death not infrequently occurs before recognizable lesions have been produced. In cases that have run a less rapid course the most striking feature is a condition in which the body undergoes rapid putrefaction. The blood is black and tar-like and the muscles are dark. Hyperemia and ecchymoses are often found in the pia, pleura, pericardium, and peritoneum, and punctiform hemorrhages may be found in the skin. The spleen and lymph-glands are usually enlarged, and the spleen may be soft. The liver and kidneys show cloudy swelling and sometimes other degenerations. Bacteria may be found in great numbers in the various tissues, especially in inflam- matory foci, or exudations, and in the renal glomeruli. It has been sug-^ gested that the presence of numerous bacteria in the blood and tissues after death may be in part due to an agonal or post-mortem invasion or to the rapid growth after death of a few organisms present during life. Varieties of Septicemia. — i. True or Progressive Septicemia. — Senn restricts the use of this term to cases which are caused by the en- trance into the circulation of microbes from some local septic focus. It is caused not only by poisons which are produced at the primary seat of infection, but also by those produced in the blood by the bac- teria which it contains. 2. Sapremia is the septic intoxication caused by the entrance into the blood of toxins or ptomains previously formed by putrefactive bacteria in dead tissues. It is not accompanied by the entrance of bacteria, and usually subsides as soon as the primary cause has been removed. 3. Intesti?ial or Ptomain Poisoning. — This form was first described by Vaughan as due to the absorption of tyrotoxicon, a poisonous chemical substance often found in cheese. The same investi- gator and others have since added to the list a large number of other poisonous ptomains. Strictly classified, poisoning by these substances is a form of sapremia. The term is sometimes employed, however, to designate conditions in which the bacteria have found their way into the circulation through the intestinal canal, particularly with reference to the bacillus coli communis. Fermentation Fever.— Closely allied to these conditions is that known as fermentation, aseptic, or resorption fever. It is a general febrile disturbance caused by the absorption of the products of aseptic tissue necrosis. It appears as a temporary condition soon after injuries and operations in which bacterial invasion has not occurred, but more par- ticularly when there has been extravasation of blood. It is supposed, in some cases at least, to be due to the entrance into the circulation of fibrin ferment. It resembles sepsis only in the febrile character of its symptoms. 148 PRACTICE OF MEDICINE Symptoms. — (i) In septice7nia, the period of incubation lasts from a few hours to several days. The onset is usually gradual and is not an- nounced by a chill. There is generally a distinct rise of temperature varying greatly in degree in different cases. Headache, nausea, vomit- ing, prostration, and mental dullness are generally present. Diarrhea may be an early symptom, but constipation is more common in the beginning. The fever may reach only ioo° F. (38.0° C.) in mild cases, but may exceed 110° F. (43.5° C.) in the worst. It is usually a con- tinuous fever, but the daily fluctuations may amount to 3° or 4°F. The pulse is rapid, often 130 or over, usually small and tense; sometimes it is soft and feeble. Leucocytosis is usually present. Cabot remarks in this connection that leucocytosis indicates a struggle between the system and the infection, and that it may be absent in the mildest and severest cases. The respiration is rapid and superficial. Cyanosis is sometimes present. The skin, at first hot and dry, becomes bathed with a profuse perspiration. In mild cases all symptoms frequently sub- side within from 24 to 72 hours; and in the severe, or fulminant, cases death- may occur within the same limit of time. Other cases run a variable course of from four or five days to as many weeks, and chronic cases last for months. The symptoms in^ the chronic form are often severe, but run a remittent or intermittent course. The exacerbations are frequently accompanied by a rigor, and chilly sensations or distinct chills often occur independently of remissions or exacerbations. Diarrhea may develop and the patient become anemic and emaciated. Erythema, petechise, punctate hemorrhages or ecchymoses, and other cutaneous eruptions not infrequently develop. (2) The symptoms of sapremia differ much in difterent cases. At times they are quite like those of septicemia, but are usually of shorter duration. Severe cases are initiated by a chill and continuous fever, reaching from 102° to 104° F. (39°— 40° C), with slight morning re- missions. A soft, full, compressible pulse is quite characteristic. Anorexia, vomiting, and diarrhea are frequently present, particularly in the intes- tinal form. The tongue is furred, becomes dr)^, assuming a '" dried-beef" appearance in severe cases. The urine is scant, rich in urates, and in- creased in toxicity. All symptoms quickly subside upon removal of the cause. (3) The s3^mptoms oS. fermentation fevcj-; The temperature usually rises rapidly without a chill, reaching a maximum of from 100° to 104° F. (38° — 40° C). It then remains almost stationa.ry for from one to three days and drops suddenly to normal. The pulse undergoes a cor- responding acceleration. There is usually little or no disturbance of the nervous system, the sensorium remaining clear or even appearing stimulated to greater activity. Diagnosis. — This depends, in many cases, upon the recognition of the source of infection. The frequent chills, irregular temperature, and sweat- ing, with rapid production of anemia and emaciation, should always arouse suspicion of sepsis in an obscure case. Secondary abscesses be- long to p3''emia, not to septicemia. The appearance of leucocytosis is often a valuable feature in diagnosis. Typhoid Fever. — This disease is usually recognized by the more grad- ual elevation and more uniform course of the fever, the absence of chills SEPTICEMIA 149 during its course, the rose-spots and the absence of leucocytosis. But the disease is not infrequently compHcated by septicemia or sapremia, causing a modification of its symptoms. Malaria, especially of the estivo-autumnal or remittent type, resembles septicemia, but the course is generally more uniform ; the greater splenic enlargement, the absence of suppurative foci, and, above all, the presence of the Plasmodium in the blood establish the diagnosis. Chronic Tuberculosis. — In this disease many of the symptoms are due to sepsis, hence the differentiation must often depend upon the dis- covery of pulmonary or other lesions and the isolation of the tubercle bacillus. In acute miliary tuberculosis, the cough, rapid respiration, and the discovery of the bacillus in most cases serve to differentiate the affection. Prognosis. — In mild cases of sepsis, in most cases of sapremia, and in all cases of fermentation fever the prognosis is good. In acute sep- ticemia it is always grave. In all septic cases, however, as much depends upon the physical condition of the patient as upon the virulence of the infection. There is much difference in individual power of resistance. Rapidly fatal cases sometimes follow the most trivial surgical, dissection, or post-mortem wounds; while cases arising from the most extensive suppuration often recover after months of severe illness. The early removal of the cause, when this is possible, has a decidedly favorable influence on the prognosis. Prophylaxis consists in the strict observance of antiseptic precau- tions, the removal of extravasated blood, and the prompt evacuation of pus cavities. Attention to the condition of the hands, especially with reference to slight abrasions, before undertaking surgical or post-mortem work, is of the utmost importance. When an injury is received during an operation, bleeding should be encouraged or increased by sucking, and the wound should be immediately cauterized. Treatment — The cause should be promptly removed. In fermentation fever, the establishment of drainage or antiseptic irrigation is usually all that is required. In sapremia of intestinal origin, prompt purgation by calomel, castor oil, or a saline cathartic is often sufficient. Intestinal antiseptics, salol, or /S-naphthol in 5-grain doses may be employed. In septicemia the treatment is largely symptomatic. The temperature may be reduced by frequent sponging or cold bathing. Antipyretics should be avoided on account of their depressing effect. The strength of patient must be supported by a nutritious, easily digested diet, con- sisting of milk, broths, eggs, egg-nog, and gruels. Codliver oil and malt preparations are beneficial in chronic cases. The heart's action should be supported by strychnin, gr. 1-30 (0.002), and alcohol. The action of the kidneys should be favored by the administration of large quanti- ties of water and potassium acetate, gr. x (0.65), or liquor ammoniac acetatis, 3 ss (2.0). Quinin in large doses, gr. x to xx (0.65 — 1.3), proves of great benefit in some cases, but is useless in others. Diarrhea, when excessive, must be controlled by opiates. Marmorek's antistrepto- coccous serum may be injected, but it is not always of benefit. Inunctions of unguentum Credd, a preparation of metallic silver, have been recom- mended, but are often disappointing. About 3 i (4.0) daily is rubbed into the sides of the thighs, abdomen, and other regions in succession I50 PRACTICE OF MEDICINE as in the administration of mercurial inunctions. In many cases sur- gical measures must be resorted to. Wernitz has strongly recommended slow, protracted irrigation of the intestine with a 0.5 to i per cent saline solution under low pressure. The intravenous injection of formahn solution (i 15000) has also been resorted to, with success in a few cases. From 500 to 750 c.c. of the solution were introduced at each injection. The measure is not free from danger. PYEMIA. SEPTICOPYEMIA. Definition. — An acute febrile disease caused by the entrance of pus- forming micro-organisms into the blood, and characterized by high fever, frequent chills, and sweating, with the formation of metastatic abscesses, phlebitis, infarcts, and hemorrhages in various parts of the body. It is pathologically identical with septicemia, except in the production of secondary suppurative processes. Etiology. — Streptococci and staphylococci are the most frequent causes of the infection, but the other bacteria named under the Etiology of Septicemia may be operative in its production, and the same suppura- tive conditions may be the sources of infection. The avenue of entrance is usually through the wall of a vein which is in a state of inflammation and degeneration. Entrance through the lymph-vessels is possible, but the germs must reach the general circulation before pyemia can develop. Pat/io/ogy.— There is first a point of suppuration adjacent to or involving a vein, rarely an artery. A suppurative phlebitis (or arter- itis) is thus induced. Thrombi are formed, and the pyogenic bacteria find their way into the clot, soften and disintegrate it into numerous fragments which are carried off in the circulation as emboli. When a vein is involved, the septic emboli are generally arrested in the lungs, and the abscesses may be confined to them. If, however, a radicle of the portal vein is involved, the emboli are distributed to the Uver. From a malignant endocarditis the pus is distributed to all parts of the body. The lesions found after death depend to a great extent upon the duration of the disease. If death have occurred early, the original phlebitis and the suppurative infarctions may be found. At a little later period, numerous miliary abscesses are often discovered. In more pro- tracted cases there may be abscesses from one to four inches in diameter, especially in the liver, lungs, spleen, or kidneys, sometimes in the brain, joints, or serous cavities. Subcutaneous abscesses may occur, especially in the vicinity of the joints. The heart muscles are usually soft, the spleen is enlarged, soft, and dark, and ecchymoses are often revealed upon the surface of the pleura or pericardium, or hemorrhages in the subcutaneous tissue. Symptoms. — Wound septicemia is always a sequel to suppuration, hence it seldom develops earlier than the seventh to the fourteenth day after the receipt of the injury. The infection ma)^ be preceded by changes in the wound. The granulations become pale, and the pus thin and ichorous or saneous and scant. The edges of the wound become ERYSIPELAS 151 puffy and edematous. A thrombosis in one or more veins leading from the focus of suppuration may be recognizable on close examination. Mild symptoms of intoxication may precede those of the infection, nota- bly a slight rise of temperature and mental depression. The pyemic invasion is announced by a severe chill, and the temperature rises to 104°, 105° F. (40° — 40.5° C.) or higher before the shivering ceases. Headache, vomiting, and extreme prostration are usual accompaniments. The pulse becomes rapid, often 140 to 160, and feeble. Chills occur at short intervals, daily or every other day, or there may be two or three chills a day. They often increase in frequency and severity as the disease progresses. The temperature range in acute cases is irregular, intermittent or remittent, with fluctuations amounting to several de^ grees in some cases, but seldom declining to the normal. In severe cases intermissions occur in which the temperature becomes normal or subnormal. Profuse sweating, anemia, and rapid emaciation are charac- teristic of the disease. The tongue becomes dry, the breath has a sweet- ish odor, and sordes often form on the teeth. The skin becomes pale or of a dusky color, the features pinched, the expression anxious. Slight jaundice is occasionally seen. Nervous symptoms are usually absent until late in the disease. Delirium develops in severe cases and deepens into coma as the fatal issue approaches. If, however, metasta- tic meningitis develops, it is promptly announced by strabismus, ptosis, deafness, and hemiplegia. Other symptoms, particularly pain, tenderness, and swelling, occur as a result of thrombosis, infarction, or abscess formations in different parts of the body. WTien these form in the lungs, rapid respiration, cough, and dyspnea are produced, sometimes with purulent or bloody expectoration. Malignant endocarditis is attended with increased pulse-rate and temperature, dyspnea, and a harsh sys- tolic bruit. Leucocytosis, reduction of erythrocytes, and moderate poikilocytosis are the usual blood-changes. Cutaneous eruptions, ery- thema, purpura, or pustules may occur, and hyperesthesia is commonly present. The urine is febrile in character, often contains albumin, casts, and sometimes pus and blood-corpuscles. Albumose has been found in it. Suppurative inflammation of the joints is not uncommon late in the disease, sometimes after the fever has subsided. Diagnosis. — Pyemia may be distinguished from septicemia, as a rule, by the extreme fluctuation of the temperature, the frequency of chills, and yet more particularly by the thromboses, infarctions, and metas- tatic abscesses. In other respects the symptoms are practically the same. The features thus combined serve to differentiate pyemia from almost all other affections. Treatment. — This is in all respects the same as that of septicemia. ERYSIPELAS. Definition. — An acute febrile disease caused by the streptococcus of Fehleisen, affecting primarily the skin or a mucous membrane and producing general symptoms of toxemia resembling those of sepsis. Etiology. — The streptococcus described by Fehleisen is regarded as the specific cause. Attempts to produce the disease by inoculating with other cocci have not been entirely successful, although some of the 152 PR.\CTICE OF MEDICINE features of erysipelas have been produced. The poison is evidently not extremely virulent, since it does not act at a great distance. The dis- ease is contagious and inoculable, however, and it may be communicated by a third person, probably also by fomites. It clings tenaciously to furniture and the walls of houses, especially in old, poorly ventilated hospitals and damp cottages. An injury or break in the continuity of the epithelial surface is regarded as essential for the admission of infec- tion, although this is frequently so shght as to escape careful search for it. The disease frequently attacks the subjects of surgical operations or women after confinement. It may follow vaccination. No injury is too trifling to admit the infection. Alcoholism, Bright' s disease, inanition, debihty, physical exhaustion, previous illness, bad hygiene, and filthy habits all predispose to the disease. Certain individuals and famihes are particularly susceptible. Some persons are attacked regularly at about the same time every year, particularly if they continue to reside in the same dwelling. Of individual immunity little is known. One attack does not confer immunity. Age is probably not of importance, since the disease occurs in all. It is less frequent toward the extremes of Hfe, probably on account of less exposure. For the same reason, no doubt, men are oftener attacked than women. Springtime is the period of its greatest prevalence. The disease is endemic in most places. Epidemics are much less frequent since the introduction of antiseptic methods into surgery and mid- wifery and of better sanitation into hospitals and dwellings. Bacteriology.— T\iZ streptococcus is known also by the names Strep- tococcus erysipelatis and S. pathogenis longus. It is peculiar in its forming long, slender chains, in its growth on different media, and in the fact that it produces this disease when inoculated into man or susceptible animals. It is probably a facultative aerobe. It cannot be distinguished morphologically from the ordinary streptococci of suppuration. Morbid Anatomy.— Tht lesions are found in the skin or mucous mem- branes. The local process is one of hyperemia which rapidly spreads from the point of original entrance for a variable distance in one or more directions. Fehleisen described three zones in the erysipelatous area : A central zone in which the process may be receding, a middle circle in which the disease is still advancing, and an outer in which it is only beginning. Section of the affected area reveals an infiltration of the skin and subcutaneous tissue, often including the fat, with granular leucocytes and serum. The leucocytes are most numerous in the cap- illaries and lymph-spaces of the peripheral zone; they are often particu- larly numerous also about the hair-follicles and sweat-glands. The edema is most pronounced in loose cellular tissue, as about the eyelids, prepuce, etc. A proliferation of fixed connective-tissue cells is described by some pathologists. Metchnikoff beheves that the inflammation is arrested in the outer zone by an accumulation of phagocytes. The visceral lesions are those usually accompanying sepsis and fever, and are not, therefore, pecuhar to the disease. Abscesses and infarctions are occasionally found in the lungs, spleen, and kidneys. Malignant endocarditis, septic pericarditis, or pleuritis is sometimes found. Men- ingitis and edema of the brain are not infrequent, and pneumonia is occasionally developed. Nephritis is not common. ERYSIPELAS 153 Symptoms. — The incubation varies from 48 hours to seven days. There are usually no symptoms, but malaise, anorexia, and slight fever may be present. An initial chill is almost invariably the mode of on- set. It may be repeated, and is generally accompanied by headache, muscular pains, sometimes by vomiting. The severity of the rigor is generally regarded as an index to the severity of the disease. The tem- perature runs up, often to 104° F. (40° C.) or higher. In an ordinary case it remains high with but slight remissions for four or five days, then rapidly subsides. Headache and delirium are especially liable to occur when the scalp is affected. Nervous manifestations are especially fre- quent in alcoholic cases. Albuminuria is usually present. In severe cases the pulse becomes rapid and feeble, delirium deepens into coma, the tongue becomes dry, hyperpyrexia develops, and death may occur within a few hours from toxemia. The local manifestations of the disease are to be seen at the point of original infection. This is often at the junction of the skin with a mucous membrane, at the inner canthus, or on any part of the face or ear. The part appears intensely red and swollen. The surface tem- perature is raised from 1° to 4° F. (0.5° — 2° C). Itching, burning, and tension are complained of. The area varies in form and is often irregular, but is readily distinguishable from the surrounding skin by its color and elevation. The process reaches its acme in three days, then begins to decline. The disease may, however, be prolonged by slow or rapid extension. The entire face is often involved and sometimes the entire body (erysipelas migrans). The skin is usually smooth and glossy, but vesicles sometimes form, and, by coalescing, produce large bullae resembling blisters. In its progress the disease follows the lymph-chan- nels, as is shown by red, edematous lines radiating from the periphery of the inflamed area. The neighboring lymph-glands become enlarged and occasionally suppurate. Abscesses are formed also in some cases by an invasion of the deeper tissues by the streptococci. The disease sometimes invades the mucous membrane of the mouth and pharynx; but it is not invariably severe in this location. The larynx sometimes becomes edematous through an extension of the inflammation from the skin directly through the intervening tissues. The cutaneous eruption is followed by profuse desquamation in most cases. Complicaiions and sequelce are rare, with the exception of those of a septic character, to which reference has been made under the patho- logical anatomy. Acute rheumatism has been observed. Pulmonary erysipelas is described by Strauss, and Ivanowski saw the lesions of erysipelas in the large intestine as an extension from the perineum. Peripheral neuritis has been observed as a sequel. Diagnosis. — There is rarely any difficulty in recognizing the disease when it affects the skin. When the oral or nasal mucous membrane is af- fected, the intense redness, swelling, burning pain, with high temperature and enlargement of lymph-nodes, should, in the absence of other specific cause, excite suspicion of this disease. Other forms of adejiiiis are not accompanied by so great fever. Erythema is not accompanied by enlarge- ment of the glands, does not show the three zones or the elevation of erysipelas. Glanders at the beginning is accompanied with hard, edema- tous induration, but the edges are not so much elevated. 154 PRACTICE OF MEDICINE The prognosis is favorable except in infants, puerperal women, and alcoholic or debilitated subjects. When the mucous membrane of the respiratory tract is involved the prospect is less favorable. The general mortality, according to Anders, is 5.6 per cent. Prophylaxis. — The patient should be strictly isolated, and the most rigid methods of antisepsis should be adopted, as in other acute infec- tious diseases. The physician while attending a case of erysipelas should not undertake an obstetric case or surgical operation of any kind. Treatment — Internal medication is usually unnecessary, except to meet symptoms as they arise. The diet should be light and nutritious, and stimulants and tonics should be administered in adynamic or alco- holic cases. The tincture of iron is not regarded with so much favor as formerly, but is useful in ordinary doses (15 drops in water after meals) during convalescence. The bromids, trional, or morphin may be required to induce sleep. Zoca/ Treatment. — Many remedies have been recommended, but ichthyol is probably the most effective. It may be applied in aqueous solution, in oil, or in an ointment in the strength of from 15 to 25 per cent, ■covering the entire surface and a surrounding area. A mask of lint should be worn over the affected part to protect it from the air. So- lutions of corrosive subhmate (i :iooo), the lead and opium wash, or ointments containing carbolic acid or other antiseptic drugs, but par- ticularly salicylic acid, are almost as effective. With a view to preventing the extension of the disease, collodion may be applied to the healthy skin just outside of the infiltrated area so as to completely surround it, •or a 2 per cent solution of carbolic acid or i 12500 solution of mer- curic chlorid or biniodid may be injected into the skin. ACUTE RHEUMATISM. ACUTE ARTICULAR RHEUMATISM, ACUTE INFLAMMATORY RHEUMATISM, RHEUMATIC FEVER. The term rheumatism has unfortunately been applied to a great number of very dif- ferent affections, and it is probable that some of the conditions now thought to be rheu- matic will in the future prove to be etiologically different. The word rheumatism has been handed down from the time of the ancient Greek writers, when the disease was attrib- uted to a humor Q>fv}ia) flowing through the system. Definition.— Axi acute infectious disease manifesting high fever, inflam- mation of the joints, profuse sweating, and a tendency to involvement of the endocardium and other fibrous structures. Etiology. — The specific cause is yet unknown. Bacteria have been found in the joints and other lesions, but their etiological relation has not been proved. It has been suggested that several different micro- organisms may be capable of producing the disease. That it is due to infection there is little doubt, from its analogy to other infectious dis- eases. It occurs in epidemic form every few years in some localities. These outbreaks are usually followed by two or three milder epidemics following seasonal influences. The onset is sudden, often during good health, with chill, fever, and other symptoms all favoring the view that ACUTE RHEUMATISM 155 it is due to a specific organism. It has been compared in many of its symptoms to pyemia, but the suppurative symptoms are absent. The avenue of entrance to the system is beUeved to be through the tonsils and possibly the adjacent mucous membranes, for tonsilitis and pharyn- gitis are often initial symptoms. The recent investigations of Walker and Beaton support the view of Poynton and Payne that the disease is due to a specific micrococcus, possibly that first described by Popoff. Two other theories have had the support of eminent authorities, but are now maintained by few. They are the chemical theory and the nervous theory. (i) The chemical theory refers the disease to an excess of either lactic or uric acid in the blood, which, it is claimed, can always be demonstrated with sufficiently delicate tests. But it is claimed, on the other hand, that these acids may result from bacterial activity, and an excess of uric acid is at least not constant. (2) The Nervous Theory. — The advocates of this theory regard the joint lesions as trophic and a result either of the action of cold upon the nerve centers or as due to an accumulation of lactic acid in the system, on account of faulty metabolism, which in its turn is a result of disturbances of the nervous system. Climate. — Rheumatism is most prevalent in the temperate zone and is favored by humidity of atmosphere. The largest number of cases occur during the winter and spring, especially in February, March, and April. In many localities the disease is endemic, and sporadic cases occur at all seasons. Epidemics are seldom observed in the United States. The age of greatest susceptibility is from 15 to 30. The disease is rare before the tenth or after the fiftieth year, but young children are by no means exempt. Infants are occasionally attacked. Sex. — Previous to puberty, rheumatism is more prevalent in girls than in boys ; in after-life, perhaps on account of greater exposure, it attacks men more than women. Heredity. — The influence of heredity is doubtful. Different members of the same family are not infrequently attacked, and some families appear to be more susceptible than others, even in successive generations. Some writers have inferred that a systemic or local type of vulnerability is transmitted. An arthritic diathesis is thought, especially by English writers, to be inherited, on account of which one individual will acquire rheumatism, another gout, and another, perhaps, arthritis deformans. But this diathesis does not manifest itself to any great degree in our country. Occupation and social position are more important, perhaps, since the disease often follows exposure to cold and wet or a sudden checking of the excretions by change of temperature. Poverty, with its attendant deprivations, and occupations necessitating a disregard of the weather are, therefore, influential in its production. Injury of a joint by direct violence, excessive activity, or strain may operate to localize the disease. The infection is believed also to be favored by anemia, inanition, nervous debility, shock, and chronic alcoholism. One attack does not confer immunity; on the contrary, it renders the individual more susceptible to future infection. Many individuals and some families appear to be immune. 156 PRACTICE OF MEDICINE Morbid Anatomy. — After death, changes are found in the joints, in the blood, and sometimes in the heart, but they are not distinctive of the disease. The Blood.— T\\t number of red blood-corpuscles is reduced more rap- idly than in any other disease. They are often as few as 2,500,000 or less to the c.mm., and the leucocytes are more than doubled in num- ber, rarely reaching 20,000 or over. The quantity of fibrin is also doubled, closely resembling the condition found in pneumonia, but the coagulability of the blood is diminished rather than increased. The Joints.— T\ie synovial membranes are swollen and hyperemic and frequently studded with fibrin flakes. The joint fluid is turbid with albumin, fibrin, and leucocytes. Pus is rarely present in uncomplicated cases. The inflammation sometimes extends along the tendon sheaths, especially in the hands, and may invade the bursae. Capillary dilata- tions, ecchymoses, or extravasations are found on the cutaneous, mucous, and serous surfaces in severe cases. The Heart— The frequency of heart involvement is diff'erently esti- mated. Some authors assert that it occurs in from a fourth to a third of all cases, probably a high estimate. The endocardium of the left side is most frequently aff'ected. The mitral cusps, particularly along the line of contact, are swollen and covered with vegetations usually of the simple, verrucose kind. Ulcerative endocarditis is rare. Contraction and deformity of the valves remain after recovery from the rheumatism. Simple fibrinous or sero-fibrinous pericarditis is not uncommonly met with. Myocarditis sometimes occurs. Sympfoms.—Such prodromes as slight malaise, headache, pains in the joints or muscles, and slight tonsihtis or pharyngitis are some- times observed. These are often absent, however, and the disease sets in with chilly sensations, less often with a distinct rigor and a rapid rise of temperature, often to 103° or 104° F. (39.5°— 40.0° C). At the same time one or more of the joints become swollen, hot, red, ten- der, and very painful. The pulse becomes moderately rapid, 100 or over, but it is usually full and compressible. Respiration is generally normal, or corresponds to the temperature. The disease reaches its acme, as a rule, within the first 24 hours. The temperature ordinarily pursues a very irregular course, fluctuating between 102° and 104° F. Qg.o°— 40.0° C). The tongue is coated, the breath foul, and the patient complains of thirst. The bowels are usually constipated. A pro- fuse acid sweat of a peculiarly sour odor is usually a striking symptom in the beginning. Later the perspiration becomes neutral or alkaline if persistent. Sudamina often form on the skin. The urine is usually scant, highly acid in reaction, and deposits much uric acid on cooling. The chlorids may be absent. Albuminuria may be present, as in other febrile conditions. The saHva is also highly acid, and an excess of potas- sium sulphocyanid has been found in it. The nervous phenomena are generally limited to insomnia and restlessness. DeUrium sometimes develops in connection with hyperpyrexia. All these phenomena are in some cases aggravated by large doses of the salicylates. So-called cere- bral rheumatism is probably nothing more than a congestion of the meninges due to toxic irritation. Cerebral embohsm rarely occurs, and probably only as a result of endocarditis. As a rule, the patient lies on ACUTE RHEUMATISM rS7 his back, shrinking from the slightest motion on account of the extreme pain it occasions, and sensitive to the shghtest jarring of his beci. The knees, ankles, elbows, and wrists are most frequently attacked, some- times simultaneously, but usually in succession. If the disease begins in one of these joints, it may remain in it for a few hours or for several days, then suddenly invade another articulation. The patient may fall asleep with the disease confined to the ankles, and awake to find the elbows or wrists involved and the original joints in a state of compara- tive comfort. This migratory tendency, as it was regarded by the older writers, is one of the strongest characteristics of the disease. In extreme cases almost all the larger joints are simultaneously affected. The pha- langeal articulations are not often involved in the first attack, and the sternoclavicular and maxillary even less frequently. Subsequent attacks frequently affect the smaller joints alone or in connection with the larger. The tendency to endocarditis should always be borne in mind, and a careful watch should be kept on the heart, particularly in young patients who have passed through a previous attack. A murmur is often heard at the apex as in other febrile diseases, which is not due to endocarditis. The course of the disease is exceedingly variable. If not overcome by treatment, it usually lasts from 20 to 30 days, then gradually sub- sides. Relapses frequently occur, and the development of complications anay prolong the illness. Subacute Rheumatism. — This is a common form of the disease in every way similar to the acute form, but milder in all its features. It may follow an acute attack, or it may run a subacute course from the beginning. It is often more persistent and less amenable to treatment than the acute form and the danger of endocarditis or pericarditis is almost as great. Acute Rheumatism in Children.— Children usually suffer from the sub- acute form of the disease. Tonsilitis is more frequently observed in the beginning of an attack. Erythema, cutaneous nodules, and endocarditis are oftener observed. The joint symptoms are, however, so slight in some cases as to be readily overlooked. Complications and SequelcB. — Hyperpyrexia is most frequent in the first attack and during the second week of the disease. The temper- ature frequently reaches 108° F. (42° C.) or even 110° F. (43.5° C.) in fatal cases. Delirium is often associated with it and may deepen into stupor or coma, but in many cases the mind remains clear. The pulse is usually rapid and feeble and the prostration becomes extreme. Cardiac Affections. — Endocarditis is the most serious and unfortunately one of the most frequent complications. The liability to it is propor- tionate to the number of attacks, but decreases with the age of the patient. The mitral valve segments are most frequently affected, the aortic next; the pulmonary and tricuspid valves are seldom involved. The most serious results of the disease are not generally realized until the development of chronic valvular lesions and failure of compensation have developed months or years after. Pericarditis may occur independentl}' or it ma}' be associated with endocarditis. It is usually simple, fibrinous or serofibrinous, but it may become purulent, especiall}'' in children. Myocarditis is infrequent, and when present it is generally associated 158 PRACTICE OF MEDICINE with endocarditis. It consists of fatty or other degeneration of the muscle fibers. Acute dilatation of the heart has been observed. Catarrhal pneumo?iia and pleurisy are sometimes associated with the endocardial disease. Bronchitis is not uncommon. Rapidly fatal pulmo- nary congestion has been observed in a few instances. Cerebral Complicaiions. — Delirium, as already stated, is sometimes de- veloped by the high temperature or by the action of the toxins. Coma sometimes succeeds it or may develop independently of it. It frequently precedes the fatal termination of the disease by only a few hours. It sometimes develops after convalescence has begun, and is occasionally due to uremia. Convulsions seldom occur. They may precede the coma or they may occur independently, especially in alcoholic subjects. Chorea has sometimes been observed as an associated disease. It is not always a result of the rheumatism. The joint pains and tenderness in children affected primarily with choreaare, perhaps, of a different nature in some cases. Chorea due to embolism following rheumatic endocar- ditis may not develop until weeks or months after the attack. Cutaneous Affectio?is. — Sudamina, erythema, petechiae, and ecchymoses may be seen. The most interesting complication of this kind is the so-called peliosis rheumatica. In it purpuric spots, with or without urticaria or erythema, accompany the rheumatic pains. The relation of the affection to rheumatism is doubtful. Subcutaneous Nodosities. — During and after the disease, subcutaneous nodules varying in size from a small shot to a pea, firm, but movable, are in rare cases found attached to the tendons of the fingers, hands, wrists, at the edge of the patella, or over the elbows, maleoli, scapulae, or spines of the vertebrae, especially in children and young adults. The skin is elevated, but not tender. The)^ develop rapidly, especially when chronic endocarditis is present, and may remain for months. They are oftener seen in England than in America and are more characteristic of gout and arthritis deformans. (See Heberden's Nodosities.) Conjunctivitis and iritis often recur with each rheumatic attack, and are amenable to the same treatment. Cystitis, orchitis, and other affec- tions of the genitourinary organs, muscular atrophy, thyroiditis, and other more or less accidental complications have been noted. Gastritis, profuse sweating, insomnia, delirium, and extreme prostra- tion are sometimes induced by the alkaline treatment. Diagnosis. — The intense painfulness and tenderness of the joints, with the swelling, wandering character of the affection, and the high tem- perature, seldom leave doubt as to the diagnosis. It is probably incor- rect to apply the term rheumatism to the secondary arthritis which .often complicates scarlatina, pyemia, and many other acute diseases, since it is doubtless due to a different kind of intoxication. It ma}^ usually be distinguished by the presence of the causative infection. Py- emia is to be distinguished by the frequent chills, intermittent character of the temperature, the often recognizable suppurative processes, and by the dusky or icteric color of the skin as compared with the anemia of rheumatism. Gonorrheal rheumatism is generally confined to a single joint. Al- though persistent, it is not accompanied by so great prostration or ACUTE RHEUMATISM 159. sweating. A poly arthritic form occasionally occurs, but the inflammation is not confined to the joint, and the swelling is generally fusiform. Acute osteomyelitis or necrosis affecting the lower end of the femur or the tibia may cause doubt. In either affection, however, the shaft and epiphyses are affected, and not the joints. Rigors frequently occur, but sweats are uncommon. The constitutional as well as the local symptoms are severe. An early correct diagnosis is extremely important for the adoption of surgical treatment. Scurvy with symptoms grossly resembling rheumatism has only re- cently been recognized as a comparatively frequent affection of infants. It affects the shaft of the bone and not the joints, however, and it is usually confined to a single locality, often an unusual one for rheumatism. Gout is generally confined to a single, small joint, especially the great toe. When it invades several large joints it is difficult of distinction. The age, family history, and habits of the patient are of value, and the discovery of tophi, little nodules about the joints, and an excess of uric acid in the urine is distinctive. Prognosis. — The prospect for recovery from the immediate disease is generally good, but the danger of cardiac complications and the lia- bility to recurrences months or years after are always to be regarded. The joints generally recover completely without more than temporary stiffness. Acute cases may always subside into a subacute form and finally become chronic. Endocarditis is usually followed by permanent valvular insufficiency or stenosis. Death, when it occurs during an attack, is generally due to hyperpyrexia, myocarditis or resultant acute dilatation, pneumonia, or pleurisy. Treatment. — The suffering is greatly mitigated by placing the patient upon a smooth, elastic mattress, in a quiet room admitting sunlight. He should have a flannel gown and should lie between blankets. Fre- quent changes are necessary on account of profuse sweating. The diet during the febrile stage should be limited to milk and fluid or semi- fluid articles. The thirst demands an abundance of pure water or lemon- ade at short intervals. Broths and soups may be given, but beef-juice should be omitted. Local Treatment. — The joint should always be kept warm and at rest. This may be done by wrapping it in flannel or cotton batting, and fixation in a splint is often of great benefit. Hot-water bottles may be applied. Relief is afforded in some cases by hot fomentations and applications of chloroform, aconite, or chloral liniments and lotions and in others by cold compresses and ice-bags. Blisters often afford relief when applied below the affected joint, and the Paquelin cautery, lightly applied, is probably better. But such measures are not often necessary. In mild cases an ointment of salicylic acid (2 per cent) freely applied to the affected joints is often all that is necessary. Another excellent application is composeci of equal parts of guaiacol and glycerin. The oil of wintergreen (gaultheria) may be applied pure. Methyl sali- cylate (50 to 100 drops) has recently been recommended. Medication. — The alkaline treatment is almost universally employed. The salicylates are regarded by Striimpell and many other authorities as specifics to such an extent that the diagnosis may be called into ques- tion when they fail to cure. Either the acid or one of its salts may i6o PRACTICE OF MEDICINE be employed. Salicylic acid should be given in lo-grain (0.6) doses, in capsules or tablets, every hour until i or 2 drams (4.0 — 8.0) have been taken. The sodium or ammonium salicylate should be given freely, gr. XV to XX (i.o — 1.25) every two hours, until the pain is relieved or physiological effects, tinnitus, vertigo, or nausea, are produced. The drug should always be chemically pure. Some prefer that made from wintergreen. Striimpell advises giving a dose of 3j to 3 jss (4.0—6.0) three times a day. Prompt relief from the pain is generally afforded. The doses may then be reduced in size or in frequency. In many cases the disease is subdued to so great an extent within two or three days that the drug may be discontinued. It is chiefly in cases that fail to respond promptly that a continued use of the salicylates proves of no benefit. It is ordinarily considered better to discontinue their adminis- tration in any case as soon as the pain has been entirely relieved, in order not to increase the anemia, which is already rapidly developing. Potassium bicarbonate in 20-grain (1.25) doses, given along with the sodium salicylate, increases its action. It may be continued after the sodium salt has been discontinued, alone or with half-dram (2.0) doses of potassium acetate. Disagreeable effects are not infrequently produced by the salicylates. The tinnitus and deafness are often extremely annoying and may be attended with vertigo and epistaxis. Delirium, dyspnea, and a peculiar nervous stimulation are produced in some cases. Many patients object to the taste, however disguised, and in some it produces extreme nausea. These symptoms may be relieved in a measure by sodium bromid, gr. XX (1.25); or the oil of wintergreen may be employed in doses of TT[xx (1.25) every two hours, in milk or emulsified with mucilage. Salol has not proved efficient in the hands of most observers. Salophen, gr. XV (1.0), has been recommended, but it is inferior to the salicylates. Sodium or potassium iodid is often beneficial as convalescence ap- proaches. It is seldom that the salicylates fail to afford relief from the suffering, but in some cases morphin, gr. y^ to % (0.008 — 0.016) hypodermically, is required. Phenacetin, gr. v to x (0.35 — 0,65), often affords relief and aids the action of the salicylates. Menzer has recently reported good results in acute and chronic rheu- matism from the injection of a streptococcus serum obtained from cul- ture on ascites fluid of micrococci removed from the tonsils. During convalescence, iron and tonics should be administered to over- come the anemia. The continued adminstration of iron sometimes appears to prevent a recurrence in persons subject to repeated attacks. The patient should avoid exposure, but fresh air and sunshine are bene- ficial. The diet should be nutritious, but without meat until conva- lescence is complete. The rheumatic subject should, as a rule, indulge sparingly in nitrogenous food and malt liquors. GONORRHEAL INFECTION. Definiiion. — An infection caused by the gonococcus of Neisser and man- ifested by symptoms of general toxemia or of localized inflammation, especially in the joints. GONORRHEAL INFECTION i6i Etiology. — The condition is due either to the entrance of the gono- coccus into the blood or to the absorption of the toxins. It occurs in about I o per cent of all cases of gonorrhea, and is most frequently seen in young men the subjects of gonorrheal urethritis. It may, however, occur in individuals of any age or either sex in the presence of the spe- cific cause. Taylor maintains that infection from urethritis is unusual until the posterior urethra has become involved. It may result from the vulvovaginitis of children. Injury favors the localization of the disease in a joint. Exposure to cold and wet is not recognized as an etiological factor. Individual susceptibility is more important. The disease is entirely independent of rheumatism or the rheumatic diathesis. The gonococcus has been repeatedly found in the blood, in the affected articu- lations, and in the pericardium when involved. Morbid Anatomy. — When death results from toxemia, the changes are those of septicemia. An original source of infection is usually found in the urethra or possibly *in a suppurating gland. The Articulations. — Inflammation and thickening of the capsular liga- ment and synovial membrane are the distinguishing features. There may be much or little effusion into the joint. The fluid is generally turbid owing to the presence of fibrin and leucocytes; suppuration is unusual, but is sometimes encountered, particularly in the wrist and knee joints. Mixed infection with streptococci, staphylococci, or pneumo- cocci is not uncommon. Hydrarthrosis occurs, especially in the knees. Edema is peculiar to the wrist and ankle. The inflammation is rarely limited to the articulation, but it extends for a variable distance along the tendon sheaths or periosteum above and below the joint. As a result, the joint has a fusiform appearance. The inflammation is limited to these structures in some cases and the joint is not affected. Fibrous thickening and adhesions are a more constant and persistent result than in acute rheumatism. Clinical Forms and Symptoms. — i. Septicemic Form. — This may occur as early as the second week of the primary gonorrhea, or as a result of secondary infections from it. It may follow any of the recognized local lesions of the disease — urethritis, conjunctivitis, vaginitis, endocar- ditis, abscess in the prostate or other glands. The symptoms are those of septicemia or pyemia. There is often a slight elevation of tempera- ture, however, in the beginning of a specific urethritis, which is not nec- essarily of this character. 2. Gonorrheal Arthritis. — The joint involvement does not generally begin until the fourth week, of a gonorrhea. It has been observed, how- ever, in the second or third week, and after several months have elapsed and the urethritis has become chronic. The clinical manifestations are exceedingly variable and most persistent in character. One or many joints may be involved. A migratory painfulness of the joint may be the only symptom. In other cases, several joints become simultaneously swollen and painful, as in subacute rheumatism. There is moderate fever, as a rule. The typical acute gonorrheal arthritis is a monarthritis. The swelling is often extreme and the pain severe. The fever may be moderate. Sup- puration of the joint occasionally occurs. The disease may become chronic, or it may run a chronic course from the start. The periartic- 1 62 PRACTICE OF MEDICINE ular form in which the inflammation is confined to the tendon sheaths is seen especially in the knee and elbow or along the tendo achilHs. 3. Gonorrheal Endocarditis.— This may occur as a complication of the other forms, or independently, even in the absence of articular in- volvement. It is often ulcerative in character and fatal in its result. Pericarditis occasionally occurs. Comp/icaf ions. —Endocarditis, pericarditis, and pleurisy may occur. Cerebral complications have been observed. Bursitis and tenosynovitis are not uncommon. The muscles and fascia, especially of the palm and sole, may become infected. Iritis is sometimes observed. Diagnosis.— The difl'erentiation between a gonorrheal arthritis and an intercurrent rheumatic arthritis is often impossible uathout the discovery of the gonococcus in the joint fluid. The diagnostician may be misled when the patient denies the existence of gonorrhea. The most distinctive features of gonorrheal arthritis are the involvement of but one or at most two or three joints or the absence of migrator_y tendency, the fusi- form character of the swelling, the tendency to invade the tendon sheath, and the extreme persistence of the disease. /Vo^rnos/s.— Notwithstanding the persistence of the disease, ultimate recovery is the rule. A greater or less degree of anchylosis often re- mains for a time. The septicemic form and the pericarditis may prove fatal. Recurrence is not unusual, especially when a fresh attack of gon- orrhea is contracted. Mixed infection adds gravit}^ to the prognosis. Treatment— The thorough treatment of the primary source of in- fection is important. The condition of the posterior urethra should be looked into. The salicylates and alkahs are of httle or no benefit. They may be employed, however, when the diagnosis has not been fully es- tablished. Potassium iodid has not proved of value. The adminis- tration of tonics, particularly of iron and arsenic, has proved the most satisfactory treatment. Good food and fresh air are highly advanta- geous. During the acute stage the patient must be kept at rest and the joint should be immobilized. The hot-air treatment has proved of bene- fit in the later stages of the disease. Bhsters, cauterization, and counter- irritants have been recommended. In persistent cases the joint cavity may be aspirated under careful antisepsis, and a 1:2500 solution of mercuric chlorid or a i 150 solution of carbolic acid may be injected. If suppuration occurs, vigorous surgical measures must be promptly adopted. SYPHILIS. LUES VENEREA, THE POX. Def/n/i/on. — A chronic infectious disease, usually of venereal origin, characterized by a great variety of pathological lesions and clinical manifestations corresponding with the stage of the disease and the part affected. It may be hereditary (congenital) or acquired. Etiology.— The specific cause has not been definitely determined. The bacillus of Lustgarten is often found in the lesions. It is a straight or curved rod having slightly enlarged ends and measuring 3 or 4/i in length. It is probably the same as that recently found by Max SYPHILIS 163 Joseph in the semen of syphilitics and propagated by cultivation on sterile normal placenta. The disease is peculiar to man, and suscep- tibility is probably universal. I. Accidental Infection. — Inoculation most frequently occurs through the skin or mucous membrane of the genitalia as a result of sexual congress. It may occur anywhere that the virus comes into contact with a tissue whose continuity is broken. The term syphilis insontium is applied to the disease when innocently acquired. The virus may be conveyed by means of such contaminated articles as drinking-vessels, towels, bed-linen, rags, razors, pipes, dental instruments. It has been communicated by kissing, tattooing, vaccination with humanized virus, and the introduction of an infected hypodermic needle. The infant may become infected by the kiss of a syphilitic person and convey the virus to the nipple of the mother. The hand of the physician has been in- oculated during surgical and obstetric work. ' 2. Inherited Infection. — This may be transmitted from either parent in whom the disease is active at the time of conception. Tertiary syphi- lis of the parent does not beget in the offspring active syphilis, but a feeble, cachectic constitution with great liability to mental defects and physical deformities. The disease may be transmitted to the fetus through the placenta when the mother has become infected during her pregnancy. Pathology. — The Chancre. — The primary lesion consists of a circum- scribed infiltration of the connective tissue with granulation and epithe- lioid cells, with an occasional giant-cell and a few bacilli, usually found in the center of the infiltration. Changes occur also in the smaller blood-vessels, nerve fibers, and lymph-vessels immediately around it. Secondary Lesions. — These are of the greatest variety, including cutaneous eruptions, mucous patches, condylomata, affections of the eye, nerves, and viscera. Tertiary Lesions. — The lesion characteristic of this stage is the gumma, the most distinctive of all syphilitic formations. It belongs to the gran- ulomata and may be either infiltrating or circumscribed in character. It may originate in the connective tissue of any structure of the body. It consists of an infiltration of a greater or less area of the tissue, with small round or polyhedral cells in which new blood-vessels are formed. Subsequent changes lead to the . formation of ulcers in the superficial tissues or to caseation, amyloid degeneration, or sclerosis in the inter- nal organs. Large cutaneous syphilids and vascular sclerosis are com- mon features of this stage. The lesions are usually symmetrical. Sympioms. — Acquired Syphilis. — The clinical manifestations are usually divided for description into three stages, although the line of separation is not always clearly defined. Following inoculation there is a period of latency of three or more weeks during which there is no evidence of the disease. Primary Stage. — The initial lesion appears as a small papule which gradually enlarges and breaks in the center, to form an ulcer with in- durated edges. The nearest lymph-glands become enlarged and indu- rated; they seldom suppurate. Seco7idary Stage.— T\\\s begins with the first evidence of constitutional involvement, from six weeks to three months after the appearance of 1 64 PRACTICE OF MEDICINE the chancre. A mild fever frequently develops; it runs a continuous course, seldom reaching 102° F. (38.8° C), but it is sometimes severe and may run up to 104° F. (40° C.)- Anemia is often an early symp- tom, the blood-count showing 3,000,000 corpuscles to the cubic milli- meter or less. In some cases the integument assumes a slightly yellow- ish, cachectic hue. A more or less distinct roseolar rash appears on the chest, abdomen, and anterior surfaces of the arms, sometimes on the entire body, but seldom on the face, and persists from two to three weeks. A papular eruption (papular syphiUd), resembling acne, sometimes appears on the face and trunk. Less frequently there is a pustular rash which has been mistaken for smallpox, or a squamous syphilid resembling psoria- sis, though less scaly. Mucous patches, flat warty excrescences, showing a tendency to ulcerate, appear at the same time on the mucous membrane of the mouth, lips, tongue, or throat, or on moist surfaces of the skin, as at the angles of the mouth. Cond3'lomata, warty outgrowths of the papillae, are often seen at the junctions of the skin with the mucous membranes, or upon surfaces which are kept moist by contact with adjacent surfaces, as in the gluteal and anal folds. The lymph-glands of the entire body become more or less indurated. Deep-seated osteo- scopic pains are complained of at night during this stage, and the an- terior surface of the tibia may become slightly swollen, roughened, and sensitive to pressure. The scalp may also become tender, and there often develops a point of extreme sensitiveness to firm pressure near the up- per end of the sternum. Iritis is not uncommon from the third to the sixth month of the disease. Choroiditis, retinitis, otitis, laryngitis, and other inflammatory affections are sometimes produced. The hair falls out, usually in patches, sometimes as a general alopecia, including the eyebrows and other re- gions; brittleness of the finger-nails is often observed. Tertiary Stage. — There is no clear mark of distinction between this stage and the secondary. It generally begins in from three to six months after the beginning of constitutional infection, unless delayed by treat- ment. It may be preceded by a short period of latency. The most distinctive features are the appearance of scattered syphilids which manifest a tendency to produce deep ulcerations, and gummatous growths in the skin and subcutaneous tissues, muscles, and internal organs. Amyloid degeneration and sclerosis are common. The internal lesions are largely a result of these processes. I. Digestive System. — Fissures, ulcers (mucous patches), or gummata may form in the tongue, causing much enlargement and interference with deglutition. The tonsils may be swollen and ulcerated, and gum- mata sometimes form in the posterior wall of the pharynx. The esophagus and stomach are seldom affected, but stenosis occa- sionally results from the pressure of large gummata. Ulceration oc- curs at times in the intestine; symptoms may be absent, or there may be tenderness and diarrhea. The rectum is a common seat of cicatricial stenosis, especially in women. The constriction usually forms above the internal sphincter and produces alternating constipation and diar- rhea, often ribbon-like stools, and reflex nervous manifestations. In the liver the disease is manifested by : («) Diffused hepatitis, a SYPHILIS 165 small-celled infiltration with hyperplasia of the connective tissue pro- ducing enlargement or contraction; (/^) gummata, sometimes large enough to be recognizable through the abdominal wall; (^) perihepati- tis with thickening of the capsule, frequently accompanied with pain and tenderness; and (^) amyloid degeneration with marked enlargement. These conditions are frequently attended with slight icterus, emaciation, ascites, and enlargement of the spleen and symptoms on the part of other organs. 2. Respiratory System. — Ulcers of the larynx sometimes develop and may destroy the vocal cords or cause necrosis of the cartilages; the epiglottis is sometimes involved in the destructive process. Syphilis of the lung is not common, but gummatous and sclerotic changes oc- casionally occur. The lesions are usually confined to the base and may involve more than one lobe. Bronchiectasis may result from the cica- tricial contraction. The symptoms suggest tuberculosis, but the disease is of slow progress and can generally be recognized by the location in the base, the absence of tubercle bacilli, and the history or evidences of syphilitic infection. 3. Circulatory System. — Vegetative endocarditis, gummatous myocar- ditis, amyloid degeneration, and fibrous induration are the usual, though infrequent, cardiac lesions. The coronary arteries may be obliterated or aneurism may be produced. The arterial system is especially liable to syphilitic changes in the nature of obliterative endarteritis. Arterio- sclerosis and the formation of gummatous deposits in the adventitia are particularly frequent in the cerebral vessels. Syphilis is probably the most common cause of aneurism. 4. Nervous System. — Either the brain or the cord may be affected. Gummata form especially in the meninges and cause, chiefly through pressure, a localized meningitis, encephalitis, or m.yelitis with degenera- tive changes and softening of the nerve tissue. Hemorrhage is some- times produced. The gummata may, through degenerative changes, become fibrous, caseous, cystic, or calcareous. The symptoms produced are those of tumor affecting the brain or cord. 5. Renal System. — The kidneys are also the seat of gummatous for- mations, producing symptoms of nephritis, albuminuria, edema, some- times hematuria. Amyloid degeneration is not infrequent, in association with the same condition in other organs, especially the liver, intestines, and spleen. Anemia and emaciation are prominent symptoms ; the skin becomes waxy. A large quantity of clear urine is voided which contains albumin and tube-casts. Dropsy and diarrhea frequently contribute to the inevitably fatal course of the amyloid disease. The bladder is not often the seat of syphilitic disease, but perforating ulcers are thought to be sometimes of this nature. Orchitis of a fibrous or gummatous nature sometimes occurs. Epididymitis is rare. Metasyphilitic Affections.— Syphilis renders the subject liable to cer- tain diseases not necessarily of syphilitic nature, as locomotor ataxia, epilepsy, paralytic dementia, and pernicious anemia. Epilepsy beginning in adult life independently of trauma is almost invariably of this char- acter. Congenital Syphilis.— The firstborn of syphilitic parents is generally premature and stillborn. When, however, the disease is present at birth 1 66 PRACTICE OF MEDICINE in a living child, it has usually the form of a vesicular or bullous cuta- neous eruption with enlargement of the liver and spleen. The child is feeble and emaciated, has the snuffles, its lips are fissured, and the joints may be enlarged. In other instances the infant appears healthy at birth, and thrives for a month or six weeks, then develops a nasal catarrh (syphilitic rhinitis), which interferes with its nursing and often leads to ozena, necrosis of the nasal septum, and the production of a characteristic deformity. Other lesions soon appear, particularly an erythematous, eczematous, or papular eruption on the nates. The child becomes weak and emaciated. It is often restless and sleepless at night. Its cry is feeble and high pitched on account of the weakness ; the face appears old and wrinkled. Gastrointestinal disturbances often develop and hasten the termination of the unfortunate life. The child sometimes survives, but it never becomes vigorous. At the age of twenty years it has often the appearance of twelve (infantilism). The skin is sallow, the hair scant, and the teeth deformed. The upper central incisors are notched, short, and wedge-shaped, narrower at the cutting edge than at the gum (Hutchinson teeth). The cranium and the long bones are often deformed ; the forehead is usually broad. Owing to a congenital weakness of blood-vessel walls, large blue dilated veins are often seen upon the head and neck. Many other lesions peculiar to the disease, but not confined to the congenital form of it, are often observed in the later life of these subjects. Diagnosis. — The features which distinguish the primary sore, or chan- cre, are its appearance not less than three weeks after the inoculation, its round or slightly oval shape varying in size from a split pea to that of a ten-cent piece, its red and indurated edges, and the absence of spreading ulceration. The chancroid is differentiated by its earlier ap- pearance, irregular shape, flat edges, and early ulceration. The syphi- litic sore is single; there may be several chancroids. The chancroidal bubo suppurates, but there are no other secondary lesions. The sec- ondary lesions of syphilis are typical, especially when a history of the primary sore can be obtained. In women, however, this is often impos- sible. A roseolar eruption with mucous patches and enlargement of the lymph-glands, with moderate fever or normal temperature, can rarely be attributed to any other affection. The chief difficulty is encountered in the diagnosis of the visceral lesions of the tertiary period. Unfortunately the results of direct inter- rogation are less to be relied upon than in any other disease. The syphilitic will lie to his own hurt, and condemn the physician who ac- cepts his statement as true. Women are frequently innocent victims, and it is often wrong to arouse a suspicion of their condition. In such cases the diagnosis must often be based upon the history of a roseolar rash, mucous patches, sore throat, possibly an iritis, as an evidence of which a contracted pupil may remain. There is, perhaps, a history of nocturnal osteoscopic pains, loss of hair, a paronychia of several fingers, and there may have been one or more miscarriages. Examination may reveal cicatrices in the mouth, throat, the inguinal region, or over the tibia, a deformed or perforated palate. The earlier cutaneous lesions are symmetrical in location; the later are not always so. The tertiary rupia produces characteristic, prominent crusts resting upon deep ulcers. SYPHILIS 167 The vesicular lesions of syphilis when found upon the hands are often confined to the palms ; when on the feet, to the soles ; they do not itch. These features exclude papular eczema and other itching eruptions. Acne is accompanied by comedones, and the sores are confined to the seba- ceous follicles. They are less inflamed and do not form ulcers. Congenital Syphilis. — The appearance of snufiles and a cutaneous eruption on the nates of a child within the first three months is not to be mistaken for any other disease. Later the anemia, emaciation, the peculiarly aged facics, especially if accompanied with enlarged joints and wedge-shaped teeth, are pathognomonic. The therapeutic test., made by the administration of large doses of potassium iodid, is of greater value in the cutaneous than in the vis- ceral forms of the disease. The drug is well borne by a syphilitic patient and causes rapid improvement of the condition, but the test is not in- fallible. Prognosis. — The prognosis is good in the early stages, except in alco- holic or cachectic patients or those debilitated by age or disease. Much depends upon beginning the treatment early. Recovery is often complete after three years' treatment. The recovery should not be regarded as permanent, however, until at least one year has elapsed without a reappearance of the symptoms after the discontinuance of medication. When treatment is begun in the later stage and when relapse occurs during persistent treatment, little hope can be entertained of ultimate recovery. One of the most difficult questions which frequently confront the physician is that of the marriage of the syphilitic. This should be unconditionally condemned until at least a year has passed without relapse and without medication. It were better, indeed, that syphilitics never married. The prognosis of inherited syphilis is always bad. The earlier the disease appears the less is the prospect of life. Prophylaxis. — Syphilis is theoretically a preventable disease and one that could be eradicated. Practically it is not so. Few problems have received so much study from the beginning of the world to the present time as that of the social evil, but the solution is not yet. The systematic inspection of prostitutes has proved only partially successful. Much of the difficulty arises from the recklessness of .young men during the early stages of the disease. It is the duty of the physician to warn his patient of the certainty of communicating the disease by contact or by the use of the same drinking-cups, towels, or other articles. The criminality of voluntarily or carelessly communicating the disease to another should be impressed upon his mind. Treatment. — The primary sore requires little treatment further than cleansing and the application of calomel or other dry powder twice or thrice daily. It is customary with most physicians to delay the consti- tutional treatment until the diagnosis has been fully established by the appearance of secondary manifestations. WTien this has been done, it is less difficult, as a rule, to convince the patient of the correctness of the diagnosis and of the necessity of continued treatment after the disease has been gotten under control. As soon as the roseolar rash has ap- peared, however, the most energetic treatment should be instituted. Mercury and potassium iodid are specific remedies. The former is 1 68 PRACTICE OF MEDICINE especially valuable in the secondary stage, the latter in the later mani- festations of the disease. The iodids of mercury are much employed, however, during the tertiary period. Inunction Treatment. — It is generally best to begin the treatment with mercurial inunction. One dram of mercurial ointment should be rubbed into the skin for a half-hour or longer every evening for two or three weeks, substituting a warm bath for the inunction every fifth or sixth evening. The sides of the chest and abdomen and the inner surfaces of the arms and thighs, places where the skin is thin, should be selected on successive evenings. Internal Treatment. — Mercury may be administered by the mouth. The blue pill (massa hydrargyri) or mercury v/ith chalk (hydrargyrum cum creta) may be given in dose of i grain (0.06), preferably combined with ^ or ^ grain (0.008 or 0.016) of opium to prevent catharsis. The mercuric chlorid is employed in doses of 1-40 to 1-20 (0.0016 — 0.0032); the protiodid ^ grain (0.016), or the biniodid, gr. 1-20 in- creasing to 1-12 (0.003 to 0.005). The subcutaneous treatment is sometimes to be preferred. The mer- curic chlorid is generally employed, ^ grain (0.02) being injected deep into the gluteus or other muscle once a week. One or two grains (6.06— 0.13) of calomel in 20 minims (1.23) of glycerin, or ten drops of a mixture of equal parts of metallic mercury and lanolin containing 2 per cent of carbolic acid, may be injected in the same manner. Fut7iigation is seldom employed in this country. For its administra- tion the patient is placed on a chair having a perforated seat, then covered with a blanket. Perspiration is started by the heat from a spirit lamp placed under the chair. After this has been accomplished, 3 ss (2.0) of calomel is vaporized by placing it in a spoon and holding it over the alcohol flame. The patient then goes to bed wrapped in the blanket. In the later stages of the disease, potassium iodid is most relied upon. It should be given in doses of from 15 to 30 grains (i.o — 2.0) or more, well diluted, three times a day for several months at a time. When the result is not altogether satisfactory, the dose may be increased so long as iodism is not produced, or the mixed treatment may be employed, com- bining about 1-40 grain (0.0016) of the mercuric chlorid with 10 to 15 grains of the potassium iodid. The action of the iodid is increased by giving it in a large draught of hot water. Some physicians occa- sionally interrupt the treatment with the potassium iodid by giving one of the iodids of mercury. Whatever the plan adopted, the treatment should be continued with- out interruption for fully a year. An occasional interval of a week without treatment may then be allowed. Two years of treatment is the minimum of time required for a cure; three years of persistent medication is much safer. Treatment of Hereditary Syphilis. — Mercurial treatment of the mother during her pregnancy is of benefit to the child and may enable it to survive. The infant may be nursed by the mother when she is in physi- cal condition to provide it with nourishment, since it is a well-known law (CoUes's law) that the mother does not become inoculated even if not previously syphilitic; but it must never be given to the wet-nurse, TUBERCULOSIS 169 for it will surely inoculate the nipple. The subsequent treatment of the infant is based on the same principles as that of adults. Calomel or mercury and chalk may be given in doses of i-io grain (0.006) t. i. d. Inunctions or baths are a less cei^tain mode of introducing the mercury into the system. For lesions corresponding to those of the tertiary period, the iodids or the mixed treatment should be employed. The sirup of the iodid of iron is an excellent remedy in these cases, since it counteracts also the anemia. The administration of tonics, particularly of iron and codliver oil, is advantageous in advanced cases. Cases that have persistently resist- ed vigorous specific treatment not infrequently begin a rapid improve- ment after resort to these remedies. Precautions. — During treatment with mercury the patient should abstain from alcohol and tobacco and he should not eat freely of acid fruits and salads. The mouth and teeth should be cleansed after each meal, preferably with a 5 per cent solution of potassium chlorate. Upon the first indication of ptyalism — an increased flow of saliva, soreness of the gums, fetid breath, or diarrhea — the mercury must be discontinued for a few days. When symptoms of iodism appear — coryza, headache, drowsiness, acne, erythema, or albuminuria — this remedy must be given in reduced doses or temporarily discontinued. TUBERCULOSIS. Tuberculosis is the most universal of all diseases, prevailing in all parts of the world at all seasons and among all races. It attacks also many of the lower animals. Among domestic animals it is most frequent in cattle, next in young swme; sheep, horses, dogs, and cats are less frequently attacked. Fowls and fish are not exempt. Wild animals are seldom affected, but when domesticated they become exceedingly susceptible to it. Rats and mice acquire the disease. Among human beings it is more destructive than all the other communicable diseases combmed, causing 14 per cent of the entire mortal ity. This fact affords only a partially correct idea of its prevalence, however, for many tuberculous persons die of other diseases, and the lesions are often found after death in those who were not known to be affected during life. The mortality from it in different countries corresponds very closely to the population. Every organ and every tissue of the body is liable to the disease, but the lungs are more frequently attacked than any other structure. It is customary, therefore, to regard tuberculosis as a general affection having localized lesions. I. GENERAL TUBERCULOSIS. Definition. — An infectious disease caused by the bacillus tuberculosis of Koch, the entrance of which leads to the formation of tubercles or to diffused infiltrations of tubercular tissue that frequently undergo subsecjuent caseation or sclerosis, and sometimes calcification. Etiology. — The Bacillus. — The bacillus tuberculosis, discovered by Koch, in 1 88 1, is the specific cause of tuberculosis in all of its many mani- festations. The disease can be produced by no other organism. The bacillus is a slender, nonmotile, aerobic rod, measuring from 1.5 to 4,a in length. It is often found in clusters. Branching forms are ex- ceptionally seen, and it has sometimes a beaded appearance in stained preparations, which has been incorrectly attributed to the presence of spores. Probably the most distinctive feature of the bacillus is the I70 PRACTICE OF MEDICINE slowness with which it takes up the analin stains and its equal reluc- tance to part with them, even under the influence of mineral acids of sufficient strength to decolorize all other bacteria. It is cultivated with some difficulty, growing best on blood serum and only at a tempera- ture of 37° C. It is often overcome in cultures by the more exuberant growth of other bacteria, but within the body it is remarkably hardy, growing luxuriantly in the presence of staphylococci, streptococci, and other organisms. Exposure in water to a temperature of 60° C. de- stroys it in 15 minutes, although it is capable of resisting ordinary desiccation for months. Cold has no effect upon it. The rays of the sun are fatal to it within from 15 minutes to several hours according to the season and the character of the sputum or other substance in which it is embedded. Diffuse daylight near a window is said to de- stroy its vitality within a week. The bacillus is believed to be strictly a parasite, as it is not known to find conditions suitable for its propa- gation outside of the body of a living animal, except in culture-media. The recent investigation of the apparent relation of the tubercle ba- cillus to the ray fungus of actinomycosis, although properly belonging to the department of bacteriology, is of much interest in this connec- tion. It has been found that when this bacillus has been passed through the bodies of such cold-blooded animals as the frog, it adapts itself better to a saprophytic existence, growing vigorously upon artificial media at ordinary temperatures, while its virulence is reduced. Regu- larly branching forms, sometimes producing threads, are commonly seen. As Lubarsch suggests, the appearance is that of a reversion to an original saprophytic state. Similar branching forms have been found upon grass and in cow's dung. The question is therefore raised by Hek- toen whether the tubercle bacillus may not be a parasitic form of some of these organisms closely related to the ray fungus and existing natu- rally upon grass and elsewhere. The case of streptothrix bronchitis re- ported by Musser seems to support this theory. Chemical Products. — The bacillus yields a series of chemical products regarding the nature of which comparatively little is known. The most important are the fluid and precipitated toxin, the aqueous tuberculin, best known in the form of Koch's tuberculin, which is a glycerin ex- tract, and the fat-free bacilli obtained by precipitation. An albumose and a ptomain have also been isolated. The virulence of the bacillus is very different when the latter is ob- tained from different sources or when it is propagated on different cul- ture-media. Prolonged cultivation causes marked reduction of virulence. Distribution of Bacilli. — The bacilli may be found in the blood in acute tuberculosis, in the sputum when the respiratory passages are involved^ in the urine, feces, and other discharges from tubercular foci. They are found also in all tubercular lesions, their numbers corresponding closely to the activity of the disease. In the lymph-glands and other structures in chronic tuberculosis they may be unrecognizable by staining methods, although they still respond to cultivation and inoculation into the lov/er animals. Modes of Infeciion. — In a great majority of cases the disease is un- doubtedly communicated directly or indirectly from person to person. To what extent tuberculous animals contribute to the dissemination of TUBERCULOSIS 171 the disease among human beings is still a matter of discussion. Cattle are looked upon by some writers as important sources of infection, particularly through their flesh and milk, notwithstanding the fact that Koch has questioned the possibility of the transmission of bovine tuberculosis to man. The immediate avenue of invasion is in a majority of cases the respiratory passages, but the infection may be hereditary or it may occur under favorable conditions through any of the cuta- neous or mucous surfaces of the body. The infective agent is generally acquired through inhalation, ingestion, or inoculation. I . Hereditary Transmission. — There are three ways in which the trans- mission of tuberculosis from parent to offspring is theoretically possible, namely : {a) By the sperm, (J>) by the ovum, and (<:) the blood of the mother through the placental circulation. Tubercle bacilli have been found in the semen, but, as Osier remarks, the chances are extremely small that the bacillus should lodge in the individual spermatozoon which fecundates the ovum, and they appear still smaller when we con- sider that the spermatozoon is made up of nuclear material which the tubercle bacillus is never known to attack. No case has been recorded in which hereditar}^ transmission from the father was an inevitable con- clusion from the facts in the case. The same objections are almost equally applicable to the theory of transmission through the ovum, for it is almost inconceivable that the ovum should survive the entrance of the bacillus. Baumgarten, however, detected a bacillus within the ovum of a rabbit which he had artificially impregnated with tubercular semen. That the fetus may become in- fected from the blood of a tuberculous mother is possible, and the view that such infection occurs is supported by the fact that tubercular lesions have been found in the fetus. It is not an accident which is Hkely to occur often, however, for the bacilli are rarely found in the general circulation except in the rapidly fatal miliary form of the disease or as a result of the perforation of a blood-vessel by a tubercular infiltration. It is claimed by some writers that the placenta is always tubercular in these cases, and tubercles have been found in it in several instances. But the value of all these speculations is minimized by the statement of Hahn, that only 20 authentic cases of congenital tuberculosis have been recorded. In nearly all cases regarded as congenital a period of two weeks or more has elapsed between the birth of the infant and the discovery of the disease. There is a possibility, therefore, that infection of the infant may have occurred through inhalation or ingestion of bacilli during the first days of hfe. The bacilli are often, no doubt, implanted upon the hps of the infant through the kisses of the tuberculous mother or through the application of her handkerchief to its face. Those who still hold to the doctrine that tuberculosis is to any great extent inherited maintain that the bacilli in many instances remain dormant in the body for a great length of time and ultimately become active when the individual's power of resistance is in some way lowered. In this regard the disease is comparable to syphiHs, which frequently ej^- hibits this type of latency. The comparison does not hold, however, when we reflect that tuberculosis frequently passes over the second gen- eration, to appear in the third, a fact which is not easily accounted for on the theory of latency. 172 PRACTICE OF MEDICINE There can be no doubt that a vulnerable type of constitution is often transmitted to the offspring of tuberculous parents, and it is highly improbable that anything more than this is ordinarily handed down. And when we add to this enfeeblement of the power of resistance, the constant exposure of the infant to the many sources of infection from the tuberculous mother, we perhaps fully account for the frequent devel- opment of the disease during the first years of life. 2. Inhalation of dust to the particles of which bacilli have become adherent is probably the most prolific source of infection. The dust becomes contaminated for the most part through the expectoration of consumptive persons, but the sputum itself, after drying, and be- coming pulverized, may be carried by currents of air. The extent to which infection is possible through the medium of the sputum becomes apparent when we reflect upon the enormous prevalence of the disease and the incomprehensible number of bacilli which each tuberculous per- son is capable of producing. As estimated by Vaughan, one person in every 60, or 1,050,000, of the entire population of the United States is tuberculous, and Nuttall estimates that each tuberculous individual may throw off from one and a half to more than four billions of bacilli in 24 hours. Examination of the dust from the walls, floor, and furni- ture of apartments occupied by consumptives almost invariably reveals the presence of large numbers of virulent bacilli. The air of such apart- ments, especially after sweeping and " dusting," contains them. Guerard reports the occurrence of 541 cases in 248 dwellings in a single ward of the tenement district of New York city, in which there was a total of 663 dwellings. Tuberculosis has repeatedly been introduced and has become prevalent in regions which had previously been exempt from it, by the arrival of those affected with it. Health resorts are converted into hotbeds of the disease to a considerable extent by the infection of the original inhabitants. Our Indian tribes were free from tuberculosis until the arrival of the white man ; a part of their present susceptibility must, however, be attributed to the adoption of civilized manners of dissipation. The universal dissemination of the disease through the contamination of the air is largely attributable to carelessness. The danger of infection could be greatly diminished through proper disposal of the sputum. It appears, in fact, that the disease has become slightly less prevalent as a result of the more general dissemination of the knowledge that a tuberculous person is a source of danger to those who come into contact with him. The breath of the consumptive is not in itself infective, but in coughing and sneezing, even in talking (Fliigge), these persons throw off fine particles of sputum so minute that they float in the air. The inspiration of these particles is a possible source of infection to another person. Fliigge, indeed, regards this as a more positive means of trans- mitting the disease than the inhalation of dry dust. 3. Ingestion. — This mode of infection is usually considered with especial reference to the ingestion of the meat or milk of tuberculous cattle. But it is probable also that the bacilli often gain entrance to the alimentary canal through the contamination of other articles of food, for example through virus carried by flies or other insects. The danger of infection through the eating of tubercular meat is compara- TUBERCULOSIS 173 tively small, since it would be possible only when the bacilli were actually present in the flesh consumed and when they escaped destruction by the processes of cooking and digestion. Koch aroused much discussion by his statement at the British Congress of Tuberculosis, in 1901, that the danger of the transmission of bovine tuberculosis to man is very slight. He estimated the extent of infection by the milk and flesh of tuberculous cattle as hardly greater than that from hereditary trans- mission. The comparative frequency of primary intestinal tuberculosis in young children is attributed chiefly to the drinking of milk containing bacilli. It has been found that these may be present in the milk of an animal whose udder is perfectly healthy and in which the disease is dormant to such a degree that it can be recognized only by the tuber- culin test. It should be remembered also that the grass bacilli closely resemble those of tuberculosis and cannot be distinguished by the usual staining test. Demme records an interesting observation that illustrates the cer- tainty of deglutition infection from the entrance of the bacilli of human tuberculosis. Four infants died in succession of primary tuberculosis of the intestine, under the care of a nurse who was suffering from tuber- culosis of the jaw, with a iistulous opening into the mouth. It was found that the nurse was in the habit of placing the food for infants in her own mouth before giving it to them. Deglutition infection is also a common form of autoinoculation among pulmonary tuberculous patients. Intestinal tuberculosis com- monly develops during the late stages of the disease as a result of the swallowing of sputum. 4. Inoculation. — The disease is seldom communicated by direct inocula- tion; and when this docs occur, the resultant infection usually remains localized. Any broken surface of the skin may become inoculated. It is therefore a not infrequent result of injury to the hands in post-mor- tem work (the post-mortem wart). It is seen also on the hands of those who handle and wash the clothing and other articles of the tuberculous patient. It is interesting to note, also, that such inoculation is by no means uncommon among farmers, butchers, and tanners who handle the meat and hides of infected cattle, and that veterinary sur- geons have repeatedly been inoculated from diseased cattle. Inoculation has less frequently been produced through the piercing of the ears, tattooing, and the bite of a tuberculous person. It has repeatedly fol- lowed the rite of circumcision, the final act of which is the sucking of the v/ound ; tubercle bacilli have been demonstrated in several instances, both in the wound and in the mouth of the operator. Inoculation of tuberculosis has been attributed also to sexual intercourse. Predisposing Jnfliiences. — Inherited vulnerability of constitution is per- haps not of so great importance as it was formerly believed to be. The tendency since the discovery of the specific germ of tuberculosis has been to minimize the importance of heredity. It is generally stated, however, that a history of tuberculosis among the ascendants of the patient is found in at least 25 per cent of cases when the parents alone are con- sidered, and in about 60 per cent when the grandparents also are taken into account. It is believed that the vulnerability of type is more certainly handed down by the mother than by the father. Some families 174 PRACTICE OF MEDICINE show a more or less continuous prevalence of the disease through five or six generations, but on the other hand it would be difficult to find a family which had passed through so many generations without ac- quiring the taint. So much depends upon the environments of the individual, his nutrition and habits of life, and above all upon exposure to infection, however, that the influence of heredity will probably remain indefinite. It has frequently been observed that children which have been removed from the parents and placed under good conditions have escaped the disease while those that remained with the tuberculous parent have become infected. Individual Peculiarities . — The " phthisical habit" has been recognized since the time of Hippocrates, yet the disease is not uncommon among persons of robust frame and free from the white skin, blue eyes, trans- parent conjunctivae, and winged scapulas which are regarded as typical of tuberculous tendency. The long and flat, or narrow, thorax, with a straightness of the upper ribs and an obliquity of the lower, conditions unfavorable to the full expansion of the lungs, are not without influence. But the "scrofulous frame" is now regarded only as an indication of vulnerability. More important from an etiological standpoint, perhaps, is the tendency to catarrhal inflamimation so often seen in these individ- uals, which Beneke attributes to imperfect development of the heart with hypertrophy of the whole arterial system, the pulmonary artery being relatively wider than the aorta and thus favoring increased intra- pulmonary blood-pressure. Environment. — The influence of environment becomes apparent not only in those individuals who live in an atmosphere charged with tuber- cular virus, but to almost as great an extent in those who are deprived of sunlight and fresh air. Animals allowed to run free in the open air after inoculation with tubercular virus sometimes recover, while those that are confined in a dark, damp atmosphere quickly succumb; and the same is true of human beings. It is due largely to the influence of environment that the disease is more prevalent in large cities than in the country, and among the poor rather than among those in comfor- table circumstances. Bad food adds to the evil effects of bad hygiene. Climate and Season. — Climate and season influence to some extent the development, and yet more the progress, of the disease. This influence is probably inferior, however, to that of the sunlight and fresh air, or the cold, wet, and temperature-changes that belong to all climates. Devitalized air — air that has been breathed over and over again in small, unventilated sleeping-apartments — undoubtedly exerts a powerful in- fluence in the production of susceptibility to infection. The disease is less prevalent, it is in fact almost unknown, in a few sparsely settled mountainous or desert regions, but this is due probably more to the absence of the infectious agent or to the outdoor life of the inhabitants than to the climate. A region which proves beneficial to strangers will not always confer immunity upon its inhabitants. Many regions have from time to time been pronounced free from the disease, but at the present time the ratio of cases, to the population of any district is very nearly the same in all parts of the world. Age. — The influence of age is recognizable rather in the tendency to the involvement of certain structures than in the general susceptibility TUBERCULOSIS 175 to infection, for no age is exempt from the disease. During infancy and childhood the bones, lymph-glands, meninges, and intestines are more frequently attacked. From the fifth to the tenth year, which is usually the period of greatest outdoor activity, there appears to be a lull in the development of the disease. From 15 to 40 we see the pulmonary, pleuritic, laryngeal, and peritoneal forms, and in more advanced life fibroid phthisis. Sex. — Women are somewhat more frequently attacked than men. But, aside from the influence of indoor life common to women and the probable influence of pregnancy and lactation in lowering the power of resistance, there is little or no difference in the susceptibility of the sexes. Race.—Oi all races, the Hebrew is the most nearly immune. The Irish are extremely susceptible. Among negroes in our country the disease is becoming more prevalent and more fatal. Occupation. — Those constantly confined to small, dark rooms and to a sitting posture, as tailors and shoemakers, or those much exposed to the vicissitudes of the weather are more frequently attacked than others. Occupations which necessitate the inhalation of dust, as those of grinders and polishers, stonecutters and coal miners, predispose by the constant irritation of the respiratory passages. Alcoholism. — Chronic alcoholism lowers the resisting power and is an especially potent factor in those whose constitution, environment, and occupation are already favorable to infection. Disease. — Bronchial catarrh is one of the most frequent conditions precedent to tuberculosis. The sequence of whooping-cough, measles, or influenza, bronchitis, bronchopneumonia, and tuberculosis is often ob- served. A catarrhal condition of the pharynx or tonsils favors infection, especially in children. Smallpox and syphilis are also thought to in- crease susceptibility. And tuberculosis frequently bears the relation of a terminal infection to diabetes, valvular disease of the heart, aneurism, hepatic or renal cirrhosis, and other for the most part chronic debili- tating afi"ections. Cancer and tuberculosis, at one time thought to be antagonistic to each other, have more recently been found associated, not only in the same person, but even in the same organ. Trauma. — Injury of the lungs, meninges, or bone, and more partic- ularly of the joints favors the localization of the disease in them. And injury or operation on a tuberculous joint has not infrequently been followed by a dissemination of the disease and the development of miliary tuberculosis. Morbid Anatomy of Tubercle. — After the tubercle bacilli have gained entrance into the tissues they rapidly multiply. The irritation of the tissues by the toxins results in the production of tubercles, small nodular granulomatous formations, not characteristic, but so common to this disease as to have given it the name tuberculosis. Tubercles are there- fore a result rather than a part of the disease-process. The formation of a tubercle consists : (i) In the proliferation of cells from the endothe- lium of the blood- and lymph-vessels, perhaps also from epithelium, pro- ducing epithelioid cells, in which the iDacilli may usually be seen; (2) around this an infiltration of leucocytes from the blood-vessels of the vicinity. (3) Giant-cells usually appear among the infiltrated cells, their number generally standing inversely to that of the bacilli present. X76 PRACTICE OF MEDICINE (4) A reticulum is formed from the fibrous tissue of the region and constitutes the external zone of the tubercle. Almost the entire process of tubercle-formation may be regarded as an effort on the part of the system to shut off the bacilli from the surrounding tissues. The nodule is not provided with blood-vessels, hence its nutrition is poor, and degen- erative changes soon occur. The most common change is caseation, but sclerosis or calcification is not unusual. Caseation begins at the center of the tubercle and invades the entire nodule. When several tubercles lie in proximity, it may extend to the entire mass. Calcification is a subsequent change and consists in the deposit of lime salts in a tubercle which has undergone caseation. Sclerosis affects especially the outer zone, but the entire mass may be converted by it into a firm, fibrous, scarlike tissue. Caseation is a destructive process; sclerosis is constructive. The former tends to the formation of cavities ; the latter to the limitation and final destruction of the tubercular process. The tubercle which is visible to the naked eye consists of a collection of small miliary tubercles, of microscopic size, or, as they are sometimes called, submiliary tubercles. Tubercular TnJiltration.~T\\^ entrance of bacilli is not invariabl}^ followed by the formation of distinct tubercles; for in some cases it produces a diffuse inflammation. Microscopic examination of the involved areas shows numerous non-vascular collections of cells without distinct nodular arrangement, the only separation being a round-celled infiltration. These large collections of cells may be the result of the coalescence of many smaller areas of infection. Coagulation necrosis soon follows their formation, and a large area of caseation (the so-called caseous pneumonia) is the result. This condition is most frequent in the lungs and the area affected may be small or large, involving only a few lobules or an entire lobe. Distribution of Tubercles. — Tubercles may be found in every structure of the body except, perhaps, the teeth. The skin, subcutaneous tissue, the cancellous tissue of bone, and the mucous membranes, especially of the respiratory passages, but not seldom those of the alimentary and genitourinary tracts; the serous and synovial membranes and the pia mater are frequent locations. Among organs, the lungs are most frequently affected, but the liver, spleen, kidneys, testes, and lymph- glands are often attacked. The dura mater, ependyma, and endocardium are seldom affected. The brain, spinal cord, adrenals, and prostate are also among the less frequently affected regions, and the heart, salivary glands, pancreas, the mammae, ovaries, thyroid, and voluntary muscles are among the rarest of all locations. The secondary changes are also to a great extent peculiar to certain regions. Caseation is most frequent in the lungs and lymph-glands; calcification is common in the lymph- glands, but less so in the lungs. Sclerosis is sometimes found in the pulmonary tubercles, but it is more common to those of the peritoneum. From the original focus the tubercular virus is distributed : (a) Directly to the contiguous tissue or through the lymph-vessels; (^) in the lung also by aspiration, the infective material being drawn into bronchi which were previously unaffected; and (r) through veins and arteries whose walls have been infiltrated or perforated, often producing general miliary infection. Practice of Medicine— French. PLATE i,:^'-^}. .:''^, Mrs ^'t-\*:-C. Miliary Tuberculosis (Acute) of the Lung. The miliary tubercles, small and irregular in shape, are distributed throughout the lung — more abundantly in the upper and middle thirds. The blood-vessels are injected with blue gelatin, so that in this photographic reproduction of the specimen the uninvolved portions of lung are dark, while the tubercles — in which the blood-vessels are compressed or obliterated — are light. (Bjy permission, from "Delafield and Prudden.") TUBERCULOSIS 177 Secondary Inflammatory Process. — The inflammation excited by the presence of the bacilli in the tissues is not always limited to the produc- tion of tubercles, for, beyond the nodular mass, there is frequently a proliferation of cells, with the production, in the lungs, of fibrinous or catarrhal pneumonia; or a proliferation of fibrous tissue and the pro- duction of so-called fibroid phthisis; in the blood- and lymph-vessels degenerative changes are often produced. Mixed infection is common, and the result is generally suppuration. A sterile cold abscess is not infre- quently formed without the entrance of pyogenic micro-organisms, doubt- less as a result of the irritation by the tubercle toxin. I. ACUTE TUBERCULOSIS. Acute Miliary Tuberculosis, General Tuberculosis, Acute Disseminated Tuberculosis. Definition. — A rapidly fatal acute tuberculous infection due to the dis- semination of bacilli through the blood-vessels and lymphatics, with the production of countless miliary tubercles in various organs and tissues. Etiology. — This form of the disease is almost always a result of auto- infection, often from a focus which is not recognizable during life. This focus is most frequently found in the lungs, pleura, lymph-glands, bones, joints, or kidneys; but nowhere more uniformly than in the tracheal and bronchial glands. Ponfick found it in the wall of the thoracic duct, and Weigert traced it in several instances to the perforation of a caseous bronchial gland into the pulmonary vein. A similar communication between a tubercular lymph-gland and a vein has been repeatedly dem- onstrated. The disease occurs more frequently in children than in adults. In some cases the general infection is so sudden, particularly when it follows an acute infection like measles or whooping-cough in a pre- viously healthy child, that it is not easily accounted for. A more or less prolonged attack of bronchial catarrh very often intervenes between the two infections. Morbid Anatomy. — The tubercles may be so uniformly distributed that almost every organ and tissue of the body is involved ; as a rule, however, they are more numerous in some regions than in others. The lungs, bronchi, liver, spleen, kidneys, and lymph-glands, the pleura, pericardium, peritoneum, and m.eninges are commonly affected, sometimes also the choroid coat of the eye, the bone marrow, especially that of the sternum, ribs, and vertebrae. The tubercles are for the most part small, from 1-500 to 1-250 inch in diameter. They are usually discrete, but they sometimes form large aggregations distinctly visible to the naked eye. They do not show secondary changes, as a rule, for the progress of the disease is so rapid that there is no time for such changes. (See Plate 11.) Symptoms.— Acute general toxemia is the most striking feature of the disease. There is sometimes a predominance of symptoms on the part of the lungs, cerebral meninges, peritoneum, or other structure, corresponding to an equally predominant invasion of these regions by the tubercles and giving rise to more or less distinct forms of the dis- 178 PRACTICE OF MEDICINE ease, as the pulmonary, meningeal, peritoneal, etc. They all belong to the same general infection of the system, however, and the local lesions merely add a few special features to the general symptomatology. (i) General or Typhoid Form. — The invasion is generally slow, often so similar to that of typhoid fever as to lead to a suspicion of that disease. After gradually increasing malaise, headache, loss of appetite, constipation, and perhaps chilliness, the temperature gradually rises to 103° or 104° F. (39.5° — 40° C); prostration rapidly ensues, and anemia and emaciation soon follow. The pulse becomes accelerated, often to 140 or more, and the respiration is rapid and labored, often from 60 to 80 in children. Cheyne-Stokes respiration often develops toward the end. The cheeks are flushed, and the face often becomes dusky. The tongue is dry, often brown; and delirium of a quiet, muttering type may early develop. There is usually a slight cough, due to bronchitis. In some cases, the onset is more sudden. The irregularity of the fever is a distinctive feature of the condition. The morning remission usually amounts to 2° or 3° F. (1° — 1.5° C), but occasionally the fever is inter- mittent and the temperature in the morning may be subnormal. On the other hand it is not uncommon to find the morning record higher than that of the evening. Rarely there is very slight fever throughout the disease, and afebrile cases have been described. Albumin and pepton are found in the urine. Sudamina are frequent and an eruption of herpes is often found upon the lips. As the disease progresses, the patient sinks into a stupor ; diarrhea may develop, with involuntary evacuations, and cyanosis often becomes extreme. Occasionally, however, the mind remains clear to the end. (2) Pulmofiary Form. — In this form, symptoms indicating the especial involvement of the lungs are added to those just described. The cough is more annoying; it has often existed for several months before the acute onset. There is usually a mucopurulent expectoration, sometimes containing traces of blood. Hemoptysis occasionally occurs. Dyspnea develops early, and cyanosis may be a prominent feature from the start ; the blueness of the lips and nails is often striking. The physical evidences of pulmonary involvement are not so great as might be anticipated. Areas of distinct dullness are exceptional. The percussion note may seem to lack resonance, but this condition is not confined to any region of the chest, and there is no means of comparison. In children a slight dullness may be detected at the base of the lung, or areas of increased or slightly tympanitic resonance may suggest the presence of solidifica- tion in other areas. Auscultation usually reveals sibilant or subcrep- itant rales. Tubular breathing may also be heard. The spleen usually becomes enlarged toward the close of the disease. Diagnosis. — The leading points of differentiation in the general form of the disease are the absence of localized lesions, the irregular tempera- ture, rapid pulse and respiration, marked dyspnea, possibly cyanosis, and the rapid progress of the disease. In typhoid fever the temperature is more regular, the respiration less rapid and free from marked dyspnea or cyanosis. Epistaxis fre- quently occurs in the beginning, and diarrhea is more frequent. The diazo reaction is common to both diseases, but the rose-spots are very rarely seen in tuberculosis, and when seen they do not occur in successive TUBERCULOSIS lyg crops and are not typical in form. Herpes is more frequent in tuber- culosis, and the tubercles may be found in the choroid. The lesions of typhoid fever and tuberculosis may, however, be found in the same person. The Widal test is the most valuable means of differentiation in a doubtful case. The presence of leucocytosis favors tuberculosis, but depends upon the existence of suppuration in either disease. In the pulmonary form the diagnosis is usually rendered less difficult on account of the tuberculous history in the family, the existence of a cough before the present illness, possibly also a recent attack of mea- sles, whooping-cough, or influenza; and the bacilli may often be demon- strated in the sputum. Malaria. — It is only the remittent form that resembles tuberculosis. The temperature is more regular, as a rule ; but the greater enlargement of the spleen and the presence of the plasmodium in the blood are more reliable features. Cerebrospinal Meningitis. — In this disease the pulse and respiration are usually less rapid, the onset is more sudden, and the nervous mani- festations, hyperesthesia, nystagmus, and disturbance of the reflexes are more prominent. Kernig's sign is not present in acute tuberculosis unless the meninges are distinctly involved. Capillary bronchitis may simulate acute tuberculosis in the beginning, but the pulse and respiration are not so rapid; dyspnea is less marked and the cough more troublesome. The fever does not usually become so high, and the prostration is not so great. 2. ACUTE MENINGEAL TUBERCULOSIS. Basilar Meningitis, Acute Hydrocephalus. Definition. — A form of acute tuberculosis in which the cerebral me- ninges are especially involved. Etiology. — Fully 50 per cent of all cases of miliary tuberculosis affect the meninges. The causes of this form are therefore the same. It is seen much more commonly in children between the ages of two and seven, but may occur at any time of life. It usually follows an involve- ment of the bronchial, mesenteric, or other lymph-glands or of the middle ear, and there may be a history of trauma. In some cases, how- ever, the affection of the meninges appears to be the primary lesion. It has been suggested that the bacilli may reach the meninges in such cases through the cribriform plate of the ethmoid. The ten cases of acute tuberculosis, mostly of the meninges, reported by Reich are of interest in this connection, since the disease followed the mouth-to- mouth resuscitation of stillborn children by a tuberculous midwife. Morbid Anatomy.— The membranes of the base are primarily and chiefly involved, but the tubercles may extend to all parts of the brain. The parts about the optic chiasm, along the larger blood-vessels and nerve-trunks, and over the tempero-sphenoidal lobes are especial points of attack. Less frequently the lesions are found on the convexities of the hemispheres. The pia is intensely hyperemic and the blood-vessels are all engorged. The walls of the vessels are not infrequently invaded by the tubercles, and thromboses sometimes result. The surface of the i8o PRACTICE OF MEDICINE pia is usually covered with a turbid, viscid, serous or fibrinopurulent exudate, and miliary tubercles are more or less profusely distributed over the affected surfaces. The lateral ventricles usually become distended with fluid, sometimes amounting to several ounces (acute hydroceph- alus), and as a result the hemispheres may become flattened. The ependyma may be softened and the septum lucidum and fornix may be broken down. The brain substance becomes edematous and infiltrated with leucocytes. Red softening, rarely white, and punctiform hemor- rhages are found. The association of acute and chronic tuberculosis of the meninges has been observed. In some cases the spinal meninges, especially in the cervical portion, have been found extensively involved. The other structures of the body are always involved in the disease. Symptoms. — There is generally a history of tuberculosis in the family and of a recent attack of measles or other acute infection, followed during several weeks or months by a gradual decline of health. During the week or two preceding the acute onset of the aff'ection there is often a complete change in the disposition of the child. It has become peevish, fretful, perhaps quarrelsome; the appetite has been lost and emaciation has become apparent. The course of the disease is divided into three stages, embracing a period of nervous excitement, a transition, and a stage of paralysis. (i) Sfage of Excitement. — The onset is usually gradual, often with a basilar headache, which increases in severity until it becomes agonizing. Persistent vomiting without regard to the ingestion of food is a marked feature, and there is usually moderate elevation of temperature, seldom exceeding 102° or 103° F, (39-o°^-39.5° C). At first on account of pain, but later on account of contraction of the cervical muscles the head sinks into the pillow. Very often the child grasps its head between its hands as if in great pain. Every now and then a loud shrill cry, known as the hydrocephalic cry, is uttered. In some cases the child screams continuously for days, or until the voice is lost from hoarseness and exhaustion. Obstinate constipation is a characteristic symptom, but diarrhea sometimes occurs in young infants. The course of the fever is irregular. The evening record frequently exceeds the morning by 3° or 4° F. (1.5° — 2.2° C). The pulse, at first rapid, becomes slow and feeble ; generally irregular. The respiration may be little disturbed. The sleep is restless and may be disturbed by muscular twitchings or nervous starts, and the child often awakes in terror. The pupils are usually contracted during this stage. Occasionally the onset is more violent with, perhaps, a convulsion, rapid rise of temperature, and maniacal delirium, sometimes leading to a fatal termination within a few days. These cases are more frequently encountered in adults or in children who have been for a long time tuberculous. They are as a rule associated with involvement of the con- vexity of the brain. Cases are also encountered in which the disease pursues a more chronic course, marked by psychical disturbances of a type that may arouse suspicion of a brain tumor. Convulsions and paralyses do not appear until a late period. (2) Transitional Stage. — The symptoms of irritation subside and there may be a deceptive promise of recovery. The vomiting ceases and the headache is no- longer complained of, but the child remains dull TUBERCULOSIS i8i and listless. It may even become delirious at night. The constipation persists, and the abdomen becomes retracted and boat-shaped (scaph- oid). The temperature is variable, but seldom exceeds 102° F. (39° C). The pulse is still irregular and the respiration is often broken by sighs. The retraction of the head persists, and opisthotonos is not uncom- mon. The hydrocephalic cry is occasionally uttered. The pupils are dilated or uneven; one large, the other small. Strabismus or ptosis may develop from paralysis of the extrinsic muscles. Tubercles may be found in the choroid coat of the eye. Livid spots of considerable size may appear in the face, and a red line (tache ce'rebrale, or Trousseau's mark) appears in the skin after the finger-nail has been drawn over it, but this is not characteristic of the disease. Convulsions sometimes occur, or the muscles of one side or of a single member may become either rigid or paralytic! A tetanic spasm sometimes seizes a single limb, and it may persist for several days. Choreic movements and tremors are not unusual. (3) Stage of Paralyses.— h. progressively deepening coma supervenes until the child can no longer be aroused. Convulsions may still occur ; and when the meninges of the cortical motor area are involved, the seizures may assume an epileptiform character. Spasmodic contractions often occur in the muscles of the neck and back, or they may be con- fined to the arm and leg of one side. Paralyses then develop. They may be either monoplegias or hemiplegias, the latter depending, as a rule, upon involvement of the cortical branches of the middle cerebral artery or upon softening in the internal capsule. Facial paralysis is the most common form of monoplegia. It is sometimes associated with paralysis of the extremities, the parts supplied by the third nerve, and the hypoglossal nerve of the opposite side. This association of paral- yses is known as the syndrome of Weber. The lesion is in the lower, inner part of the crus. Optic neuritis may also be found. The pupils again become contracted, the eyelids remain partially open, and the globe is rolled upward. Toward the close of the disease the temperature often becomes sub- normal; in exceptional cases as low as 93° or 94° F. (33.0° — 34-o° C); occasionally, however, there is, shortly before death, a rapid rise to 106° or even 110° F. (41.0^—43.0° C). The pulse becomes rapid, and the child sinks into a typhoid state with a dry tongue and low delirium. Leucocytosis is not infrequently present throughout the course of the disease. The duration of the disease is from two or three to four weeks, seldom longer. Diagnosis.— The diagnosis is seldom difficult when the character of the invasion and the distinctive features already referred to are fortified by a history of tuberculosis in the family or the presence of a tuber- culous lesion in another part. But in young infants many other dis- turbances, as a gastroenteritis, may excite rapidity of the pulse and respiration or convulsions. The train of symptoms is, however, entirely different. In gastroenteritis, diarrhea is present and the fontanels are depressed; they are usually prominent in meningitis. The hydrocephalic cry and irregularity of the pulse and respiration are absent. Lobar pneumonia in young children is often mistaken for meningitis, but less frequently, perhaps, for the tubercular form of it. In it the onset 1 82 PRACTICE OF MEDICINE is more sudden, retraction of the head, constipation, and paralytic mani- festations are absent or much less prominent. Otitis media, accompanied by the retention of pus, may cause meningeal irritation with the production of symptoms suggestive of meningitis ; the latter condition is in fact sometimes produced. Puncture of the drum membrane and evacuation of the pus quickly establishes the diagnosis. Cerebrospi?ial Meningitis. — From this disease the tubercular form is distinguished by the less sudden onset in most cases, but especially by the absence of the diplococcus intracellularis in the fluid obtained by lumbar puncture. The bacillus tuberculosis may be obtained in it. In both conditions the tension of the fluid is increased, but the withdrawal of a sterile fluid is also quite characteristic of the tubercular form of the disease. Prognosis. — The disease is almost invariably fatal. Recovery is so improbable that in the few cases that have been reported the diagnosis has been called in question. Quite recently, however, a case has been observed in which recovery occurred after the demonstration of the bacilli tuberculosis in the cerebrospinal fluid. Calomel was the only therapeutic agent employed. Treatment. — It is considered useless to attempt more than the relief of suffering. To this end the patient should be placed upon a soft bed in a moderately dark room and he should be disturbed as little as possible. For the relief of pain and restlessness sodium bromid, gr. V to X (0.3—0.6), and chloral, gr. ij to iij (0.1—0.2), may be given to a child; but if this fails, and especially in the meningeal form, opium in the form of paregoric, Dover's powder, codein, or morphin should be given in sufficient doses to control the nervous manifestations. It may become necessary to administer food by the rectum and drugs hypo- dermically when the vomiting is uncontrollable or the delirium active. An ice-cap should be applied to the head. The constipation may be relieved by enemata, glycerin suppositories, repeated doses of calomel, or a saline laxative of which the effervescent magnesium citrate is gen- erally the most acceptable. The diet should consist chiefly of milk with broths and eggs. II. LOCALIZED TUBERCULOSIS. I. TUBERCULOSIS OF THE LYMPHATIC SYSTEM. Tubercular Adenitis, Scrofula, Tubercular Lymphadenitis, Scrofulosis. Etiology. — The disease is much more common between the first dentition and puberty than in infancy or adult life. It may occur, however, at any time of life. The bacilli gain entrance through the mucous membrane of the mouth, throat, bronchial tubes, or intestine, possibly sometimes through the integument. The condition is therefore favored by a catarrhal condition of these mucous membranes, and more remotely by inherited syphilis or a tubercular tendency, both of which favor the development of catarrh. Rachitic children are also readily infected. In adults the condition may follow the inhalation of dust. It often follows an attack of whooping-cough, measles, or influenza. TUBERCULOSIS 183 Morbid Anatomy.— Tht enlargement of the afifected glands is due chiefly to an increase in the number of their lymphoid cells. These cells also appear swollen and their nuclei are large. Miliary tubercles, some- times containing giant cells and bacilli, are also found in the glands. When the process is acute, the glands occasionally become hyperemic; suppuration is unusual. Later the tuberculous tissue may undergo caseation and calcification. When suppuration occurs it is usually with- out the presence of pyogenic organisms, and the pus is sterile. In the neck a fistulous opening sometimes forms through the skin for the evac- uation of the pus. The bronchial glands often become enormously enlarged. Death may result from perforation and evacuation of their contents, after suppuration, into the trachea or bronchi; from com- pression of the esophagus; from erosion of the pulmonary artery or aorta or, more remotely, from rupture into the mediastinum or pleural cavity. The bronchial glands are probably the most frequent source of the acute dissemination of miliary tubercles. Symptoms. — (i) General Adenitis. — This form is characterized by a more or less general enlargement of all the lymph-glands of the body. It is most frequently seen in the negro and especially in connection with pulmonary tuberculosis. The condition is usually accompanied by high fever and often runs a rapidly fatal course. It frequently resembles Hodgkin's disease. In infants and children a general adenitis is encoun- tered in which one group of glands is involved after another, ultimately terminating in a fatal invasion of the meninges. (2) Cervical Adenitis. — This form is the most common in children. The swelling involves the submaxillary and anterior cervical glands, less fre- quently the posterior cervical. It is generally unilateral in the beginning, but both sides are not infrequently aff"ected. The individual glands are much enlarged and firm. In size they vary from as small as a pea to as large as a walnut. They are not usually painful or sensitive to pressure. Large masses may be formed, which entirely obliterate the lines of the neck. It was probably from this deformity that the disease received the name scrofula, from scrofa, a pig. Coryza and acute nasopharyngeal catarrh are common accompani- ments of the adenitis in these cases, and any influence which aggravates the catarrh tends to increase the enlargement of the glands. Moderate fever is often associated with the acute catarrhal symptoms. Slight inflammation of the glands may occur and ultimately pass into suppura- tion. Anemia soon appears and emaciation follows in most cases. The general condition is poor; wounds heal slowly, and there is a tendency to conjunctivitis or keratitis, otitis and eczema. After the disease has afifected for some time the cervical glands there is frequently an involve- ment of the supraclavicular, axillary, and bronchial, and this extension of the disease is usually followed by pulmonary tuberculosis. On the other hand, the condition may terminate in recovery after months or years. It is an interesting fact that persons who show scars of early tubercular adenitis in the neck are seldom the victims of pulmonary tuberculosis in later life. (3) Tracheobronchial Adenitis. — Enlargement of these glands ordinarily produces cough, dyspnea, or asthmatic seizures. Auscultation sometimes reveals the evidence of compression to the extent of a roughened inspir- 1 84 PRACTICE OF MEDICINE atory murmur and prolongation of expiration. A venous purr may sometimes be heard by auscultation over the upper portion of the ster- num, with the head of the patient thrown far back. Extreme enlargement may cause compression of the esophagus with more or less complete interference with deglutition. Traction diverticula have also been attrib- uted to this cause. Infection of the pleura or lung by direct extension of the infection or acute miliary tuberculosis, as a result of the rupture of a suppurating gland, is liable to develop at any time. The same results are sometimes observed without perforation. Bronchopneumonia is a common sequel. (4) Mesenteric Adenitis. — This form of tuberculous adenitis produces a condition often spoken of as tabes mesenterica. In it the mesenteric and retroperitoneal glands become enlarged and indurated and often undergo caseation, less frequently calcification, and very rarely suppura- tion. The condition may be primary, the infection occurring from the intestinal mucous membrane, but it is commonly secondary to other tubercular disease. The patient, usually a child, becomes anemic and rapidly emaciates. The skin is dry and wrinkled and the hair falls out. Periodic fever is usually observed and may be attributed to the dis- ordered digestion, which is a prominent feature. Diarrhea, with large, watery, fetid stools, is usually present, and the abdomen is tympanitic. The abdominal walls become thin, and when meteorism is not present the enlarged glands may sometimes be felt through it. The peritoneum is often involved in these cases. Enlargement of the mesenteric glands is a frequent result also of pulmonary tuberculosis. Diagnosis. — The cervical form of the disease is rarel}- difficult of rec- ognition. The tuberculous history, chronic enlargement, and tendency to caseation or suppuration leave little doubt of the character of the adenitis. The condition is to be differentiated from syphihtic, lymph- adenomatous, leukemic, and malignant adenitis. Syphilis. — The glands of the groin, axilla, and epitrochlear region are the more usually involved in this disease. Suppuration rarely occurs in them, and the administration of antisyphilitic treatment promptly reduces the swelling. Ly7nphadenoina (^Hodgkin' s Disease^. — The glands are more movable, even less sensitive, and do not suppurate or undergo caseation. It is more common in adult males. The disease affects groups of glands; it is common in the posterior cervical, but rare in the submaxillary or anterior cervical. Lezckemia. — The glandular enlargement may resemble that of tuber- culosis, but the condition is recognizable by the profound anemia and extreme leucocytosis. Sarcoma. — The enlargement of the glands is much more rapid and the adjacent tissues are soon involved in the disease. Carcinoma attacks the glands only secondarily and those nearest the primary growth. Treatment. — The measures recommended for the treatment of general tuberculosis should be carefully followed, giving the child all the benefit of fresh air and good diet. Local applications are seldom of benefit; mas- sage is often harmful. The application of equal parts of guaiacol and glycerin has proved of apparent benefit. The internal administration TUBERCULOSIS 185 of sirup of the iodid of iron often assists in reducing the swelUng. Cod- liver oil is especially useful in children. Careful removal of the glands has been performed with benefit, but it has undoubtedly been the means of disseminating the virus. It should be attempted only when rapid increase of size or suppuration threatens to produce rupture of the glands. 2. TUBERCULOSIS OF THE SEROUS MEMBRANES. (i) General Serous-membrane Tuberculosis. This form of the disease may be only a part of an acute miliary tuberculosis, or it may be an independent form of tuberculous infection, without visceral involvement. The serous membranes may become in- volved simultaneously or, as is more generally the case, in rapid suc- cession. ((3!) The disease may be acute, the infection being derived from the bronchial or mediastinal lymph-glands, or in women from the Fallopian tubes. The pleurae and peritoneum are generally involved. (/;) A chronic form occurs also in which there is exudation and the for- mation of cheesy masses in the pleurge and peritoneum, and it is not infrequently accompanied with inflammatory and suppurative processes. In extremely chronic cases the tubercles become hard and fibrous, the membranes become much thickened, and little or no exudation occurs. The pericardium may be implicated in either of these forms of the disease. (2) Tuberculosis of the Pleura. Eiiology. — Fully one-third of all cases of acute, nontraumatic pleu- risy are of tubercular origin. Some authors regard all such cases as of this character, since a very large number of them respond to the tuberculin test and others are followed by pulmonary tuberculosis a few months or possibly several years afterward. But on the other hand there can be no doubt that many acute cases entirely recover. The condition may be : (a) Primary and independent of other tuberculous infection; (^) a part of an acute mihary tuberculosis; (r) secondary to the ordinary form of pulmonary tuberculosis, or to a tubercular proc- ess in the cervical or bronchial glands, or the bodies of the vertebrae; or (^/) it may be a part of a general involvement of the serous mem- branes. Probably not all instances of the development of pleuritic inflammation in the course of chronic pulmonary tuberculosis are of a tuberculous nature, however, for they frequently leave only fibrous adhe- sions between the two layers, without discoverable tubercle-formation. Symptoms. — The infection is generally unilateral and it may pursue an acute, subacute, or chronic course. Such prodromal symptoms as cough, mucopurulent expectoration, anemia, emaciation, sometimes an occasional hemoptysis, may precede either of the forms for many months, especially when the disease occurs in the course of chronic pulmonary tuberculosis. Acute Form. — The actual onset of the pleuritic involvement is often announced by the occurrence of a sharp stitch in the side or by a dis- tinct chill. An exudate quickly forms in most cases, and, partly at least as a result of it, there are cough, dyspnea, and moderate elevation of 1 86 PRACTICE OF MEDICINE temperature, usually from ioi° to 103° F. (38.5° — 39.5° C). The ex- udate may be serous or serofibrinous in the beginning, but frequently becomes seropurulent, sanguinolent, or purulent as the disease progresses. A purulent change is invariably induced by tapping without proper antiseptic precautions. The most characteristic fluid is slightly green- ish, opalescent, seropurulent, and contains granular fat and a few leu- cocytes. Tubercle bacilli and other bacteria may be present, or the fluid may be sterile. In many cases, after a course of from three to six weeks, the fever and pain subside and the exudate is gradually absorbed. In other cases the disease becomes chronic. The subacute and chronic fot'ms may follow the acute or they may develop so insidiously as to appear chronic from the first. After a long period of cough, emaciation, and loss of weight and strength, slight pleuritic pain may be complained of, or physical examination may first reveal impaired expansion of the affected side of the chest, with an accumulation of fluid in the pleural cavity, or dullness due to thickening of the pleura. The fluid may be serofibrinous or purulent. The thick- ening of the pleura varies from ^^ to i inch (0.5 — 2.5 cm.) and there is sometimes only a small quantity of a thick caseous fluid at the base of the cavity. The pleural cavity may, indeed, be almost completely obliterated through hyperplasia of the membrane and the formation of adhesions between the parietal and visceral layers. A most virulent type of empyema or pyopneumothorax is developed in these cases by the rupture of an abscess cavity or a softened caseous nodule in the lung. In the less fatal cases of primary tuberculosis of the pleura the lung may ultimately become involved or an acute miliary tuberculosis may be instituted. Diagnosis. — The diagnosis of pleurisy is considered under the diseases of the pleura. The tuberculous character of the condition is sometimes determined with much difficulty if the disease be primary, but in the presence of pulmonary or other recognized tuberculous infection there is always a strong probability of its tubercular nature. The presence of blood or tubercle bacilli in the exudate or the discovery of bacilli in the sputum is highly confirmatory of the diagnosis. When no other means is sufficient for the determination of the condition, the successful inocu- lation of a guinea-pig with the aspirated fluid will establish the diag- nosis. Treatment. — This combines the general methods of treating tuber- culosis and those for the relief of pleurisy. (3) Tuberculosis of the Pericardium. Etiology. — The pericardium is much less frequently affected than the other serous membranes. It is usually secondary to disease in other parts, perhaps never primary in character. It may be a part of a miliary tuberculosis or it may result from tuberculosis of the mediastinal or bronchial glands, or it may be a direct extension from disease in the pleura or lung. Either layer of the pericardium may be involved and the disease may be either acute or chronic, simple or purulent. The quantity of the exudate varies from a little more than normal to as much as 64 ounces (Musser). The disease is sometimes latent TUBERCULOSIS 187 and may be discovered only at autopsy. As in tuberculous pleurisy, the membrane may be greatly thickened and the layers of the pericar- dium may become more or less completely adherent. As a result of the latter condition hypertrophy and dilatation of the heart are pro- duced, and valvular insufficiency often results from this change. A loud, blowing systolic bruit is often heard at the apex, corresponding in time to that of either a stenosis or an insufficiency. Treatment — The treatment consists in the application of the meas- ures employed in a nontuberculous pericarditis and those for the general treatment of tuberculosis. (4) Tuberculosis of the Peritoneum. Eiiology. — The condition is probably never primary in its origin. It may be secondary to tuberculous disease of the endometrium or Fallopian tubes, the intestine, or mesentery. It has also been traced to disease of the epididymis, the vesiculge seminales, or prostate. It may be a part of a miliary tuberculosis, the bacilli reaching the peri- toneum through the blood; or of a general tuberculosis of the serous membranes. It may result from the perforation of a tuberculous focus that has undergone softening or suppuration in any of the adjacent organs. Trauma of the abdomen is thought to have an influence in producing localization of the infection in the peritoneum. Cirrhosis of the liver and hernia are thought to favor its development. The disease may occur at any age, but is especially frequent in children, when it is usually a result of the extension of infection from the intestine or mesentery. Its occurrence in the two sexes is probably about equal, since it has been noted more frequently by the gynecologist than by the surgeon; but in men it is oftener found on the post-mortem table. Morbid Anatomy. — The tubercles are usually numerous, studding the entire surface of the peritoneum; more rarely they are confined to a circumscribed area. The character and the quantity of the exudate vary considerably, and the other conditions correspond to these features. When the disease is a part of an acute tuberculosis, the peritoneum is studded with young, gray, translucent tubercles, smaller than pin- heads. In a less acute form the tubercles show a tendency to become clustered into patches or nodular masses, and the peritoneum is often much thickened. It is also hyperemic in many cases, and covered with a layer of fibrin. The subsequent changes may be of a caseous, sup- purative, ulcerative, or sclerotic character, with the production of a variety of lesions. The tubercles are often opaque, yellowish, and ca- seous, and the larger masses that«are formed may undergo caseation or suppuration. The omentum is especially prone to involvement and often becomes shrunken into a dense roll. The mesentery also becomes greatly thickened by a fibrous increase and may draw the attached intestine into a firm, tumor-like mass. The tissues are frequently much indurated and pigmented. The skin also shows pigmentation in many of the more chronic cases. The exudate is generally abundant in the acute form, but it may be much or little in the chronic. In character it may be either serous, fibrinoserous, or hemorrhagic; it is not often purulent. The adhesions are numerous in chronic cases. They some- 1 88 PRACTICE OF MEDICINE times campletely encapsulate the exudate, forming several isolated sacs. The tubercles may be concealed between the adherent surfaces. Large masses are sometimes formed which are readily mistaken on palpation for cancerous formations. The wall of the intestine is sometimes per- forated within these circumscribed areas. A localized tubercular peritonitis sometimes occurs, producing large caseous, often pigmented masses on the surfaces corresponding to the localization of tuberculous ulcers wdthin the bowel, or to similar tuber- culous formations in the Fallopian tubes ; hkewise on the inferior surface of the diaphragm when the pleura or pericardium is affected. Symptoms. — The condition may be either acute or chronic : («-) Acute Tubercular Peritonitis. — In the very acute cases the onset may be sudden and violent, with intense pain, great tenderness, meteorism, and vomiting. Constipation is usually present, unless diarrhea is pro- duced by the simultaneous presence of tubercular enteritis. These cases resemble acute enteritis, appendicitis, hernial strangulation, the perforation of a typhoid ulcer, or acute obstruction. The course of the disease may be intermittent, attacks of severe pain alternating with intervals of almost complete relief. Fever is usually present, often reaching 103° or 104° F. (39-5° or 40.0° C). With the formation of the exudate, the abdomen becomes more distended and the presence of fluid may be recognized by dullness and fluctuation. The other symptoms of acute general peritonitis — rapid pulse, distended, motionless abdomen, dorsal decubitus, elevated knees, and anxious, Hippocratic facies — are generally noted in acute cases. In less acute cases the symptoms develop slowly and the pain is less severe. There may be a gradual rise of temperature, possibly to 103° F. (39.5° C), and the cKnical picture may be that of typhoid fever. In some instances the disease remains for a long time latent until the ascites causes it to be recognized. The exudate may become so abundant as to interfere with respiration and cause embarrassment of the portal and renal circulation. Subacute cases are particularly liable to pass into the chronic form. (JT) Chronic Tubercular Pei'itonitis. — This form corresponds to the caseous, suppurative, and sclerotic conditions referred to under Morbid Anatomy. The abdomen often becomes firm and indurated. The shrunken omentum and intestine may often be felt through the abdom- inal wall as large, tumor-like masses. The fever is usually slight, or it may be absent; a subnormal temperature is not uncommon, the oscilla- tion often being confined for days between 95.5° and 97° F. (35.2° and 36.2° C). WTien, however, suppuration occurs, the temperature rises and pursues an irregular course. With* the progress of the disease, anemia and emaciation become more and more pronounced, with cor- responding loss of strength and reduction of weight. More or less com- plete occlusion of the bowel may develop at anj- time or the intestinal wall may become tubercular and diarrhea often sets in with bloody dejections. Intestinal perforation may take place and cause a sudden, violent exacerbation of the symptoms. Leucocytosis is generally absent in all forms of tubercular peritonitis. Diagnosis. — The condition, especially when discovered at operation, is to be distinguished first from the non-tuberculous nodular grown:hs TUBERCULOSIS 189 that are occasionally found upon the peritoneum. The differentiation can be made in many instances only by the demonstration of the bacillus tuberculosis or the tuberculin test. The condition is perhaps often mistaken for tubercular peritonitis. In the acute cases the dif- ferentiation is usually to be made from typhoid fever, appendicitis, strangulated internal hernia, and intestinal obstruction ; and in chronic cases from ovarian cyst and other abdominal tumors with fluid con- tents, as well as from chronic peritonitis of nontuberculous nature just referred to. Typhoid Fever. — This is excluded by the absence of epistaxis, enlarge- ment of the spleen, or roseola, and the negative reaction of the Widal test. Appendicitis. — In this disease the abdominal distention is more uni- lateral, the right rectus is tense, the right knee alone elevated; and the presence of a sausage-like tumor in the ileac fossa, with tenderness at McBurney's point, is distinctive. Leucocytosis is usually present. Hernial Strangiilatio7i. — This condition or obstruction from any other cause develops suddenly; the patient may be free from suspicion of tubercular disease. The pain is localized and paroxysmal; tympanites is marked. The most valuable symptom is feculent vomiting, which generally sets in within a few hours. Acute Enteritis. — This is liable to cause confusion only when it occurs in a tuberculous subject. The profuse diarrhea tends to reduce rather than to increase the abdominal distention, and there is seldom marked elevation of temperature or the typhoid state. Abdominal Tumors. — The differentiation of these growths, of whatever kind, is to be made chiefly by a study of the etiology. In the presence of an evident source of tubercular infection, in the lung, genitourinary tract, or elsewhere, the condition is most likely to prove tubercular. Ovarian cyst is generally slower in growth, -and malignant neoplasms more rapid, than tuberculous nodules. Febrile attacks and digestive dis- turbances are less frequently observed in connection with them. Prognosis. — The chance of permanent recovery is exceedingly poor. Spontaneous recovery sometimes occurs in cases regarded as tuberculous, and laparotomy frequently gives relief. Cures have been claimed from it in«from 70 to 80 per cent of cases, but relapse is the rule in cases of known tuberculous character, sometimes after months or years of apparent freedom from the disease. Treatment — The treatment is constitutional, symptomatic, and sur- gical. The former embraces the methods for general tuberculosis. Rest is essential. The food should be the most nourishing and as largely as possible of meat. Pain may be relieved by hot fomentations, poul- tices, ice-bags, the application of iodin or turpentine stupes ; but opiates may be required. Constipation calls for laxatives; excessive diarrhea, for opiates and astringents. Guaiacol, iodoform, and salol may be used as intestinal antiseptics, and they possibly exert an influence on the disease. Withdrawal of the fluid by repeated aspiration under strict asepsis has proved efficient in some cases, but laparotomy is generally resorted to when other methods fail. In children the administration of sirup of the iodid of iron and the application of guaiacol in glycerin to the abdomen have sometimes proved beneficial. I90 PRACTICE OF MEDICINE 3. TUBERCULOSIS OF THE RESPIRATORY ORGANS. (i) Tuberculosis of the Nose. The nasal cavities are rarely the seat of tuberculosis. It is not infre- quent, however, to find the bacilli within the nostrils of healthy indi- viduals, and this fact probably indicates that this mucous membrane is less susceptible to infection than that of the lower respiratory passages. WTien the disease occurs, it is usually secondary to tuberculosis elsewhere. Symptoms. — The condition is one of catarrh, with more than the ordi- nary tendency to hyperplasia of tissue and the formation of ulcers. These in turn lead to the formation of large crusts and frequent epistaxis, especially upon removal of the accumulations. The condition is usually a part of a late tuberculosis and not, there- fore, of long duration. The treatment consists of the removal or de- struction of the nodes and ulcers, but as the disease is attended with little or no pain the adoption of painful measures can hardly be advised. (2) Tuberculosis of the Larynx. Etiology. — The disease is rarely primary in character, and, when it is so, it probably originates from inoculation with bacilli in the inspired air. As a secondary infection it is not uncommon, especially as a late complication of pulmonary tuberculosis. The infection may originate from the sputum which passes over the larynx from the lungs or it may be conveyed through the blood-vessels or lymphatics. A lesion is necessary to permit the entrance of the bacilli, and such a lesion may no doubt be produced by violent coughing. Morbid Anatomy. — The mucous membrane becomes swollen, partic- ularly over the arytenoid cartilages, and tubercles form in it, at first in the vicinity of the blood-vessels. Hyperemia does not, however, ap*- pear until comparatively late. The tubercles group themselves into a few small nodules, as a rule, then undergo caseation and break down, leaving shallow ulcers of unequal size and irregular shape. These are situ- ated, in most cases, over the arytenoid cartilages, on the vocal cords, and on the epiglottis. The adjacent mucous membrane becomes thick- ened, especially over the arytenoids. Later the ulceration may lead to the total destruction of the vocal cords and epiglottis and the development of perichondritis, sometimes with exfoliation of cartilage. The disease shows a tendency to spread in all directions. It may extend laterally and upward to involve the fauces, pharynx, and tonsils, or downward over the cricoid cartilages. Stenosis of the larynx is one of its infrequent results, being produced by the contraction of cicatricial tissue following the ulceration. Symptoms. — The involvement of the larynx is usually announced by a huskiness of the voice that increases to a decided hoarseness and in extreme cases to complete aphonia. Deglutition and phonation be- come difficult and painful. The cough is at first not very severe, but later, when ulceration has occurred, it becomes extremely trouble- some, hoarse, and ineffectual, often paroxysmal. Dyspnea is a frequent accompaniment of the condition, \\Tien the epiglottis becomes exten- TUBERCULOSIS 191 sively ulcerated, swallowing is correspondingly difficult. Food often enters the larynx and causes paroxysms of coughing and threatened suffocation. Laryngoscopic examination reveals a characteristic thicken- ing and pallor of the mucous membrane, or, later, an extensive destruc- tion of tissues. The ulcers are shallow, have an irregular outline, and- the base is usually covered with a gray, necrotic exudate. The vocal cords are thickened, usually ulcerated. Diagnosis. — The disease is to be distinguished chiefly from catarrhal and syphilitic laryngitis. Catarrhal laryngitis may occur in a tubercu- lous patient. The differentiation is often difffcult, since the presence of bacilli may be only accidental. Ulceration is seldom so extensive, and the peculiar pallor is not usually present. From the syphilitic form the tubercular is to be differentiated chiefly by the history of the case, the presence of tubercle bacilli, and the absence of general glandular enlarge- ment. Prognosis. — The prospect for cure is not only bad in all cases, but the development of laryngeal tuberculosis in the course of the pulmonary disease adds an element of great gravity to the case. Treatment. — The general treatment is that of the underlying pul- monary tuberculosis; nothing is so important as fresh air and light, with tonics and nutritious food. Local Treatment. — The ulcers should be kept clean with an alkaline spray. Astringents may be applied in the same manner. A solution of menthol and camphor gives great relief. Creosot should sometimes be added to the solution. In advanced cases cocain may be required, particularly at mealtime, to prevent the pain of swallowing. Insuffla- tion of iodoform after thorough cleansing is thought to promote heal- ing. Extensive ulceration requires the care of a specialist who may be able to improve the condition by curetting and applying caustics, silver nitrate or lactic acid. After destruction of the epiglottis the patient is able to take nourishment only in fluid form, sometimes by sucking it through a tube with the face downward, but generally only through the stomach-tube. (3) Tuberculosis of the Lungs. Pulmonary Tuberculosis, Phthisis Pulmonum, Consumption. Infection of the lungs arises most frequently from the inhalation of bacilli-laden dust; less frequently through the blood- or lymph-vessels. The conditions developed are not identical. When the bacilli have entered through the bronchial tubes, the primary lesions are usually found in the smaller bronchi and bronchioles. Their walls become in- filtrated with granulation cells and surrounded by layers of lymphoid and epithelioid cells forming peribronchial granulations which are often found in a state of caseation. The lumen of the tubes becomes closed by a caseous mass of desquamated epithelium. The condition is not confined to single groups of alveoli, but affects more distinctly lobules, sometimes even an entire lobe. When the bacilli reach the lungs through the blood or lymph, the primary lesions are located in the walls of the alveoli, capillary vessels, or the connective tissue of the interalveolar septa. Tubercles of the 192 PRACTICE OF MEDICINE miliary type, small, microscopic collections of cells, are formed within a few days, but soon coalesce to form larger masses. The subsequent changes in them are the same as have been previously described under the head of Morbid Anatomy of Tubercle, on page 175. The condition may be either localized or general throughout the lungs. When the disease is a part of a general tuberculous infection, the tubercles are found in all parts of both lungs. When the process is localized, it is generally confined to the apex of one lung; a little more frequently (about as 7 to 5) in the left; next most frequently in one lower lobe, near the base or in the middle portion, as a rule. From the area originally involved the disease gradually extends until it invades the greater part of both lungs. The mode of extension is either : (^) Directly to contiguous tissue, through which numerous foci are frequently merged; (^i^} by transmission through the blood-vessels or lymph- channels to more distant parts of the lungs ; or (^) by the inoculation of other parts from the sputum in its passage outward or through its aspiration into adjacent lobules. There are three principal forms Of pulmonary tuberculosis, the acute pneumonic, the chronic ulcerative, and the fibroid. (/) Acute Pneumonic Tuberculosis. Pneumonic Phthisis, Caseous Pneumonia, Phthisis Florida, Galloping Con- sumption. Of this disease there are two forms, the pneumonic and the bron- chopneumonic, distinguishable clinically and by their pathological lesions. (a) The Pneumonic TyJ>e.—Th.t process may be confined to a single small area, perhaps to oiie apex, but it may involve an entire lung. It is usually rapid in its progress. The affected area becomes solidified, heavy, and airless, much as in lobar pneumonia. The sohdification is due to the infiltration of the alveolar septa with serum and leucocytes and the filling of the air-cells with an exudate consisting chiefly of pro- liferated and desquamated epitheHal cells. The entire area subsequently undergoes caseation, and small cavities are formed, except in the more rapid fatal cases. The infiltrated area may appear so nearly homo- geneous on post-mortem examination as to render the recognition of the tubercles quite impossible without the microscope. As a rule, how- ever, the character of the lesions will be revealed by the finding of the more chronic changes in other parts of the lungs. The bronchial glands are always enlarged, and the pleura over the affected areas is covered with fibrin or caseous matter. The surrounding portions of the lungs may be hyperemic, but there is never any evidence of a tendency to resolution. Symptoms. — The disease may develop insidiously in a person who has been debilitated by illness, alcohohsm, or overwork and exposure, or it may be announced by a chill. It sometimes occurs in individuals in apparently good health. A severe cough develops, the sputum be- comes mucopurulent, sometimes "rusty," and often contains bacilli and later elastic tissue from the disintegrating lung. The temperature rapidly rises, perhaps to 103° or 104° F. (39.5°— 40° C). There is pain TUBERCULOSIS ' ' 193 in the side. Sweating usually occurs at frequent intervals, especially at night. The pulse is accelerated, the breathing becomes rapid, a.nd dyspnea may become urgent. Physical examination reveals consolida- tion, indicated by dullness, increased fremitus, absence of vesicular mur- mur and tubular breathing. The urine may show the diazo reaction. The condition is almost identical with that of lobar pneumonia, but the crisis does not occur and the condition becomes progressively worse. The rusty sputum becomes changed into the "prune-juice" expectora- tion, the prostration becomes extreme, the feet become edematous, and cyanosis may develop. Death sometimes occurs as early as the second or third week, but it may be delayed as long as two or three months. Occasionally the acute symptoms subside and the case progresses as one of chronic tuberculosis. Diagnosis. — When the disease occurs in one who has not previously been the subject of recognized tuberculosis, the differentiation from lobar pneumonia may be for a time impossible. The condition may not be suspected, in fact, until the disease is found to be growing worse instead of undergoing resolution after the period of the expected crisis has passed. By this time, however, it may be possible to demonstrate the bacilli in the sputum. The occurrence of repeated chills or frequent chilly sensations, and more particularly the character of the tempera- ture curve, may arouse suspicion, for the oscillations are usually greater than in lobar pneumonia, often amounting to 2° F. (1.1° C). (Ji) BroncJiopneu7nonic Type. — This form of the disease is more com- mon than the pneumonic, and is met with especially as a sequel to the bronchitis of measles, whooping-cough, diphtheria, or other acute infection in children who are predisposed to tuberculosis. Not infre- quently, indeed, the disease is the rekindling of a tubercular process already existing in the individual. The process begins in the smaller bronchi, which become filled with a cheesy accumulation of desquamated epithelium. As a result, the alveoli are closed, and a catarrhal pneu- monia is virtually established. In the beginning the affected areas are hyperemic, but later they become opaque and caseous. The consolidation is usually confined to more or less isolated areas between which the lung still contains air, but in extreme cases an entire lobe may become al- most solidified. The bronchial glands are usually much enlarged. In another class of cases the affected areas are small and confined to different parts of both lungs, generally to the apices. A similar condi- tion sometimes results from the aspiration of blood and the contents or tubercular cavities into the unaffected portions of the lungs during a hemoptysis. Mixed infection sometimes occurs when other organisms gain entrance, but in many cases the bacillus tuberculosis alone is found. Symptoms. — In children the disease frequently engrafts itself upon a bronchial catarrh without for a time exciting unusual symptoms further than a prolongation of the condition. On close observation, however, the child will be found to have a fever, with flushed cheeks toward evening (hectic fever). The breathing becomes more rapid and the expectoration more abundant. Emaciation also develops with much rapidity. On physical examination slight dullness may be detected at one or both apices, occasionally in other parts of the lungs. 13 194 PRACTICE OF MEDICINE In other cases the onset is more abrupt. The child may be in an enfeebled condition from previous illness or it may be the subject of rickets or of unrecognized tuberculosis. There is a sudden rise of tem- perature and severe cough, with rapid solidification of one or both apices, and numerous subcrepitant rales are heard on auscultation. These cases sometimes terminate fatally within three or four days, and with- out microscopic examination of the lesions there may be nothing to indicate the tubercular character of the bronchopneumonia. In adults the disease may attack an individual in good health, but it is much more frequently observed in those who have been debilitated or those who are the subjects of tuberculosis. The attack generally begins with a succession of chills or chilly sensations, followed by high fever, rapid pulse and respiration. Sometimes there is hemoptysis. Emaciation and loss of strength and weight rapidly follow. The physi- cal signs in the early stage of the disease are only those of broncho- pneumonia, but later the areas of dullness become distinctly recognizable. As the disease progresses, the fever becomes irregular, sweating is often profuse, and frequent chills may occur. The case may terminate' fatally within three weeks, or it may gradually subside into a chronic condition lasting for several months. (2) Chronic Ulcerative Tuberculosis of the Lungs. Morbid Anatomy. — In the great majority of cases the lesions are first found in one or both apices, usually an inch or more below the sum- mit. From this point the process passes rapidly or slowly downward. This extension of the disease is probably in part a result of the aspi- ration of the sputum or caseous matter into the bronchial tubes. The new growth of tubercles is then located in the tapering extremity of the terminal bronchus, near the entrance to the infundibulum. From the smaller bronchi the process may extend upward, however, to the larger tubes. The disease extends also directly from the affected center to adjacent tissue. It may follow the lymph channels, producing a chain of young tubercles radiating from the primary center, and it may be carried by the blood. Autoinfection no doubt occurs as the result of the inhalation of dried sputum from the patient's own clothing, or possibly from some other source. The disease thus progresses from one region to another until an entire lobe, an entire lung, or a greater part of both lungs becomes converted into a mass of tuber- cular tissue in different stages of growth and degeneration. The processes of infiltration, caseation, and sclerosis have been con- sidered under the head of Morbid Anatomy of Tubercle. As a result of these processes many different conditions are produced. Caseation leads to necrosis of the tissues and ulceration, with the formation of cavities. This frequently occurs in the wall of a bronchial tube. As a result, the wail is rendered thin and less resistant to the expansive force of the air in coughing. The walls stretch and form fusiform dilatations (bronchiectatic cavities). The further destruction of the tissues is often hastened by the entrance of pus-forming germs into these cavities. The necrotic destruction may begin, however, among the air-cells, particu- larly in the apex. Recent cavities, still in a state of formation, have uneven, ragged surfaces or they are lined with caseous debris. Such Practice of Medicine.— French. PLATE II Diffuse and Focal (Chronic) Pulmonary Tuberculosis — " Chronic Phthisis." In the upper third of the lung there is tuberculous broncho-pneu- monia with commencing ulceration of small bronchi : nearly complete consolidation from the extension and coalescence of small tuberculous foci and diffuse formation of fibrous tissue. In the lower third of the lung are irregular, dense, sharply outlined tuberculous foci (chronic miliary tubercles). In the middle third there is tuberculous pneumonia of the exuda- tive type, the incompletely consolidated areas having become, in part, caseous. The less involved portions of the lung in this, as in the other injected specimens, are the darker. (Zfy permission, frotn ' '' Delajield and Prudden.") TUBERCULOSIS 195 cavities may surround a small blood-vessel or a bronchus, and the end of a small bronchial tube sometimes protrudes into them. A blood- vessel thus surrounded becomes inflamed, and an endarteritis obliterans is developed, often completely closing the vessel. Old cavities are usually smooth and lined with firm (pyogenic) membrane, upon which pus is constantly formed. The largest cavities are generally a result of the coalescence of several smaller ones. In this manner an entire lobe, al- most an entire lung, may be excavated. When the tubercular process is situated near the surface of the lung, the pleura invariably becomes inflamed and later infiltrated with tubercles. A small cavity immediately under the pleura sometimes breaks through it and produces a pneumothorax, by permitting the escape of air. This accident is generally prevented, however, by the inflammatory process, which rapidly forms adhesions between the two layers of the membrane. This adhesive inflammation is sometimes so extensive that almost the entire pleural cavity of one side becomes obliterated. Very rarely a cavity evacuates its contents through the chest-wall. Sclerosis is a reparative process, but it seldom results in the com- plete repair of the tubercular lesions, except, perhaps, in the earliest stage. In some other instances it separates the caseous masses from the sur- rounding tissue by a firm wall, and occasionally it closes small cavities after they have discharged their contents. Calcification may follow either caseation or sclerosis, but more frequently the former. Its oc- currence does not always indicate an arrest of the tubercular process, for Hving bacilH may remain in the periphery of the calcified nodule. An awakening of the process with the destruction of surrounding tissue sometimes causes the discharge of small calcified masses in the form of the so-called lung-stones. The bronchial glands are also implicated in all cases. In the more acute they become swollen and edematous; they are nearly always tu- bercular. Caseation occurs in them, and, in the chronic cases, calci- fication. Suppuration sometimes occurs. Other Organs. — Important changes occur in other organs, especially the larynx, intestine, liver, spleen, kidneys, pericardium, and cerebral me- ninges. Many of the changes are tubercular in character. As a result, no doubt, of the toxemia and anemia, degenerations are common, es- pecially in the organs just enumerated. The hver is the seat, also, of extensive fatty infiltration. Amyloid degeneration is of common occur- rence in the more chronic cases and affects particularly the intestines, liver, spleen, and kidneys. Symptoms. — Mode of Onset. — (jx) In many cases the disease remains for a time latent. Considerable progress is often made by it before the infection is recognized. In some instances it advances to the forma- tion of a cavity in one of the apices before the patient realizes his ill- ness. In other cases the greater prominence of symptoms on the part of other organs may not only mask the pulmonary condition, but it may for a time mislead both the patient and his physician. The most common of these conditions are the tubercular aff'ections of the bones and joints, caries of the vertebrae, ribs, sternum, or lymph-glands, lum- bar and psoas abscesses, otitis, and anal fistula. (Ji) With Cough.— \n probably the greatest number of cases the 196 PRACTICE OF MEDICIx\E disease begins with the symptoms of bronchitis. The patient has per- haps suffered for years from a nasopharyngeal catarrh, with great sus- ceptibiUty to "cold." These attacks grow more severe, or after some unusual exposure a severe bronchial catarrh develops. The sputum becomes mucopurulent, and there may be a slight elevation of the even- ing temperature. Dyspnea is often a noticeable accompaniment, and it sometimes assumes a paroxysmal form resembling asthma. (^) A7iemia is often one of the earliest symptoms. It is recognizable, however, by the cardiac palpitation, indigestion, or perhaps amenorrhea which results from it, rather than by the appearance of the patient. The blood usually shows reduction of hemoglobin, of 2 5 per cent or more, and leucocytosis, becoming more pronounced as the disease progresses. The red corpuscles are often normal in number, and the blood-plates greatly increased. (^3 Dyspepsia. — Many cases begin with an acid dyspepsia, character- ized by eructations, vomiting, or pain and a sense of burning in the stomach. The connection of this symptom with the affection of the lung is probably often overlooked. {/) Hemoptysis. — The existence of the disease is often announced by a more or less profuse hemorrhage of the lungs. Repeated hemorrhages sometimes occur. After a hemorrhage the disease sometimes remains for a long time quiescent, but in most cases the tubercular process ad- vances with greater rapidity. (_/) Pleurisy. — The first symptom to attract attention in some cases is pleurisy, with dry friction-sounds over the apex. The disease may also follow a pleurisy with exudation. The cough persists after the effusion has been absorbed, and a localized tubercular process may soon become recognizable. (^) Chills. — In some cases the onset is accompanied with chills, fever, and sweating not unlike those of malaria or sepsis. It is not uncom- mon to elicit a history of slight chills at a time corresponding to the beginning of the infection in cases that have been characterized by a greater prominence of other manifestations. The hectic flush of the cheeks in the afternoons soon becomes apparent in these cases, and a close watch of the temperature at short intervals will reveal an irregular curve quite unlike that of malaria, though more like that of sepsis. (/^) With Laryngeal Symptoms. — In a fairly large group of cases there is a history of periodic hoarseness or aphonia preceding the recognized onset of the disease. It is only in a small minority of these cases, however, that the larynx is the primary seat of the infection, and such manifestations disappear more or less permanently after the pulmonary disease has become far advanced. (0 Enlarged Lymph- Glands. — Tubercular enlargement of the lymph- glands of one side of the neck, particularly those of the supraclavicular region, and often associated with enlargement of the axillary glands of the same side, has often been recognized for months or years before the development of recognizable lesions in the lungs. Typical Course. — From the great variety of clinical pictures presented in this heterogeneous disease it is difficult to select one that can be called typical. Few cases are alike, yet there is a train of symptoms that are more or less common to a majority of them. TUBERCULOSIS 197 The classical description of the disease divides its course into three stages, designated by the old Latin writers : phthisis incipiens, phthisis confirmata, and phthisis desperata. These stages correspond to the more modern description of the development of tubercles, their soften- ing, and the formation of cavities. And although this division is little employed at the present time, it is more or less clearly apparent in many cases. In the early stage there is the persistent cough. It may be a per- sistent hacking little noticed by the patient during his busy moments, and it may become troublesome only when he lies down or arises in the morning. The expectoration is generally slight and of a clear mucous character; occasionally it is streaked with a little blood. The appetite is lost or becomes capricious, and the digestion becomes feeble, the bowels are generally constipated, but diarrhea sometimes develops. The patient grows anemic and he loses flesh; his strength fails, and slight exertion causes dyspnea and rapid breathing. The heart's action also becomes irritable. Slight elevation of temperature may generally be observed at this time, but not always at any definite time of the day. In many cases there is the cachectic flush with slight fever toward even- ing. An elevation of the temperature on the affected side amounting to 1° or 2° F. (0.5° — 1.5° C.) has been observed by Peter, but it is not invariably present. Night-sweats are often an important symptom. All these manifestations may develop in the course of a few weeks, or they may occupy as much as two or three years. Recovery is possible in the less rapid cases, but as a rule there are alternating periods of improvement and decline. As the disease progresses, the patient's ap- pearance becomes distinctive. The face becomes drawn or pinched, the expression anxious; the cheeks appear hollow and the eyes sunken, though still bright; the skin becomes sallow, sometimes appearing stretched; the finger-ends become thick or clubbed and the nails incur- vated (Hippocratic fingers) and blue. The patient, always hopeful, still boasts of his strength, while his cheeks are flushed and his breath- ing short. Every cold contracted, every attack of indigestion, every fatigue, hastens the decline. Winter is the worst season for the consump- tive. The cough then becomes more severe, the expectoration more abundant and more purulent. Microscopic examination of the sputum reveals numerous bacilli and frequently the elastic tissue from the lungs. Numerous micrococci are also present in some cases. From the begin- ning of cavity-formation, much depends upon the physical endurance and resoluteness of the patient. Many persons, through sheer deter- mination, continue their usual pursuits until the most advanced stage is reached ; others yield more readily to the growing inclination to rest. Sooner or later in all cases there comes a time when the bed becomes the mercy-seat. Each day it is longer occupied and returned to with less reluctance. The fever becomes high, the emaciation advances more rapidly, and the weakness grows more extreme. The approach of death becomes more and more apparent to all but the patient. The end is often hastened by a colliquitive diarrhea which generally indicates the implication of the intestine in the tubercular process, but in other cases the decline is long drawn out and life hangs as by a thread for days and weeks. The end comes peacefully in a coma or amidst pitiful Strug- 1 98 PRACTICE OF MEDICINE gles against the inevitable. The average duration of the disease in i,ooo cases among the upper classes in England was found by C. J. and C. T. Williams to be 7 years and 8.72 months. Among the lower classes it is much shorter. Special Symptoms. — Local. — (i) Cough is one of the most constant symptoms throughout the disease. In the beginning it may be so slight as to attract little attention; the patient is often little aware of it, but later it is often so distressing as to interfere with sleep. It is often out of proportion to the evidences of pulmonary involvement, being sometimes excessive, sometimes unaccountably mild. It is at first bronchial in character, but after the formation of cavities it becomes paroxysmal, and it is aroused more particularly by changes of position, as when the patient lies down or arises from sleep. Not infrequently the paroxysms induce vomiting. The sound of the cough is often pecu- liarly hollow. It becomes husky or hoarse when the vocal cords are involved. (2) The Sputum.— (jC) The quantity of sputum is exceedingly variable. In some cases, even after months of constant cough, there may be scarcely a trace of it, while in others the expectoration is profuse from the beginning. After large cavities have formed, the quantity sometimes becomes enormous; a pint (500 c.c.) may be expectorated in 24 hours. The sputum at first consists of clear, glary mucus from the bronchial tubes, or it may consist largely of alveolar epi- thelium in a state of myelinic degene- ration. It contains numerous small air bubbles and floats on the surface of water. The appearance of small grayish or yellow, purulent masses is Fig. 1 3. -Tubercle bacilli in sputum. ^^^^ distinctive, for it is in them that the tubercle bacilli are most numerous. As the caseous nodules in the lung begin to soften, the sputum becomes more abundant and assumes a more uniformly purulent appearance. It is often expectorated in coinhke (nummular) masses which sink in water. The only pathognomonic feature of tuberculous sputum, however, is the presence of the bacilli. When these exist in it, the case is always one of tuberculosis. They may be few or many. When only one or two are found or when they are absent from the sputum of a suspicious case, repeated examinations should be made, for the presence of a few may be accidental, and their supposed absence may be due to faulty technique in the collection of the sputum or in the process of staining. (For methods of staining, see p. 748.) Other bacteria are not infrequently found, particularly when large cavities exist. They are especially streptococci, occasionally staphylo- cocci and pneumococci. Sarcinae are sometimes present, and such fungi as the aspergillus even more frequently. (^) Elastic Tissue.— TMx's, is found only after the affected tissue has begun to disintegrate. It may be derived from the bronchial tubes, the al- veoli, or the walls of the arteries. That from the bronchi forms an elon- TUBERCULOSIS 199 Fig. 14.— Elas- tic tissue in spu- tum. gated network, or several long, slender fibers may lie close together ; that from the blood-vessels may have the same appearance, but thin sheets, like fragments of the intima, are sometimes found. The alveolar elastic tissue is generally branched and it may retain the outhne of the air-cells, as in Fig. 15. (f) Blood. — This is sometimes only sufficient to tinge /^ the sputum, and it may be recognized only on microscopic \^ examination. When hemoptysis occurs, blood is the chief element of the expectorated matter. It has a bright red color and is usually so- intimately mingled with air as to appear frothy. (^(T) Calcareous Fartides. — These are only occasionally found and their discovery is of little significance further than the fact that there must be some disintegration of lung tissue to permit their escape from the tissues in which they were embedded. They represent calcified tubercular nodules. In size they vary from a millet-seed to a cherry. Only one or quite a number may be coughed up. They occasionally originate in a bronchial gland which has ulcerated into a bronchial tube. (3) Pain is not usually a prominent symptom. It may be absent throughout the disease. In many cases there is, however, a constant sense of discomfort in the affected part of the lung, which becomes a more or less severe pain upon coughing. Sometimes there is sharp, lancinating pain as a result of involvement of the pleura. When the cough is very troublesome, the lower portion of the chest often becomes painful, in part, perhaps, from the muscular exertion. Periodic attacks of pleurisy or intercostal neuralgia are not uncommon during the disease. (4) Dysp?iea is often absent except as it may result from exertion. In some cases, on the other hand, it is a prominent symptom from the begin- ning; it may even become less pro- nounced as the disease advances. In the more acute cases the respiration often becomes rapid, but when the process is slower it may be but little accelerated, even after an entire lung has become solidified. A cardiac dyspnea may develop in cases com- plicated with hypertrophy or rapid action of the heart. In some cases occasional attacks resembling asthma occur. (5) Hemoptysis.— ^^vcioxx\xd.g^ of the lungs occurs in from 60 to 80 per cent of cases. It is nearly five times more frequent in men than in women. It occurs early in the disease, often before the existence of recognizable lesions; or late, after the formation of large cavities. The early hemorrhage sometimes follows a gradual decline of health, Fig. 15.— Elastic tissue with thelium and bacteria. epi- 2 00 PRACTICE OF MEDICINE with anemia, slight cough, or indigestion, but it often attacks without warning young healthy individuals free from predisposition to tubercu- losis or recognizable tuberculous taint. Although such hemorrhages are regarded as of tuberculous origin, physical examination fails to re- veal it, and the sputum often contains no bacilli. Not infrequently the patient continues in good health. In another group of cases the hemor- rhage follows some unusual exertion, as swimming or athletic sport; no recognizable lesion may exist, but the sputum contains bacilli. The quantity of blood is usually small, only a dram or two, perhaps ; fatal hemorrhage is exceedingly rare. In most cases repeated hemorrhages occur. They are sometimes so frequent as to justify the appellation hemorrhagic phthisis, given to the condition by some authors. Late hemorrhages are more frequently profuse; a pint or more of blood may be lost within a few minutes, and a fatal syncope may result. The blood usually comes from the erosion of an artery or the rupture of a small aneurism within a cavity. A fatal termination is more apt to follow a succession of profuse hemorrhages. Thirst and dyspnea result from the loss of blood. The pallor which is present is in part anemic, in part a result of the alarm occasioned by the hemorrhage. In some instances the blood is retained within a large cavity and is not ejected. The other symptoms are dyspnea, thirst, sometimes sigh- ing or yawning, and a bloodlike odor may be detected. After a hemor- rhage, blood continues to appear in the sputum for several days, but its color becomes darker. In some cases an oozing from small vessels within a cavity may keep up the expectoration of bright arterial blood for a much longer time, and the appearance of hemorrhage is maintained. The more remote effects of hemorrhage are very different in different cases. Improvement sometimes follows, for a time at least, but in a majority of cases the progress of the disease becomes more rapid. General Symptoms. — (i) Fever. — This is oneof the most important feat- ures of the disease, its presence being especially valuable in prognosis,, for fever denotes waste and loss of strength; its absence indicates a possibility of improvement. In the early stages, the presence of slight fever is apt to escape observation, unless the temperature be taken at comparatively short intervals, as once every two hours. The highest temperature usually occurs between 2 and 6 p.m., the lowest between 2 and 6 a.m. In not a few cases the temperature becomes subnormal in the early morning hours. Yet many cases reach an advanced stage without fever. Frequent observations will usually show slight elevation of temperature after exercise or excitement of any kind. The fever of the early stages is probably of different origin from that of the late stages. It is doubtless due to the tuberculization or advance of the tubercular process within the lungs, being produced, no doubt, by the absorption of toxins, since the same effect is produced by the injection of tuberculin. In the late stages it may be due to the same influence, but it is often septic in character, and possibly arises from mixed infec- tion and absorption of other toxins than those of the tubercle bacillus. The fever may be either remittent or intermittent in type. Either form may occur in either stage, and the two sometimes alternate as the proc- esses in the lungs change from time to time. The occurrence of a daily chill followed by fever and sweating is not uncommon, and it is, perhaps,, TUBERCULOSIS 201 often mistaken for malarial infection. The fever of the advanced stages is more apt to be continuous; and the more rapid the processes of softening and suppuration, the less will be the iluctuation of tempera- ture. A fluctuation of only a degree or two is also suggestive of the presence of tubercular pneumonia, which may develop at any time dur- ing the course of the disease. A wide range from day to day is highly characteristic of tuberculosis, for there is often a difference of from 3 ° to 5° F. (1.5° to 2.5° C). The curve may be constantly above nor- mal or it may drop several degrees below in the night-time. After hemoptysis the temperature is often higher, possibly in part from the absorption of altered blood, but often on account of the catarrhal pneu- monia that is developed. (2) Sweating. — Profuse sweating is often a serious symptom. It most frequently assumes the character of night-sweats, occurring as the fever drops in the early morning hours, but often also during a nap in the daytime. It is more common after the disease has become advanced, but it may be present from an early stage. Some patients are so for- tunate as to escape it altogether. (3) Pulse. — In acute cases the pulse becomes rapid, from 100 to 120 or higher. The rate does not always correspond to the temperature, and the acceleration may not develop until several days after the dis- covery of fever. In chronic cases the pulse may remain normal, full or small, regular or irregular ; it is generally regular, but weak and soft. A capillary or venous pulsation may sometimes be seen, the latter especially on the backs of the hands. A dicrotic pulse is oftener observed in this than in any other chronic disease (Vierordt). (4) Respiration. — A careful count usually shows increased activity of respiration. It may be slight in early, mild cases. WTien there is involvement of a large area of lung tissue and when fever develops, however, the breathing becomes more accelerated. The ratio of the respiration to the pulse is usually maintained. An intensely fetid odor of the breath is not infrequently noticeable. It is usually indicative of a mixed infection. (5) Emaciation. — Next to the temperature chart, the record of weight gives the most valuable indication of the progress of the disease. A gradual decline is the rule, although it may amount to so little as not to be observed without actual weighing. In febrile cases the emaciation progresses with greatest rapidity. (6) Psychical State. — One of the most striking features in many cases is the hopefulness of the patient, a pleasing delusion of recovery which clings to the last and should not be dispelled. Physical Signs. — (^ 51 ^ -Pi 53 53 \, ©-. 54 55 THE PARASITES OF MALARIA. (Marchiafava and Bigftami in " Twentieth Century Practice.") EXPLANATION OF PLATE V. Figs. 1-14. — The hematozoa of Quartan Fever; Figs. 1-9, Progressive endo- globular development of the quartan parasite; Figs. 10 and 11, Endoglobular fission forms; Fig. 12, Free sporulation ; Figs. 13 and 14, Free pigmented forms, one flagellated. Figs. 15—33. — Hematozoa of Tertian Fever: Figs. 15-24, Progressive en- doglobular development of the tertian parasite ; Figs. 25-27, Endoglobular fission forms; Figs. 2S-30, Free sporulation; Figs. 31-33, Free pigmented forms, one flagellated. Figs. 34-55. — Hematozoa of Estivo-autumnal (quotidian) Fever; Figs. 34-50, Endoglobular development of the quotidian parasite; Figs. 42, 48 and 49, parasites in altered red blood corpuscles (brassy bodies) ; Figs. 51-55, en- doglobular forms in sporulation. SECTION II. Diseases Due to Animal Parasites. PROTOZOAN DISEASES. MALARIA. INTERMITTENT FEVER, CHILLS AND FEVER, FEVER AND AGUE, SWAMP FEVER, PALUDISM. Definiiion. — Infection by the plasmodium malariae of Laveran, wdth the production of a febrile disease, of which the following are the princi- pal forms : (^u type, repeated chills occur, followed with profuse sweats, great prostration, and other symptoms of sepsis. The chills sometimes occur with a regularity that suggests quotidian or tertian intermittent fever. Heart symptoms of greater or less severity may be present, but very often they are so mild as to be entirely obscured by the general condition. DISEASES OF THE HEART ^^^ The typhoid type is more common. It is characterized by a more uni- form temperature curve and greater nervous disturbance, headache, restless sleep, delirium finally passing into coma. More active cerebral symptoms sometimes appear, the case being readily mistaken for one of basilar or ccrebro-spinal meningitis. Profuse sweats generally occur, and petechitil, erythematous, and other cutaneous eruptions may appear. The tongue is heavily coated, sordes collect on the teeth, and abdominal distention, with diarrhea or constipation and vomiting— these are fea- tures of many cases. In this form, as in the septic, the endocarditis may be entirely overlooked; it may, in fact, be unrecognizable upon the most careful examination. Embolisms. — The course of the disease may be suddenly changed by the development of embolism in one or more parts, with manifestations peculiar to the part affected. They are generally announced by a sud- den localized pain corresponding to the location. A chill often announces- the dissemination of the emboli. Following their lodgment there are evidences of inflammation, and, later, those pointing to the formation of an abscess. There is then, as a rule, tenderness on pressure, especially over the liver, spleen, or kidneys. Infarction or abscess of the lung or empyema may follow a pulmonary embolism; albuminuria, hematuria, and, later, pyuria, that of the kidney. Jaundice commonly accompanies other evidences of embolism of the liver. Heart Syviptoms.—T\\.^ valvular lesions are all the more serious in their consequences because they are so suddenly developed. Congestion of the lungs is a constant result, a condition that is manifested in extreme dyspnea and marked cyanosis ; edema of the lung may also be induced. These disturbances are, as a rule, more severe when the disease attacks a previously healthy endocardium than one that has been the seat of old valvular lesions, for in the latter condition the heart, already hyper- trophied, is better able to overcome the circulatory derangement that is set up. Diagnosis. — When the heart symptoms are prominent, the diagnosis is not difficult; in their absence, it may be extremely so. It is generally to be based upon the history of the previous affection, the sudden onset, with chill, high fever, sweating, and the characteristic physical signs, when present. The development of embolism throws additional light upon the case. The differentiation from a simple endocarditis is not difficult. In a majority of cases the symptoms resemble either general septicemia or typhoid fever. As the clinical manifestations are in reality septic there can be no differentiation between the condition and sepsis, in the absence of a history of previous valvular involvement or present cardiac symptoms. The differential diagnosis lies between typhoid fever, malaria, and acute miliary tuberculosis. Typhoid fever is to be excluded by the fact that the disease follows a pneumonia or other infectious disease, as well as by the sudden onset without prodromes, the rapid rise of temperature, early prostration, the irregular or intermittent course of the fever, the presence of cardiac symptoms, marked leucocytosis, and probably by the development of embolisms. Intermittetit fever and other forms of malaria are excluded by the 334 PRACTICE OF MEDICINE absence of the Plasmodium from the blood, and usually, upon close observation, by the irregular periodicity of the chills and sweats. Acute tuberculosis is attended with pulmonary symptoms, usually with enlargement of lymph-glands, and the bacillus tuberculosis may be found in the sputum. The difficulty of arriving at a differential diagnosis is greater when either of these affections occurs in the subject of a val- vular lesion. Prognosis. — The disease, when severe, always terminates fatally. The correctness of the diagnosis may generally be questioned when recovery occurs. A few undoubted recoveries have, nevertheless, been observed. Treatment. — The treatment is that of other pyemic affections, with local applications to the precordial region when indicated. Perfect rest is essential. The strength of the patient should be maintained by a nutritious, mostly liquid diet and the regular and free administration of alcohol and strychnin. The salicylates and other alkalis are distinctly beneficial in some cases, and quinin in full doses in others. It is improb- able, however, that any form of medication exerts much influence upon the morbid process. An ice-bag to the region of the heart may quiet its action and possibly to some extent reduce the inflammation in cases characterized by pronounced local disturbance. CHRONIC ENDOCARDITIS. Chronic Interstitial or Sclerotic Endocarditis, Chronic Valvular Disease OF the Heart. Etiology. — There are two groups of cases : (a) A majority of cases follow an acute endocarditis and are marked by rapid progress ; and Qb^ cases which run a chronic course from the beginning. Going back a step further, the starting-point of the condition in fully half the cases is an attack of acute articular rheumatism, and, in a majority of the remaining cases, it is one of the other infectious diseases that have been referred to under the etiology of acute endocarditis. Like acute endocarditis, too, it is more frequent in young persons than in those beyond middle life. The disease more commonly attacks the mitral valve. It is probable also that many cases which appear to begin insidiously and to pursue a chronic course from the beginning, originate in some mild affection during which no involvement of the heart was recognized. In other instances, the slowly progressing sclerosis is induced by alcoholism, syphilis, chronic nephritis, gout, toxic substances in the blood, and sometimes, no doubt, by habitually excessive exercise. In a large group of cases the condition is part of a general arteriosclerosis. Morbid Anatomy. — In this, as in the acute form of the disease, the primary lesion is in most cases the warty vegetation, but the sclerotic process reduces these excrescences to minute, hard nodules and they are often no longer discernible. The edges of the valves now appear opaque, yellowish gray, uniformly thickened, firm, and inelastic. In the aortic valve the sclerosis begins around the corpora Arantii; in the auriculoventricular valves, it begins just within the margin of the leaf- lets. The appearances are often very similar to those of arteriosclerosis in the aorta. As a later change, the valves become misshapen, corru- VALVULAR DISEASES OF THE HEART 335 gated, curled, and variously distorted. They may become shrunken into mere stumps, and the leaflets may become adherent over a variable portion of their lines of contact, forming an annular diaphragm. So long as this agglutination does not occur, the most extensive thicken- ing and deformity of the segments may be found, the valves being ren- dered functionally useless, permitting extreme regurgitation, without occasioning appreciable stenosis. When, however, the edges have become adherent, the subsequent contraction necessarily induces some degree of stenosis. The orifice sometimes has a funnel-like appearance. In another class of cases the leaflets become firmly attached to the mural endo- cardium immediately back of them, or, in cases of the aortic valve, to the intima of the vessel, thus preventing them from coming into apposi- tion to close the orifice. The chordae tendineae generally become in- • volved in the sclerosis, beginning at their attachments to the valves and extending to a variable part of their length, sometimes beyond them into the papillary muscles. The edges of the valve leaflets are thus drawn together and the orifice correspondingly narrowed. Calcification of the degenerated, sclerotic tissue of the valves is a common result of the process, sometimes so extreme as to convert the entire valve into a calcareous plate. Ulceration resembling that of atheromatous disease may occur or a true ulcerative endocarditis may be set up at the edges of these plates or beneath them. The warty vegetations of acute endo- carditis may also be found, and over the surface there is not infrequently deposited a layer of fibrin from the blood. The changes that occur in the valves of the right heart are identical in character with those just described, but they are much less frequent. The walls of the heart, especially those of the ventricles, are enormously thickened during the existence of compensatory hypertrophy, but, after dilatation has super- vened, they are often reduced to extreme thinness. Both conditions are frequently found coincidently in diff"erent chambers. VALVULAR HEART DISEASE. Under this heading may be conveniently studied the results of the different forms of endocarditis of the valves. The eff'ect of endocarditis upon the valves is to produce either (a;) incompetency (insufficiency, with regurgitation of blood), or (^b~) steno- sis (partial closure of the orifice). Either of these conditions may exist separately in either of the valves, or they may be combined, affecting the same or different valves at the same time. Incompetency, or insufiiciency, is a condition in which the complete closure of the valve is prevented by erosion, perforation, deformity, or adventitious bands and adhesions. It permits the blood to flow through the orifice in an abnormal, reversed direction. Stenosis, or narrowing, of the valve orifice, on the other hand, prevents the normal flow of blood through it. As a result of either condition a chamber of the heart is engorged with blood; yielding to the increased blood-pressure within, it becomes acutely distended. The heart possesses a certain de- gree of reserve force which enables it for a time to meet the emergency, however suddenly it may occur, as it ordinarily does the distention caused by sudden active exercise. In most cases a valve lesion develops 336 PRACTICE OF MEDICINE gradually, the distention of the cavity is correspondingly slow, and the reserve force is sufficient to carry on the circulation without serious interruption until another change has had time to occur, namely, a hypertrophy of its walls. This is known as a compensatory hyper- trophy. The increased muscular power of the heart, in other words, compensates for the valvular leakage. The walls become thickened and the blood is carried in increased quantity and with increased force from the enlarged cavity through the defective orifice. The loss to the general circulation that would otherwise result from either regurgitation or stenosis is thus prevented. Compensatory hypertrophy may enable the heart to perform its function with regularity for a long time, but it cannot restore the integrity of the organ. With the increase of muscular force, or working power, there is a corresponding diminution of the reserve force, and the heart is no longer able fully to meet emergencies. Unusual exertion is met with increased action, but it is the increased action of an abnormally large and strong heart ; as a result, the blood- vessels become engorged, the rhythm is disturbed, and more remote disturbances follow, depending in character upon the valve affected and the nature of the lesion. This is known as a disturbance of compensa- tion. The compensation fails at first only when the heart is called upon to perform extra work, but the failure becomes permanent if the heart is constantly subjected to undue strain. The failure is gradual, however, and for a time after the heart is unable to perform extra work it is still capable of maintaining the circulation with the body at rest. A final failure usually occurs, and the organ can no longer perform its function under the most favorable conditions. With the decline of the muscular power in the walls of the heart, the chambers become more enlarged, and a condition of extreme and per- manent dilatation is produced. A very remarkable form of compensa- tion has been described in which the shrinkage of one valve segment through sclerosis is met with a compensatory lengthening of the other segments, but it is at least an extremely exceptional possibility. The dilatation and loss of compensation are often greatly hastened by degenerative changes in the heart muscle. This is particularly the case when the circulation through the coronary arteries is impeded and the nutrition of the organ diminished. The same result is produced to some extent also by the anemic condition of the system, and this in turn may be added to by poor food, alcoholism, mental emotions, or any illness, especially an acute febrile disease. The special changes in the different chambers of the heart are considered in connection with the affections of each valve. Remote Effects of Valvular Lesions. — The more direct effects of val- vular disease are seen in the lungs, but changes occur also in the liver, spleen, kidneys, and, in cases of long standing, in almost every organ of the body. The pulmonary vessels are greatly distended, and as com- pensation is lost they become permanently dilated. Their branches often become distinctly varicosed. The circulation is sluggish and the lungs appear deeply congested. Proliferation of the fibrous tissue with pigmentation leads to brown induration. Areas of collapse are some- times produced, and infarctions often form within the dilated vessels. The condition of the liver is that known as chronic passive hyperemia. VALVULAR DISEASES OF THE HEART 337 The organ is enlarged, the blood-vessels dilated, the connective tissue proliferated, and pigment is at the same time deposited about the cen- tral vein of the lobule. The spleen, kidneys, stomach, and intestines are also congested. MITRAL IXCOMPETEN'CV. Etiology. — Mitral insufficiency is the most frequent form of valvular defect. It may occur at any time of life, but commonly affects younger persons than are the subjects of aortic lesions. It is slightly more fre- quent in women. In a majority of cases it is due to endocarditis fol- lowing rheumatism. It may depend upon: (d;) Changes in the segments of the valves, shortening, deformity, or retraction, with which there are generall}^ associated a thickening and shortening of the chordse. ten- dineae. Qli) The segments may be normal, yet prevented from accurate coaptation and closure of the orifice by extreme dilatation of the ven- tricle or improper action of the papillary muscles. This is known as muscular incompetency. A variable degree of stenosis is usually as- sociated with the incompetency, but less frequently in cases affecting children. From this purely mitral condition there is to be distinguished a relative insufficiency that ensues upon excessive dilatation of the left ventricle as a result of profound anemia, myocarditis, or loss of tone in the heart muscles due to prolonged febrile or wasting disease, all of which conditions render the valve segments incapable of closing the relaxed or dilated orifice. A relative insufficiency sometimes results from a sudden destruction of an aortic segment. The left ventricle is dilated, the mitral valve rendered incompetent, and the lungs are en- gorged, sometimes to the extent of producing slight hemoptysis. The hypertrophy of the left ventricle, associated with chronic interstitial nephritis, occasionally yields to dilatation, and pulmonary and systemic engorgement results, which resembles that of a primary mitral lesion. In the same way the hypertrophy due to overwork, alcoholism, or peri- carditis in children may lead to conditions almost identical with those of mitral incompetency. Pathology. — (c?) With each systole of the left ventricle, a part of the blood is thrown back through the imperfectly closed mitral orifice into the auricle. This blood, together with that entering from the pulmonary veins, produces a dilatation of the auricle. Hypertrophy ensues, but the walls of the auricles are incapable of extensive hypertrophy, and the con- dition may be regarded as one of dilatation alone. (/^) An increased quantity of blood is thrown into the left ventricle with each auricular systole, causing dilatation of this chamber also. To meet this, the wall of the ventricle undergoes hypertrophy, and the normal pressure within the aorta is maintained, (r) The regurgitation of blood into the left auricle during each diastole of the ventricle, in addition to producing the changes described, prevents the normal flow of blood from the pul- monary veins, and these vessels are dilated. The pulmonary circulation is obstructed and (^/) the pressure in the right ventricle is increased. As a result, this chamber becomes dilated and hypertrophied. (^) Dilatation and hypertrophy of the auricle are finally produced, usually 338 PRACTICE OF MEDICINE after tricuspid regurgitation has resulted from the extreme dilatation of the ventricle. The hypertrophy of the ventricles enables the heart to maintain the normal blood-pressure until subsequent degenerative changes occur. The hypertrophy then giv^es place to greater dilatation, and failure of com- pensation ensues. Relative incompetency, due to muscular relaxation and the other influences that have been referred to, is seldom followed by full com- pensation. Sympioms. — The severit}' of the symptoms varies inversely with the degree of compensation. When the disease develops suddenly with the rupture of a valve, symptoms of extreme incompetency are manifested. But when the incompetency develops slowly, the reserve force of the heart and the prompt hypertrophy may maintain the circulation to such an extent that no subjective manifestations are produced. In most cases, however, the patient experiences shortness of breath, palpitation of the heart, and slight cyanosis after exertion. In some cases the cyano- sis is more constant. The face is somewhat congested, the lips, ears, and finger-nails have a bluish tinge. In cases of long standing, es- pecially in children, the fingers become clubbed. The compensation may become so perfect, however, either spontaneously or through treat- ment, that, although some of these evidences of the disease remain, the patient is able to pursue his usual occupation for many years. Such persons are more liable, however, to attacks of bronchitis, and slight hemoptysis is likely to occur as a result of the pulmonary engorge- ment. With the failure of compensation, the symptoms become more intense and more constant, as a result of the rapid increase of venous engorge- ment. Dyspnea becomes constant and it is often accompanied with cough and watery, sometimes bloody, expectoration containing pigmented alveolar epithelium. Cyanosis is not always a constant feature, but it is sometimes intense, particularly after exertion or coughing. The sleep is often restless and broken by sensations of suffocation. The peripheral veins become distended, and the skin has sometimes an icteric hue. Dropsy ensues, beginning in the feet and ankles, and gradually invad- ing the body, particularly the serous cavities. The liver is enlarged. The urine becomes scant and albuminous, usually containing epithelial, granular, or blood casts. Gastric and intestinal digestion is impaired. After repeated attacks of this character, and repeated relief by treatment, a stage is finally reached which can no longer be mastered, and death ensues from pulmonary edema or the extreme cardiac dilatation, rarely from sudden heart-failure. Physical Signs. — Inspection. — The impulse of the heart is forcible and heaving during the stage of full compensation, but wavy and feeble after compensation has failed. The apex beat cannot always be seen. The precordial region is sometimes prominent in children. Palpation. — A strong impulse can be felt bejieath the sternum, over a variable distance to the right of it, and to the left as far as the axil- lary line in extreme cases. The position of the apex beat is not constant, but varies with the relative enlargement of the ventricles and the total enlargement of the heart. It is usualh' found to the left of the nipple. VALVULAR DISEASES OF THE HEART 339 sometimes in the axillary line. It may be as low as the sixth intercostal space, but is higher in extreme dilatation of the right ventricle. A thrill at the apex is pathognomonic of mitral incompetency, but it is seldom to be felt. Percussion. — The area of percussion dullness is greatly increased, par- ticularly in the lateral direction. In cases of long standing, with great dilatation of the ventricles, it may extend from one or two inches (2.5 — 5.0 cm.) to the right of the sternum to three or four inches (7.5 — 10. o cm.) left of the nipple. The upper margin of the dullness is little, if any, higher than normal. Auscultation. — The characteristic sign of mitral insufficiency is a sys- tolic murmur heard with greatest intensity at the apex, or in many cases a little beyond it. The first sound is often entirely replaced by it. The murmur is transmitted with great distinctness to the axilla and generally to the angle of the scapula as well as a variable distance up- ward and downward along the spine. In many cases it is audible over all parts of the chest. It is usually of a blowing or puffing quality, some- times ending in a musical tone, but it may be so harsh and loud as to be heard a distance of a few inches from the chest. When, however, the dilatation of the right ventricle is excessive, and the apex is pushed back from the chest-wall, the murmur may be indistinct or almost in- audible. In many cases, too, it becomes audible only after slight exer- tion or when the patient leans forward or lies upon his back. Sometimes it is heard best along the left margin of the sternum. A rough presystolic murmur sometimes accompanies the systolic, probably as a result of an associated mitral stenosis. A soft tricuspid murmur of regurgitation is occasionally heard with it over the lower sternal region in cases of extreme dilatation of the right ventricle. The second sound at the apex is generally distinctly heard, and the pulmo- nary second sound is accentuated. It is heard in the second interspace at the left of the sternum. The loudness and other qualities of the mur- mur give but little indication of the character or gravity of the valvular defect. The pulse is generally irregular, and often extremely so in the beginning. After compensation becomes completely established, or under proper treatment, it may become full and fairly regular, but a moderate irregularity generally persists. Diagnosis. — The most typical signs of mitral regurgitation are : ((^7) Increased dullness in a lateral direction, indicating great transverse enlargement of the ventricles; (^) a systolic murmur heard with greatest intensity at the apex, but transmitted to the axilla and back; and (r) accentuation of the pulmonary second sound. The condition is most readily confounded with the so-called accidental, or hemic, murmurs and less definitely understood conditions. These sounds, no doubt, originate within the ventricle, and they may be transmitted to the axilla. The\- are usually soft and blowing in character, and they are not associated with dilatation or accentuation of the pulmonary second sound. The history of the previous condition is also different, being in one case an infection, in the other an abnormal state of the blood. It is not always possible to determine whether the regurgitation is due to an actual lesion of the valve leaflets or to a dilatation of the ventricle and consequent enlargement of the orifice due to overwork. 340 PRACTICE OF MEDICINE arteriosclerosis, or other cause. Some writers have asserted that an organic mitral lesion sufficient to produce incompetency cannot be diag- nosticated with certainty in the absence of a presystolic murmur indic- ative of stenosis. MITRAL STENOSIS. Etiology. — Narrowing or obstruction of the mitral orifice generally occurs in young subjects and it is considerably more frequent in females. Congenital cases have been noted. It is generally due to endocarditis following rheumatism or one of the other diseases which lead to it. In some cases no cause can be positively determined. This possibility of its originating in a mild attack of one of the other acute infections should be borne in mind in obscure cases. Morbid Anatomy. — The obstruction may be found to depend upon a thickening of the valve curtains, upon an agglutination of their edges, or upon induration of the valve-ring. The condition may be so complete as to give the valve a funnel shape or to leave only a buttonhole slit, too small to admit the tip of the finger. The cusps may be greatly deformed, curled or twisted, or they may be converted, by the deposi- tion of lime salts, into little more than calcareous plates. The chordae tendinese are often so contracted that the papillary muscles appear to be inserted directly into the valve segments. Valvular insufficiency is an almost constant accompaniment of the stenosis, the deformed valves being incapable of accurate coaptation. As a result of the obstruction to the flow of blood from the auricle, that chamber becomes dilated and hypertrophied. Its walls rarely attain a thickness of more than half an inch (1.2 cm.), or about three times the normal thickness. The congestion of the lungs is extreme; more so than in any other valvular lesion. The engorgement of the pulmonary veins and of the "lesser circulation" in turn retard the entrance of blood from the heart; the right ventricle in consequence becomes hypertrophied and dilated, the tricuspid valve is rendered rela- tively incompetent, and, just as in mitral insufficiency, the tension be- comes increased in the general venous circulation. The left ventricle, receiving less than the normal supply of blood, undergoes little or no hypertrophy, unless incompetency also exists. In some instances it appears abnormally small, owing to the great enlargement of the right. The total enlargement of the heart is not usually extreme. An ante- miortem thrombus is commonly found in the left auricle, and white thrombi may be found in the auricular appendages. A globular concretion as large as a walnut ("ball thrombus") has been found in a few instances. Symptoms. — The subjective manifestations are much the same as in mitral insufficiency, but slower of development, and the pulmonary engorgement is more extreme. The arterial circulation is impoverished, while the venous is congested. The symptoms after the failure of com- pensation are the same as those seen in mitral insufficiency, notably, rapid, irregular action of the heart, dyspnea, and cyanosis. Hemoptysis is more common. The remote effects have been described on page 336. Physical Signs. — Inspection. — The strongest impulse is seen beneath the lower portion of the sternum. In children the area may be abnor- mally prominent. A pulsation is often seen in the third or fourth inter- VALVULAR DISEASES OF THE HEART 341 costal space, near the left of the sternum, when the chest wall is thin. The apex beat cannot always be recognized; it is not usually displaced beyond the line of the nipple. Palpation. — A presystolic fremitus or thrill is often felt in the fourth or fifth intercostal space, within the nipple line. It is usually short, harsh, and distinct, and terminates with a sharp shock in the usual cardiac impulse. When present it is pathognomonic of mitral stenosis. The evidences obtained from inspection are confirmed. The strong impulse beneath the sternum and in the third and fourth left interspaces can be distinctly felt; sometimes there is also a distinct impulse in the second interspace due to the pulsation of the conus arteriosus of the right auricle. Percussiou. — The area of dullness is increased tranversely, but not nearly to the extent seen in mitral insufficiency. In extreme cases it extends from two inches (5 cm.) to the right of the sternum to the nipple, or a short distance to the left of it, rarely more than an inch even when incompetency is also present. Auscultation. — The characteristic sign of mitral stenosis, during the stage of compensation, is a presystolic murmur heard most distinctly at the apex or a short distance to the right of it. This is usually a prolonged, rough, purring, or rumbling murmur, heard just before the first sound and terminating in it. Its character and the time of its occurrence are readily understood when it is remembered that it is produced during the passage of the blood through the narrowed orifice from the auricle into the ventricle. It usually begins in the latter half of the auricular systole, but sometimes earlier, and ends at the first sound, which is generally sharp, clear, and distinct. It is often audible over only a very limited area. The systolic apex murmur not infrequently accompanies the presys- tolic, owing to the commonly associated regurgitation. It is usually low and indistinct, but it may be loud and transmitted to the axilla. The pulmonary second sound is strongly accentuated and sometimes reduplicated, but the aortic second sound is generally reduced in force. A tricuspid murmur is occasionally heard over the lower sternal region or to the right of it in cases of long standing, owing to regurgitation through that valve. After compensation has failed, the presystolic murmur and thrill are lost, but the sharp first sound and the shock usually persist. In some cases the irregular action of the heart is so extreme as to obscure the auscultatory signs. Diagnosis. — Mitral stenosis is not difficult of recognition in a typical case, and the sources of error are few. But during the failure of com- pensation, when the thrill and murmur are absent, the valvular condi- tion may be overlooked. Its existence should be suspected from the hypertrophy, the sharp first sound, the accentuation of the pulmonary second sound, and the great irregularity of the heart's action in most cases. The Flint murmur, which is more fully described under the head of Aortic Incompetency (p. 345), should not be mistaken for that of mitral stenosis, since it is usually confined to the middle period of auricular systole, and it is heard only in association with the murmur of aortic 342 PRACTICE OF MEDICINE regurgitation, a lesion that is rarely coexistent with this condition. The aortic regurgitant murmur is heard at the base better than at the apex, and replaces the second sound of the affected valve. Aneurism of the arch of the aorta may be suspected when the left recurrent laryngenal nerve is compressed by the dilated auricle, causing paralysis of the vocal cord of the same side, but it can generally be excluded by the absence of the other diagnostic signs of aneurism and the presence of those indicative of stenosis. Prognosis. — Patients with mitral stenosis often live many years, ex- periencing little discomfort except under the strain of excessive exertion. After compensation has failed, however, the prospect of relief through treatment is less favorable than in mitral insufficiency, since the possi- bility of compensation is greatly limited by the narrow mitral orifice and depends for the most part upon the remote force of the hypertro- phied right ventricle. AORTIC INCOMPETENCY. Etiology. — This form of valvular lesion ranks next in frequency to mitral insufficiency. It is met with in about one-third of all cases, oftener in men than in women, and generally in those of middle age. It is most frequently due to endocarditis, which may be of the ulcera- tive form or a result of rheumatism or other infectious disease. The lesions are not uniform. They may be : (rt-) Disease of the cusps with destruction of tissue or nodular excrescences along their edges, but in most cases there is a more uniform sclerosis, often leading to agglutina- tion of the edges and partial closure of the orifice. The segments are often in a state of calcareous degeneration. (/^) In many instances the disease is a part of an arteriosclerosis the result of syphilis, alcohol- ism,, or nephritis, (r) The cusps are sometimes ruptured by violent muscular effort, as in lifting, running, or bicycling (the athlete's heart), but the valve is generally in an abnormal condition from previous dis- ease at the time of rupture. (^) In another group of cases the insuf- ficiency is due to a dilatation of the valve-ring from atheromatous disease of the artery or the presence of an aneurism of the ascending aorta close to the heart. (,?) Congenital insufficiency is met wdth as a very rare condition. Morbid Anatomy. — The deformity of the valve ma}' consist of an ul- ceration or partial destruction of the cusps ; a superficial or deep rent may be found in cases that have proved rapidly fatal. The cusps may be contracted, curled, puckered, or converted into calcareous plates. A segment is sometimes found adherent to the intima of the aorta and held back by the adhesion. The left ventricle is greatly hypertrophied and in cases of long duration it is sometimes enormously dilated as a direct result of valvular insufficiency. With each ventricular diastole a part of the blood is regurgitated from the aorta into the ventricle, and the hypertrophy occurs in response to the overdistention that is thus produced. The heart sometimes weighs from 40 to 50 ounces and has therefore received the name cor bovinum, for it reaches a greater degree of hypertrophy and dilatation than in any other form of heart disease. The papillary muscles are sometimes flattened. VALVULAR DISEASES OF THE HEART 343 Among associated conditions more or less constantly observed are a thickening of the edges of the mitral leaflets and often a relative insuf- ficiency of the valve, arising" from the extreme dilatation. The left a,uricle generally becomes dilated and hypertrophied. After these lesions have become established, pulmonary engorgement, with subsequent hy- pertrophy and dilatation of the right heart, ensues, in the same manner ^s in mitral insufficiency. Moderate dilatation occurs, indeed, before insufficiency of the mitral valve has been induced. Changes occur, as a rule, in the arterial system also. The ascending portion of the aorta becomes dilated, and sclerotic or atheromatous disease of the intima is commonly produced. Following these changes the orifices of the coro- nary arteries often become obstructed, or these vessels may also undergo atheromatous change. The supply of blood which they receive is dimin- ished by the reduction of the pressure in the aorta during the ven- tricular systole, the period in which they receive their supply. This in turn impairs the nutrition of the heart muscle and induces fatty or parenchymatous degeneration or interstitial myocarditis, and thus hastens the dilatation and ultimate failure of the heart. The pain and occasional attacks of angina are attributed to changes in the nerves of the heart or to pressure upon them by the sclerotic tissue associated with the interstitial myocarditis. A more or less general arteriosclerosis is commonly found in the vessels thoughout the body, as a result of the sudden strain thrown upon them by the forcible contractions of the hvpertrophied ventricle. It is a remarkable fact, however, that in some instances, particularly in rheumatic cases, although there have been evidences during life of enormous distention of the arch of the aorta, innominate, and right carotid, these vessels are found to be almost perfectly normal and free from dilatation after death. A greater or less degree of stenosis sometimes accompanies the insufficiency, but it is not so uniformly present as in the corresponding lesion of the mitral valve. Symptoms. — This disease often exists for a great length of time with- out producing definite disturbances. Among the earliest symptoms manifested, but often referred to some other cause, are headache, flashes of light, tinnitus and vertigo or faintness upon rising suddenly. Slight ■exertion often causes palpitation and shortness of breath, and this may be accompanied with distress or actual pain in the cardiac region. Pc'iin is a comparatively early symptom in some cases. It may be a dull ache confined to the precordial region, or sharp and spasmodic, often radiating to the left shoulder and sometimes down the arm or up the neck. It seldom radiates to the right side. Topical ^lttacks of angina pectoris occur in some cases. After failure of compensation, symptoms of a more definite character are induced. Dyspnea is often a most marked feature; it is usually worst at night and compels the patient to sleep with his head high, oi sitting in a chair. The sleep is disturbed by dreams and nervous starts or sensations of suff'ocation more frequently than in any other form •of valvular lesion. Cough is a common symptom, due to the engorge- ment of the lungs, but hemoptysis and cyanosis are seldom observed in an uncomplicated case. The patient is usually anemic. The blood- count may fall below 3,000,000 in the c.mm. Edema of the ankles 344 PRACTICE OF MEDICINE generally supervenes; at first, perhaps, as a result of the anemia, later as a result of the failing of the circulation. General dropsy rarely ensues in the absence of extreme incompetency of the mitral valve as an associated lesion. Intercurrent attacks of acute endocarditis are not unusual and often lead to a hastily fatal termination of the disease. Embolism is also a frequent complication. It is announced by sudden pain, perhaps asso- ciated with tenderness in the affected region, as in the spleen. Hema- turia develops when the kidney is the seat of the lodgment, and paral- ysis when the brain is involved. The closing weeks, perhaps months^ of the patient's life are most distressing. Great restlessness, delirium,, and moroseness are commonly developed. The patient sometimes be- comes acutely insane and he may attempt suicide. To what extent such maifestations are a result of the valvular condition and to what extent they may be referred to an associated uremia in different cases, has not been determined. Sudden death occurs more frequently in this than in any other form of valvular disease. Physical Signs. — Inspection. — The cardiac impulse is strong and heaving. The apex beat is displaced to the left, but seldom beyond the anterior axillary line. It may be as low as the sixth or seventh intercostal space. The precordial space sometimes appears prominent, especially in children. The vessels of the neck throb, and in extreme cases pulsa- tion of the superficial vessels of the entire upper part of the body, es- pecially in the suprasternal notch, becomes visible. Ophthalmoscopic examinations reveal similar pulsation of the retinal vessels. Palpation. — A forcible impulse is felt, except in the late stages of the disease, when it becomes softer and wavy. There is sometimes a distinct pulsation of the entire precordial region, and sometimes also in the second right intercostal space, due to the pulsation of the aorta. A depression of one or more of the left interspaces, between the sternum and mammary line, is occasionally perceptible during systole. A dias- tolic thrill can occasionally be felt over the base. The pulse of aortic incompetency is characteristic. The impact is strong and jerky, often apparently full, but it immediately collapses under the finger.. The forcible impulse is due to the strong contraction of the ventricle, which throws the blood into the arteries with much force, but the regurgitation permits the blood to fall back almost in- stantly. This peculiarity can sometimes be better recognized when the hand is held high above the head during the palpation of the pulse, thus favoring the recoil after the first impulse. On account of this feature, the pulse is often referred to as the water-hammer pulse. An- other distinctive feature of the pulse is that it is delayed, a perceptible interval elapsing between the systole of the heart and the radial impulse, particularly in the advanced stage of the disease. Palpation of the vessels of the neck reveals a similar pulsation and sometimes a thrill. The pulsation and thrill commonly felt i^ the suprasternal notch in this disease occasionally lead to the erroneous diagnosis of aortic aneurism. A venous pulsation is occasionally observed, but it is seldom so strong as to be recognized on palpation. An arterial pulsation of the liver is occasionally noted, and less frequently that of the spleen. A capillary pulsation is not infrequently obtained either by gently compressing the VALVULAR DISEASES OF THE HEART 345 finger-nails or by drawing the finger-nail across the forehead. Be-neath the compressed nail or at the margin of the hyperemic line an alternat- ing flush and paling can be seen. It is not, however, fully pathogno- monic of aortic insufiiciency. Peraission reveals a great increase of the area of dullness, greater in extreme cases than in any other valvular lesion. Its direction is more particularly downward and outward to the left. Auscultation. — The murmur of this lesion is one of soft, blowing, sometimes musical quality, long in duration, and heard with greatest intensity, as a rule, at the base of the heart, in the middle of the ster- num opposite the third costal cartilage, or along the entire right side of the sternum from the second cartilage to the xiphoid. The murmur may be harsh when the cusps have become calcified or in cases of traumatic rupture of a segment. The second sound may persist, but it is often entirely replaced by the murmur. A short, soft systolic murmur is sometimes heard at the base, but in most cases the first sound is clear and distinct until late. When a partial stenosis accompanies the in- sufficiency, and especially when the cusps are adherent along a part of their edges, a sharp, rough systolic murmur is heard. It must not be regarded as a feature of the incompetency, but as a comparatively fre- quent complication. In many cases no abnormal sound is heard at the apex, but when relative insufficiency of the mitral valve has been induced an apical systolic murmur accompanies the diastolic which is heard at the base. This murmur should not be confounded with the interesting bruit sometimes heard at the apex and known as the Flint murinu7\ This is a more or less distinct rumbling sound, described as echoing in qualit}-, usually occurring at the middle of diastole ; sometimes it is more immediately presystolic, and heard only at the apex. It is recognizable in about half the cases of aortic incompetency. It is less distinct than the presystolic murmur of mitral stenosis, although it is virtually a mur- mur of that character. It is attributed to the forcible impact of the regurgitated blood upon the large anterior curtain of the mitral valve, possibly causing it to interfere with the simultaneous entrance of blood from the left auricle. It is not accompanied by the accentuation of the first sound, and it is always associated with the murmur of aortic in- sufficienc3\ A double, to-and-fro murmur can sometimes be heard by auscultation over the carotid and femoral arteries. Diagnosis. — In the ventricular hypertrophy of chivnic neplwitis a mur- mur with greatest intensity at the base may be heard, but the second sound is distinct and accentuated, and the urinar}^ examination reveals the condition of the kidneys. The hypertrophy is usually moderate. The differentiation can be further established by cryoscopy. The freezing- point of the urine is high, sometimes above the normal limit, — 1-30° C, in renal disease, but below' — 2.20° C. when the heart is affected. Anemic nuii-murs are heard at the base, but they are usually softer, of shorter duration, and unaccompanied with hypertroph}^ No thrill can be felt, and the arterial pulsations are absent ; a venous purring can some- times be heard in the cervical veins. The prognosis depends upon the extent of the insufficiency, the char- acter of its cause, and the presence or absence of myocardial changes and other complications. Cases due to endocarditis arc more favorable '346 PRACTICE OF MEDICINE to life than those due to arteriosclerosis. After degeneration of the heart muscle, compensation rapidly fails; and after other valvular lesions ensue, the downward progress of the case becomes more rapid. AORTIC STENOSIS. Etiology. — Narrowing of the aortic orifice is a comparatively rare ■form of valvular lesion, except when it is associated with aortic incom- petency. It is generally due to the encroachment of atheromatous disease of the aorta upon the valve ring or segments. It may, however, result from a chronic endocarditis following the acute form of the dis- ease, or it may accompany the arteriosclerosis of advanced life. It is a disease of the aged. Morbid Anatomy. — The cusps of the valve are usually adherent to a variable extent along their margins ; they may be thickened, more or less distorted, and calcified. Sometimes, on the other hand, they show little or no change beyond the adhesion of their margins, and form a rather thin membrane, the aortic surface of which still shows the primitive raphe separating the sinuses of Valsalva. When they retain this ap- pearance the condition is sometimes regarded as congenital. When there is much deformity, the valves are incompetent. Vegetations and deposits of fibrin are sometimes present. The left ventricle becomes greatly hypertrophied by the increased work thrown upon it, but there is little or no enlargement of the chamber (concentric hypertrophy). Dilatation is encountered only as a very late change. After it supervenes, however, the other lesions constituting the "vicious circle" are developed, includ- ing relative insufficiency of the mitral valve, dilatation of the left auricle, pulmonary engorgement, hypertrophy and dilatation of the right ventri- cle, and, finally, general venous engorgement. Symptoms. — Many patients remain free from subjective symptoms for a great number of years, as long, in fact, as the obstruction is compen- sated for by the strong action of the hypertrophied ventricle. The manifestations are generally due to the diminution of the blood supply to the brain, notably, vertigo and faintness. After dilatation has oc- curred and the compensation has been lost, the usual symptoms make their appearance. Physical Signs. — Inspection. — There may be no recognizable impulse, especially in old men with firm chest-walls and emphysematous lungs. The apex beat, when recognizable, is feeble, as a rule, but, with increasing hypertrophy of the left ventricle, it becomes more prominent, and it is then displaced outward and downward. Palpation. — The thrill is more commonly felt in this than in any other valvular lesion. It is usually felt over the base and may be well marked. The apex beat cannot always be felt, and, when recognizable, it varies in force and position with the h3^pertrophy. The pulse is small, firm, and of only moderate fullness. Percussion. — The area of dullness is not usually extensive. It may be increased in a downward and outward direction, but it is often obscured by the presence of pulmonary emphysema. Auscultation. — The typical sign of aortic stenosis is a harsh, rough systolic murmur, most intense at the base, but transmitted to the great VALVULAR DISEASES OF THE HEART 347 vessels. A musical tone is sometimes heard. The second sound is gen- erally absent ; sometimes it is replaced by a murmur of regurgitation when the valvular defect is so great as to cause incompetency. Very similar to this murmur is the bruit caused by hemic conditions or that caused by the passage of the blood over a roughened orifice or cal- careous plates in the wall of the aorta near the valve. After the com- pensation has failed, the murmur becomes softer and less distinct. Diagnosis. — The condition is not usually difficult of diagnosis, and the only source of error, as a rule, is the adventitious murmur just re- ferred to. This can be excluded by the hypertrophy of the left ventricle and the small, firm pulse. A distinct murmur, especially if musical and heard in this region, is generally due to aortic stenosis. The prognosis depends upon the condition of the valve. Uncompli- cated stenosis is not incompatible with fair health so long as compen- sation is maintained, but, associated with regurgitation and after com- pensation has failed, the consequences are more serious. TRICUSPID INSUFFICIENCY. Etiology. — The tricuspid valve is seldom incompetent as a result of disease, and a regurgitation of blood through it is commonly a result of relative insufficiency due to dilatation of the right ventricle following lesions of other valves, or obstruction of the pulmonary circulation in emphysema or interstitial pneumonia. Symptoms. — A systolic pulsation is transmitted to the veins of the neck as a result of the regurgitation of blood into the auricle with each contraction of the ventricle. This pulsation is distinctly visible, as a rule, in the right jugular, sometimes also in the subclavian and axillary veins. When the valves of the veins remain intact it may amount to only a slight wavy vibration. The pulsation is often transmitted to the liver ; the pulsation of the organ can be felt, in bimanual palpation, with each systole; very rarely, it can be seen. A systolic murmur can be heard over the lower sternal region and to the right, sometimes as far as the axillary line, but often over only a very limited area. It is generally soft in quality and variable in pitch. Another marked feature in many cases is an extreme distention of the veins of the upper part of the body when the patient strains or coughs. The pulsation of the veins is distinctly visible during this distention. Percussion shows an increased area of dullness, especiall}' to the right of the sternum. The symptoms belonging strictly to the condition are obscured in most cases by those of the underlying disease. The congestion of the organs is general, however, and that of the kidneys is often a distinct feature of the disease. Anasarca develops toward the close, affecting the face and upper extremities more than it does in other valvular lesions. Diagnosis. — This is clear in the presence of hypertrophy of the right ventricle, with venous engorgement and pulsation and a systolic mur- mur heard with greatest intensity in the lower sternal region. TRICUSPID STENOSIS. Etiology. — This is a rare lesion except in congenital cases, and these are often associated with other defects that are incompatible with life. 348 PRACTICE OF MEDICINE It may, however, be acquired. It then occurs in adult life, and fully 80 per cent of recorded cases have been seen in women. It is seldom the only valvular lesion present ; in most cases the mitral or both the mitral and aortic valves are defective. In most cases, too, the tricuspid lesion is a result of one of the other lesions. Physical Signs.— A. presystolic thrill has been observed in some in- stances. The dullness is somewhat increased, particularly to the right of the sternum. A pre_systolic murmur is heard at the base of the xiphoid cartilage or just at the right of it. The patient is generally cyanotic, sometimes extremely and constantly so. When the condition is thus extreme, an intense general dropsy often ensues. The prognosis is always exceedingly grave, owing to the impossibility of relief through any such change as compensatory hypertrophy, PULMONARY VALVE LESIONS. Functional Murmurs.— A soft blowing murmur is very often heard in auscultation over the second left intercostal space in children and sometimes in adults in ill health, especially when the patient is lying down. It may be heard also in anemia or after slight exertion during convalescence from any of the acute fevers. But it is heard also in some individuals in good health with thin chest-walls, during expiration. It is purely functional and of little significance. Pulmonary insufficiency is an exceedingly rare condition sometimes resulting from congenital malformation, as when the segments are agglu- tinated. It may result from endocarditis. It has been suggested also that a " safety valve" leakage sometimes occurs when the pulmonary vessels become engorged. The murmur is diastolic and is heard most distinctly at the second left intercostal space. The right ventricle becomes hypertrophied and dilated. The aortic sounds and the radial pulse remain normal. The bruit is often distinguished with much difii- culty from that of aortic insufficiency, except by the absence of the usual results of that lesion. Pulmonary stenosis is one of the most important congenital defor- mities of the heart. It may, however, be encountered in adult life as a result of endocarditis or atheroma. When congenital it generally con- sists of an agglutination of the margins of the valve segments to such an extent as to greatly diminish the size of the orifice. The stenosis is generally compensated for by an incompleteness of the ventricular septum or patency of the foramen BotalH. Tricuspid stenosis is some- times associated with the lesion. The diagnosis is difficult. The right heart is generally hypertrophied, and a systolic murmur can sometimes be heard in the left intercostal space. It may be transmitted to the right, but never along the great vessels, as is that of aortic stenosis, with which it might otherwise be confused. The pulmonary second sound is feeble or quite inaudible. Association of Valvular Lesions.— Valvular lesions are generally asso- ciated in the following order of frequency: (i) Mitral and aortic lesions; in children mitral and aortic insufficiency are most frequently combined; in adults mitral insufficiency combines with aortic stenosis; (2) mitral and tricuspid lesions; (3) mitral, aortic, and tricuspid; VALVULAR DISEASES OF THE HEART 349 (4) insufificiency or stenosis of the aortic valves is more frequently associated with mitral insufificiency than with mitral stenosis. Prognosis of Valvular Lesions. — The prognosis in all valvular lesions depends for the most part upon the extent to which compensation is maintained. This may be estimated from the degree of dilatation that is present and from the character of the heart's action. The prognosis is more favorable when compensation can be brought about by treat- ment, but it is then less favorable than when it is spontaneous, and before dilatation has occurred. Age is also an important factor in prog- nosis. Children are generally poor subjects of valvular lesion, but com- pensation sometimes develops at puberty, and with care life may then be greatly prolonged, providing the constitution be vigorous and the patient free from attacks of rheumatism, influenza, or other infection. Women generally tolerate valvular lesions better than men, probably because of less exposure to overexertion or other influence that dis- turbs compensation. The prognosis is impaired by all acute infections, as well as by syphilis, alcoholism, the arthritic diathesis, chronic pul- monary and renal disease. The prognosis of the different lesions has been referred to under each heading. Treatment of Valvular Lesions. — Stage of Compensation. — i. The admin- istration of cardiac remedies to a patient whose heart is acting regu- larly, with full compensation of the defect, is one of the most serious errors that can be committed. Nothing is then required but to guard the patient against the influences that are likely to disturb the action of the heart. It is often injudicious to inform him of his condition, especially when it is discovered accidentally during an examination. On the other hand, the discovery may prove to be a valuable one to the patient by enabling him to avoid excesses that tend to hasten the loss of compensation. Under all circumstances the physician should remember that a bruit does not always signify a valvular disease, and he should be absolutely sure of the correctness of his diagnosis before divulging it. The temperament of the patient should also be considered in connection with the character of the lesion. As a rule, he should be given the assur- ance that valvular disease of the heart is not necessarily fatal and that the duration of his life depends to a great extent upon the manner in which he conducts himself. He should be instructed with regard to the influences which are most harmful in his condition. A practical man leading an active life or engrossed with much business care and worry should be frankly told that he has reached the time for rest, especially when he is suffering from an aortic lesion. A nervous person with a less serious defect will often be moved to unnecessary precaution and con- finement by the merest hint that he has a heart lesion. It is not usually necessary or advisable to forbid all activity; the patient should rather be instructed to take such moderate outdoor exercise as he can endure without disturbing the rhythm of the heart, as indicated by palpitation, dyspnea, or precordial pain. Any exertion or excitement that disturbs the regularity of the heart's action must be avoided. The diet need not be restricted, as a rule, except so far as to avoid overeating and the ingestion of indigestible articles likely to cause flatulency. Alcohol and tobacco should, as a rule, be interdicted. 2. Stage of Lost Compensation.— \.o%% of compensation is sometimes so 350 PRACTICE OF MEDICINE suddenly fatal as to afford no opportunity for treatment. It is gen- erally gradual, however, and may be relieved unless it has been too long disregarded by the patient. The heart must be given rest. This can be accomplished by confining the patient to bed for a week or ten days, thus relieving it of unnecessary work. In some cases this of itself • is sufficient to re-establish compensation. It is not always possible, and indeed not always necessary, to secure absolute regularity of action, particularly in mitral lesions. Regularity is more desirable in aortic disease, since irregularity here is generally significant of failing com- pensation. In severe cases associated with cardiac dilatation, when the dyspnea is urgent and accompanied with cyanosis, venesection affords the promptest relief in cases showing extreme venous engorgement. Purgation acts in a similar manner, but it is slower. The regular action of the bowels is important in all cases. Medicinal Treatment. — Heart tonics should be employed in most cases to assist in restoring compensation, or to maintain it when restored through rest. They should not be used beyond the quantity required to secure the desired result. Digitalis is universally employed and can be relied upon to maintain its action for many years in some cases. A half-ounce (15.0) of the fresh infusion or TT|,xto xx (0.6 — 1.2) of a good tincture should be given every three or four hours until the heart's action has become full and regular. Then the quantity can generally be reduced to half the original amount or less. When dropsy is present, however, the full dose, if tolerated by the stomach, should be continued until the edema has disappeared, and in cases of this char- acter it is often necessary to maintain the dosage throughout the re- mainder of the patient's life. It should be employed in all cases of fail- ing compensation of whatever character, but theoretically at least it should be given with greater caution in cases of stenosis than in those of regurgitation. The only ill-effect that is usually observed in the use of digitalis is the production of nausea and vomiting in some cases, a symptom which quickly subsides upon withdrawal of the drug. When persistent vomiting is induced, tr. strophanthus, Tl^vto viij (0.3 — 0.5), may sometimes be employed in its stead, but it does not always fully replace it. Strychnin is often of great benefit in giving strength to the heart muscles and may be employed in connection with the digitalis ; occasion- ally it can be used as a substitute for digitalis. When anemia is a marked feature, as it so often is in aortic incompetency, iron or arsenic should be given in full doses. Treatment of Special Symptoms.— i. Djspnea.— The chest should be carefully examined in order to determine whether the dyspnea be due to the cardiac incompetency or to hydrothorax or pulmonary edema. When hydrothorax is present, the fluid should be withdrawn by aspira- tion as often as it becomes excessive. The pulmonary edema may some- times be relieved by purgation and diuresis, and held in check by full doses of digitalis and strychnin. Cupping the chest may prove bene- ficial. For the dyspnea and restlessness at night there is no better remedy than morphin, gr. yg (0.008), or codein, gr. ]4 (0.016). Glonoin often affords prompt relief in cases in which the arterial tension is- high, but it must generally be given at short intervals and in increas- ing doses in order to produce more than transitory effects. The par- HYPERTROPHY OF THE HEART 35r oxysmal dyspnea (cardiac asthma) sometimes yields to the compound spirit of sulphuric ether, 3 ss to j (1.8 — 3.6), administered in cold water and repeated in an hour if necessary. Potassium bromid is also useful in these cases. Dyspnea due to associated bronchitis or emphysema in elderly persons calls for special treatment of those conditions. 2. Palpitation and Angina. — In cases of excessive dilatation, an ice-bag" applied to the cardiac region often affords relief to both these symp- toms. Tr. aconite may be employed to regulate the heart's action and is sometimes better than digitalis, especially in aortic incompetency. It should be given in doses of gtt. ij or iij every two or three hours. Nitroglycerin may prove beneficial. Potassium iodid, gr. x (0.60) t. i. d., relieves the pain in some cases. Potassium bromid and elixir of ammonium valerianate are also of service; but when the pain is severe, morphin (gr. ^; 0.016) with atropin (gr. 1-120; 0.0005) should be administered hypodermically. 3. Edema. — The patient should be placed upon a dry diet, and an effort made to reduce the edema with hydragogue cathartics. The circu- lation should be maintained by full doses of digitalis, and the action of the kidneys further stimulated with mild diuretics — potassium bitartratc, citrated caffein or sodium and theobromin salicjdate. Calomel in doses of gr. i-io (0.006) is an excellent diuretic in cardiac cases, but it must be discontinued as soon as its action becomes apparent. When the edema of the lower extremities becomes extreme, it is better to puncture the skin than to allow it to rupture, although the necessity should be prevented, if possible, by bandaging with flannel. The legs should be bathed with an antiseptic solution before the punctures are made and at regular intervals, morning and evening, thereafter. In hospitals the patient should be isolated in order to protect him from erysipelas or other infection of the wounds. 4. Insomnia. — Sleeplessness often calls for special treatment. In some cases the bromids with valerian or camphor induce quiet sleep. Trional in a single dose of gr. xx or xxx (1.30 to 2.0) before retiring may be tried when they fail. Paraldehyd, amylene hydrate, and urethane are also employed, but their action is uncertain. Morphin fails to induce sleep in some cases. The insomnia often subsides with the restoration of compensation. 5. Hemorj'hage from the nose, lungs, stomach, or uterus requires- prompt treatment. Opium is always indicated, but ergot, astringents, and styptics are generally useless. In other respects the treatment is- the same as that of hemorrhage from the same sources in other con- ditions. The warm salt infusion must sometimes be resorted to. HYPERTROPHY OF THE HEART. ENLARGEMENT OF THE HEART. Definiiion. — An enlargement of the heart due to increased thickness of its walls. The condition may be general, but is usually confined to one or more chambers, more commonly to the ventricles. There may be simple hypertrophy or hypertrophy with dilatation (eccentric hyper- trophy) ; one chamber may be hypertrophied and another dilated. " Con- 352 PRACTICE OF MEDICINE centric hypertrophy" is a term now seldom employed to describe thick- ening of the walls with apparent diminution of capacity, probably due in all cases to post-mortem contraction. Simple hypertrophy is a little more frequently seen in the left ventricle than in the right. Etio/ogy.— The muscle of the heart, like any other striped muscle, responds to increased exercise by undergoing hypertrophy, becoming larger and stronger. Hypertrophy is in all cases a result of overwork, and it is often favored, no doubt, by overstimulation, especially with alcohol, while working to excess. The immediate causes of hypertrophy of the right and left ventricles are sufficiently different to receive separate consideration : Hypertrophy of the left ventricle, with or without general enlargement of the heart, results from : (i) Prolonged or habitual muscular exercise, as in athletes. Excessive hypertrophy is seldom due to this cause alone. (2) From such conditions of the heart itself as (ecialist is generally necessary. Cleanliness of the affected mucous membranes is essential. This can be accomplished by sniffing from the hand or allowing to flow into the nostrils a warm alkaline solution. Seiler's tablets may be used, or a solution may be made with a dram each of salt and bicarbonate of soda in four ounces of warm water. The engorgement of the mucous membrane may be greatly relieved in many instances by frequent spraying with a solution of menthol, 3 ss (2.0); camphor, gr. xx (1.3); in liquid albolin ^ ij (60.0). HAY FEVER. AUTUMNAL CATARRH, HAY ASTHMA, ROSE COLD. Definition. — A catarrhal affection of the upper respiratory passages, with asthmatic breathing, generally attributed to irritation of the mu- cous membranes by vegetable dust or pollen. Etiology. — The disease generally prevails in August and September, but it is occasionally contracted in the spring. Men are a little more frequently attacked than women. The disease is more common in the United States than in Europe, and more prevalent in cities than in the country. Only certain individuals are affected, and in these there is generally some abnormal condition, as deviation of the nasal septum, polypi, or hypertrophy of the turbinated bones, to account for their susceptibility. Most patients are also distinctly neurotic, and a heredi- tary tendency often appears. An attack has been induced in a suscep- tible person by suggestion, with an artificial rose. Dunbar has recently discovered that the pollen of rye, oats, wheat, rice, corn, and all other forms of grass contains an albuminoid sub- stance which is capable of producing all the symptoms of hay fever in a susceptible person at all times of the year, whether it be applied locally to the nasal mucous membrane or introduced subcutaneously. Symptoms. — The same individual is generally attacked at the same time, often on the same day, of each year. The onset is announced by persistent sneezing, or the patient may be seized during the night with an asthmatic attack. The condition quickly becomes one of severe coryza, to which are added paroxysms of coughing and more or less frequent asthmatic seizures. The patient is rendered unfit for business, is generally greatly depressed and often melancholy. Diagnosis. — The diagnosis is generally evident. Asthma of other origin is not attended with coryza or so great mental depression. Prognosis. — The disease seldom results seriously, but relief from the attack and removal of the tendency are alike difficult. Treatment. — The attack is relieved in most cases by a visit of six weeks to the mountains. The seashore is better in some cases, and a sea-voyage gives relief to all. When such means are unavailable, medic- inal treatment must be applied. Irrigation of the nose with a solution of quinin, gr. j (0.06), to water, 3 ij (60.0), has been recommended. Spraying the nostrils with a solution of adrenalin hydrochlorid (i :5ooo or less) has been recommended. More is generally to be accomplished by treatment of the patient in the intervals than during the attacks. The nasal chambers should be carefully examined by a specialist, and 384 PRACTICE OF MEDICINE abnormal conditions remedied. The neurotic condition calls for the ad- ministration of tonics, particularly strychnin, and iron or arsenic. Dun- bar believes that he has succeeded in producing a curative serum. EPISTAXIS. NOSE-BLEED. Etiology. — The causes are local and constitutional, (i) Among the former are injury, blows, rubbing, picking, coughing, sneezing, the lodgment of a foreign body, or the presence of neoplasms. The presence ■of chronic nasal catarrh favors its occurrence. (2) The principal constitutional causes are: ((?) Arterial engorge- ment, so-called plethora, or the hyperemia which sometimes attends the invasion of an acute infection. (^) Venous engorgement, particularly when it is due to an advanced valvular heart disease. (^) Abnormal states of the blood, as hemophilia, purpura, scurvy, pernicious anemia, or leukemia. (^) Sudden reduction of atmospheric pressure, as in ascend- ing to great altitudes. (^) Vicarious menstruation and cessation of chronic hemorrhoidal bleeding are possible causes ; and (_/") mental emo- tion may induce it. The source of the blood is generally a capillary oozing from the septum, floor, or outer wall. Symptoms. — There is sometimes a prodromal sensation of fullness or throbbing, but the bleeding often starts without warning. Except in abnormal blood-states, it is generally confined to one side. If the bleed- ing occur at night, the blood may be swallowed during sleep and vom- ited later. The quantity of blood lost is generally less than an ounce, but in severe hemorrhages it may be so great as to produce syncope. As this condition comes on, the blood ceases to flow. Death rarely results from epistaxis, but the patient may be left in an anemic and debilitated condition, especially if he be the subject of nephritis or heart disease. Treatment. — Moderate epistaxis is often beneficial, even in the passive congestion of heart disease. When it is necessary to interfere, the bleed- ing spot should be found, if possible, and subjected to pressure or cauteri- zation. If this cannot be done, ice may be applied to the nose and ice- water sniff"ed or douched into it. Hot water is equally effective. Astrin- gent solutions may be employed, as alum or zinc (2 to 4 per cent). Solutions of iron or tannin are sometimes effective, but they are exceed- ingly uncleanly. Pledgets of cotton may be dipped into the solutions or impregnated with the astringent powder and introduced. When these measures are ineffectual, the posterior nares should be plugged, and, this failing, the entire nasal chamber should be firmly packed with pledgets of cotton or gauze threaded on a string. The tampon must not remain longer than 48 hours. Treatment of the constitutional condition should not be overlooked. NASAL NEUROSES. .IS term is applied chiefly to alterations of the sense of smell. These are : (<3;) Anosmia, or a more or less complete loss of smell ; {F) hyper- LARYNGITIS 385 osmia, or an abnormally acute sense of smell; and (^) parosmia, in which the sense is altered or perverted. The affections are generally- attributed to alterations in the nerve-endings in the Schneiderian mem- brane that may result from any of the forms of inflammation. Besides these, injury and disease of the fifth nerve may be followed by a loss of the reflexes, so that sneezing is no longer induced by irritation. DISEASES OF THE LARYNX ACUTE LARYNGITIS. Eiiology. — The disease may be primary or secondary; primary as a result of atmospheric conditions, or "cold," inhalation of irritating dust or fumes, injury by foreign bodies, or excessive speaking; secondary in connection with the acute infections, catarrh of the nose or throat, or when associated with pulmonary disease. Symptoms. — There is generally a sense of tickling or pain in the larynx aggravated by the inhalation of cold air and sometimes !by swallowing; a cough which may be "croupy," and huskiness of the voice. Dyspnea is often produced in children and may result from associated edema in adults. On examination the mucous membrane is found to be hyperemic, the condition involving the vocal cords, but most pronounced in the aryepiglottic folds. There are usually no con- stitutional disturbances in an uncomplicated case, except occasionally slight fever in children. Diagnosis. — The differentiation is generally to be made from spas- modic, diphtheritic, and edematous laryngitis. In spasmodic laryngitis the paroxysm comes on suddenly, and it subsides completely without hoarseness or pain. It is purely a nervous condition. Diphtheritic or membranous laryngitis is generally accompanied with a similar disease of the tonsils or pharynx, and there is a history of possible contagion in most cases. The cervical glands are generally enlarged and the illness is more severe. In edema of the glottis there is greater dyspnea, and examination reveals the condition. Treatment. — The patient, particularly if a child, and when fever is present, should be confined to bed in a warm room. The air should be kept moist by the evaporation of water, and steam may be inhaled. Hot or cold applications over the larynx are beneficial. The larynx must be given rest, speaking being forbidden. Dover's powder at night and ammonium chlorid and ipecacuanha or squill during the day are the principal remedies. Aconite may be given for the fever. CHRONIC LARYNGITIS. Etiology. — Repeated attacks of acute laryngitis, persistent overuse of the voice in the open air, and the inhalation of irritating dust or tobacco smoke are the most frequent causes. Diseases of the nose and pharynx often lead to laryngitis. Symptoms and Diagnosis. — There is pronounced hoarseness, some- times amounting to aphonia, sometimes pain and soreness, and more or 25 386 PRACTICE OF MEDICINE less constant tickling and cough. The local signs of inflammation may be slight, yet enough, as a rule, to distinguish it from tuberculosis of the larynx, in which the appearance is one of anemia. Ulceration does not occur, except in late tuberculosis or in syphilis. Treatment.— The larynx must be given rest; tobacco and alcohol must be abstained from, and other causative agencies removed. Inhala- tions of steam, sprays of menthol and camphor, afford relief. Silver nitrate and other remedies may be employed, but these and the treat- ment of the nose and pharynx, which is sometimes necessary, would better be intrusted to a specialist. EDEMATOUS LARYNGITIS. EDEMA OF THE GLOTTIS. Etiology. — («) Any disease attended with general dropsy, especially nephritis and cardiac disease ; (<5) acute infections, especially diphtheria, scarlet fever, smallpox ; (^) chronic disease of the larynx ; (df ) injury by vapors, hot fluids, or poisons ; (^) repeated attacks of acute laryngitis, are the most common causes, (y) An angioneurotic origin has been referred to. Symptoms. — A sudden, urgent dyspnea develops, increasing in sever- ity until the face becomes livid, the voice is lost, the heart's action becomes tumultuous, and, if continuing for 24 to 36 hours, sometimes earlier, death may appear imminent. A fatal termination sometimes occurs. Examination reveals the swelling, particularly in the aryepi- glottic folds; sometimes it is deeper in the larynx (subglottic). The prognosis is always serious. Treatment. — If the symptoms be not urgent, cold may be applied externally and pieces of ice may be held in the mouth, but in most cases the edematous swelling should be scarified without delay, the larynx being first sprayed with cocain (4 per cent). If this fail, tra- cheotomy must be performed. NEUROSES OF THE LARYNX. SPASM OF THE LARYNX. Laryngismus Stridulus, Spasmodic Laryngitis. Two forms of spasm of the larynx are recognized, one a spasm of the adductor muscles without inflammation, usually occurring in early infancy and doubtless a pure neurosis (laryngismus stridulus) ; the other occurring in later childhood as a result of catarrhal inflammation (spasmodic croup). I. Laryngismus Stridulus.— This form is more frequent in male infants between the ages of six months and two years. The attacks are usually attributed to reflex irritation, particularly from the gastrointestinal tract. They are especially common in rachitic infants and those affected with cerebral or spinal disease. Spasm of the larynx may occur in adults also as a manifestation of hysteria, or as a result of the inhala- tion of irritating fumes, the lodgment of a foreign body, tubercular or syphilitic ulceration. BRONCHITIS 387 Symptoms. — The attack commonly occurs at night. The child awakes struggHng for breath. Respiration has ceased. The face is livid, and the struggle may assume the appearance of a convulsion, or a convulsion may actually occur; but in a moment the spasm relaxes, with a long crowing inspiration. The attack may recur several times during the night, and even during the daytime, or at intervals of several days for a week or longer. There is no cough, hoarseness, or other evidence of catarrh. Death has occurred in feeble infants or as a result of cerebral hemorrhage induced by the attack. Treatment.— Tht attack is usually too short to require treatment. In the interval, however, search should be made for the cause of the irritation ; errors of diet should be corrected, the bowels regulated, and the rachitic or other underlying condition treated. Fresh air, sunshine, exercise, and cold sponging all assist in overcoming the abnormal excita- bility of the nervous system. Spasmodic Croup.— This is a more frequent affection and occurs in weakly or robust children between 2 and 6 years of age. The child awakes suddenly during the night, generally after midnight, gasping for breath; or a loud, hoarse cough may be the first indication of the condition. The voice is hoarse and the respirations are sonorous. Cya- nosis may be produced, but, as a rule, the paroxysm subsides within a half-hour and the child falls asleep, to awake in the morning entirely free from it, or perhaps still a little hoarse. The attack may be repeated on several succeeding nights. The prognosis is good. Treatment. — The paroxysm may be relieved by a few inhalations of chloroform, by an emetic, by the inhalation of steam discharged from a convenient vessel under an improvised tent, or by a hot mustard-bath. When the hoarseness continues during the day, a cough sirup containing ammonium chlorid and sirup of ipecacuanha should be prescribed. Other Neuroses.— Chief among these are hyperesthesia, anesthesia, paresthesia, and hysterical aphonia. True paralysis of the vocal cords is encountered chiefly as a result of diphtheria, the growth of tumors in the larynx or in a situation where they press upon the recurrent laryngeal nerve, as is the case with aneurisms of the arch of the aorta. Tubercular laryngitis is considered under the head of Tuberculo- sis (p. 190). Syphilitic laryngitis is referred to under the head of Syphilis (p. 165). DISEASES OF THE BRONCHI. ACUTE BRONCHITIS. Definition.— An acute inflammation affecting the mucous membrane of the bronchial tubes of large and medium size. A similar affection of the smaller tubes, known as capillary bronchitis, is considered under the head of Bronchopneumonia. Etio/ogy.— The disease is probably of microbic origin. Atmospheric conditions, especially cold and excessive moisture, sudden changes of temperature, and the presence of dust or irritant vapors doubtless exert a predisposing influence. The disease is often caused by direct extension of inflammation or infection from the nose or pharynx. It may be 388 PRACTICE OF MEDICINE secondary also to other diseases, particularly to measles, malaria, ty- phoid fever, and other infections. The predisposing" causes are many, especially : (^a^ Age. The disease is more common in early and late life; heredity is often an important factor. (^) Habits; indoor, sedentary life without exercise. (^) Poverty and privation. (dT) Occupations which necessitate the breathing of dusty air. (^) General health, but particularly the presence of pulmonary disease, as tuberculosis; or a gouty diathesis. (7^) Climate and season. The disease is much more common in changeable climates and in the winter season. Morbid Anaiomy. — The essential lesions are hyperemia, swelling, and increased secretion, and these are found in the mucous membrane of the trachea as well as in that of the bronchial tubes. The disease is gen- erally a tracheobronchitis. Desquamation of epithelium occurs, and the submucosa becomes to some extent hyperemic and edematous. The bronchial lymph-glands are generally enlarged and hyperemic. Symptoms. — The onset may be sudden or gradual; it is generally preceded by coryza, except in individuals alread}- affected with pulmonary disease. There is generally a slight chilliness, rarel}' a rigor, with languor and aching of the limbs and back. Fever follows in the more severe cases, especially in children, but it seldom exceeds 103° F. (39.5° C), and the pulse is rapid. A dry, harsh, paroxysmal cough develops, and during the paroxysms the patient often experiences a sharp pain behind the sternum and through the chest. Headache may also be present. The cough soon gives rise to a scant, viscid expectoration; this in a few days becomes mucopurulent, then purulent and more abundant. The cough now becomes less painful and the fever subsides. In infants the bronchial secretion is not expectorated and there may be little cough. The disease must be recognized in them through the dyspnea, rapid respiration, and fever, with the physical signs that are always present. In the aged, too, the disease often begins insidiously, with prostration, rapid respiration, and even delirium, with but little cough. At either extreme of life there is great danger of extension to the finer bronchi. Diagnosis. — The disease is readily recognized upon physical examina- tion, if not by the general symptoms present. In robust individuals of middle age, little is to be observed on inspection. In the infant and old person, however, the respiratory movements become rapid, and, in the former, there may be slight sinking of the intercostal spaces during inspiration. The upper part of the thorax sometimes appears expanded and the lower part depressed. In adults the dyspnea and acceleration of breathing correspond to the degree of fever. The bronchial fremitus can sometimes be felt. Percussion seldom furnishes exact information in a case of simple bronchitis. On auscultation, numerous rales are heard. In the beginning these are of a dry character, sibilant, or sonorous, but later there are moist, mucous rales. They are heard intermittently, coughing causing them to. disappear for a time, as a rule, but they are distinctly audible in all parts of the chest, though with greater distinctness in some regions than in others. Sometimes the disease is confined almost exclusively to one side, especially when it is a complication of tuberculosis. The vesicular murmur is disturbed in rhythm^ and pitch. Both inspiration and expiration are prolonged, expiration more than inspiration,-. and BRONCHITIS 389 the pause is shortened. The pitch is raised. The sputum is not al- together distinctive in character. After the disease has fully developed, it consists largely of pus, in which alveolar cells are found in greater or less numbers and in different degrees of degeneration. The features which especially distinguish simple bronchitis from other affections are, the character of the rales and their general distribution. Bronchopneumonia and acute tuberculosis are chiefly to be excluded. In the former, fine moist rales are heard along the margins and at the base of the lungs. The prostration and dyspnea are greater. In acute general tuberculosis, the high temperature, great prostration, night- sweats, and other symptoms rarely fail to distinguish it from acute bronchitis. Prognosis. — Acute bronchitis, of itself, is seldom a serious disease in middle life, but in the very aged and the infant it should always be so regarded. It may terminate fatally in these patients through asphyxia or exhaustion, and the danger of its extending to the finer tubes and producing a bronchopneumonia is always a great one. Treatment. — In mild cases in persons of middle age the disease may generally be relieved or greatly modified by the administration of hot lemonade, a hot foot-bath, and a full dose of Dover's powder at the time of retiring for the night. In severe cases, the patient should be kept in bed. A saline cathartic should be given in the morning. A mus- tard-plaster applied to the chest relieves the pain behind the sternum. The air of the patient's room should be warm and moist. A Turkish bath sometimes proves of the greatest benefit, providing the patient can remain over night in the bath-house; otherwise it is unsafe, on account of the exposure that must follow it. A full dose of quinin (gr. X — XX ; 0.60 — 1.2) at night benefits some cases. A mixture con- taining ammonium chlorid or potassium acetate (gr. j — ij; 0.06 — 0.12) and sirup of ipecacuanha (TT[ij — v; 0.15 — 0.3) in each dose, with con- finement to bed, is generally all that is required for a child in an uncom- plicated case. The compound sirup of squill is often employed. Senega and wild-cherry assist in checking the secretion in the later stage of the disease. An emetic is often effective in clearing out the bronchial tubes when obstructed to such a degree as to cause alarming cyanosis. Inha- lations of steam impregnated with the vapor of benzoin, eucalyptus, or turpentine is often beneficial. The vapor may be inhaled through a paper funnel inverted over a pitcher containing a quart of boiling water to which a dram of the medicament has been added. In the extremes of life, attention must be given to the general nutrition of the patient, and stimulants should generally be given in quantity suitable to the age and physical condition. CHRONIC BRONCHITIS. Etiology. — Chronic bronchitis may result from repeated attacks of the acute form, but, as a rule, it runs a subacute course from the beginning and is directly attributable to disease of the lungs or other organs. Among diseases of the lungs, the most commonly bearing a causative relation are tuberculosis, emphysema, asthma, chronic interstitial pneu- monia, and chronic pleurisy with adhesions. Among diseases of other 390 PRACTICE OF MEDICINE organs, valvular heart disease, and nephritis are the most important. The disease is much more frequent in persons past middle life, but it is often encountered in the young. It is often spoken of as the " winter cough" of old people, beginning, as it does, with the first onset of cold weather and continuing until summer returns. It is much more preva- lent in cold and changeable climates, and especially near the seacoast. Morbid Anaiomy. — The changes are not constant. In some cases the mucosa and muscular layers are found in a state of atrophy, in some they are thickened and infiltrated. The surface of the mucosa may be granular, smooth, and in places destitute of epithelium, or ulcerated. Bronchiectatic dilatations are common in cases of long standing. Em- physema is always present. S/mpfotns. — Cough is a constant symptom. It is generally most troublesome at night, and a prolonged coughing spell is usually in- duced by the accumulation of mucus after a few hours' sleep. Dyspnea is generally a prominent feature, occurring especially upon exertion, as in climbing a hill or ascending a flight of stairs. It is due either to deficient aeration of the blood or to cardiac weakness. A sense of op- pression or of soreness in the chest is usually complained of, which appears to be due either to the strain of coughing or to the exaggerated action of the respiratory muscles. Acute pain is unusual. All the symp- toms are subject to frequent changes. Inclement weather, change of temperature, and exposure produce exacerbations. The disease is always worse in winter. For a number of years it may almost wholly subside during the summer, but each year the period of relief becomes shorter until the cough and expectoration become constant. Evening elevation of temperature is frequently observed, especially during the more severe periods of the disease ; but in many cases it is so slight as to be over- looked. The sputum is variable, changing from time to time. Some- times it consists of thick, tenacious mucus, sometimes of almost pure pus; in some cases it is always thin and fluid or frothy. Cases of "dry catarrh" occur also, in which there is little or no expectoration. These and other differences in the character of the sputum have led to the recognition of four forms of chronic bronchitis : («) The common form, which has just been described, (^) bronchorrhea, (r) putrid bronchitis, and ((/) dry bronchitis. Bronchorrhea. — This name is applied to cases in which the bronchial secretion is excessive in quantity. The sputum is generally purulent, rather thin and greenish; sometimes it is almost serous in character, but, on the other hand, it may be tenacious. The entire bronchial mucous membrane is usually affected. Although the condition is not one of bronchiectasis, it is apt to lead to dilatation of the bronchi, and the accumulation of secretion may cause the development of a putrid bronchitis. Fetid or Putrid Bronchitis.— This is characterized by an abundant expectoration of fetid, mucopurulent, heavy greenish, or thin grayish sputum mixed with frothy mucus, which separates on standing into three layers, the upper consisting of the frothy mucus, the middle of clear serum, and the lower of thick purulent matter often containing the so-called Dittrich's plugs, firm yellow masses as big as peas, composed of granular matter, fat-globules, and fatty acids, with putrid animal BRONCHITIS . 391 matter and sometimes fungi. Fever is more constant in this form than in simple bronchitis. This form, too, is often associated with bronchiectasis, gangrene or abscess of the lung, or advanced tuberculosis. Dry catarrh, as already stated, is characterized by a more or less complete absence of expectoration. It is generally associated with em- physema in old persons. Physical Signs. — The physical signs are nearly the same as those of acute bronchitis. The resonance on percussion is slightly tympanitic. Sonorous and sibilant rales are heard, and mucous rales of every variety are always present, and generally in all regions of the lungs. An occa- sional extension of the catarrh to the smaller tubes is common, during which times subcrepitant rales can be heard at the base and margins of the lungs. Treatment. — Prophylaxis is of the greatest value. The patient should, if possible, make such changes of occupation or residence as will enable him to avoid the inciting causes of the disease. The climate in this country best suited to the condition is found in southern California, at San Diego, or, better, in the villages in the foot-hills of the mountains near that city or Los Angeles. The southern part of Florida is suitable for a winter's sojourn. Next in importance is the constitutional con- dition of the patient. If there be an arthritic diathesis, heart or kid- ney disease, these should receive attention. If the patient be tuberculous, the treatment of that condition overshadows that of the bronchial affection. The digestion must be regulated with especial reference to the prevention of flatulency, a most distressing condition to the patient. The clothing should be warm, but modified to suit changes of tempera- ture. All exposure must be avoided, particularly the respiration of cold air. While the patient should take moderate exercise, he should avoid overexertion and hard work. The medicinal treatment must be suited to the case. Potassium iodid or the sirup of the iodid of iron is more generally beneficial than any other remedy, particularly when the secretion is scant. When the secre- tion is free, the fluid extract of senega may be added to the solution. Atropin is sometimes of service in bronchorrhea. Among other remedies generally used are ammonium chlorid, sodium benzoate, and other alkalis, ipecacuanha, tolu, tar, creosot, sandalwood, resin of copaiba, compound tincture of benzoin, and terebene. Inhalations of the vapor of turpentine, benzoin, creosot, eucalyptus, or a spray containing one of these or the wine of ipecacuanha are all recommended. In fetid bronchitis, a spray containing carbolic acid (2 per cent) should be used to destroy the odor. FIBRINOUS BRONCHITIS. CROUPOUS, EXUDATIVE, PLASTIC, OR PSEUDOMEMBRANOUS BRONCHITIS. Definition. — An acute or chronic inflammatory affection of the bron- chial mucous membrane characterized by a deposit of plastic matter which becomes detached and is expectorated in the form of a more or less extensive cast of the bronchial tree. A distinction must be made between true fibrinous bronchitis, a comparatively rare disease, and those conditions in which the expectoration of similar molds results from an 392 PRACTICE OF MEDICINE accumulation of clotted blood in hemoptysis, an extension of the diph- theritic membrane, or of the fibrinous exudate in acute pneumonia. Etiology. — No specific cause is known, but it is probably not the same in all cases. The disease is more common in Europe than in this country and usually occurs during the late springtime. It is not limited to any period of life, but is rare under the tenth or after the fortieth year. It is twice as frequent in men as in women. The patient is gen- erally in an anemic, debilitated condition when attacked, as a result of such diseases as measles, scarlet fever, pneumonia, or typhoid fever, and many are tuberculous or syphilitic. Its occurrence in pregnancy, and its association with such cutaneous affections as herpes and pemphi- gus, have been repeatedly noted. Various bacteria have been found in the secretions, but none has been identified with the disease. Morbid Anatomy. — The bronchial mucous membrane has "been found hyperemic, the epithelium sometimes intact, sometimes desquamated. The inflammation is more general in the acute form than in the chronic. The casts (Fig. 23), pure white or cream, color, sometimes streaked with blood, are firm and elastic and cor- respond in size to the lumen of the part of the bronchial tree in which they originate. They are probably composed of mu- cin, although they have been generally regarded as fibrinous. Symptoms. — The acute form may have a sudden, severe onset, with high fe- ver, chill, dry cough, dysp- nea, and constriction of the chest, but in most cases it begins as a simple acute bronchitis, with cough, scant expectoration of clear mucus, and possibly a slight elevation of temperature. In children it is often preceded by malaise. Much differ- ence has been noted in the severity and abruptness of the initial symp- toms in different cases. A chill may mark the transition from the simple to the fibrinous form. The pulse-rate is accelerated, and, with the development of casts, the cough becomes more harassing and parox- ysmal and the dyspnea more pronounced. Slight hemorrhage sometimes accompanies or follows their expulsion. Relief follows the removal of the obstruction, but it is transitory, and the paroxysm may recur within a few hours. In severe cases, digestion becomes impaired, nutrition is interfered with, and great nervous irritability may be exhibited. Re- covery takes place by a gradual subsidence of the symptoms ; the casts no longer appear, the temperature, although high, rapidly declines, appetite and strength return. Fatal cases generally terminate in from three days to two weeks, sometimes suddenly by suffocation. Fig. 23. — Casts from a case of fibrinous bronchi- tis. (2-5 natural size.) Practice of Medicine.— French. PLATE X. Bronchiectasis with Chronic Tuberculosis. The ragged communicating cavities involve a large part of the lung and are bron- chiectatic in origin. The bronchial lymph -nodes are enlarged, tuberculous, and caseous. The pleura and interlobar septum are thickened by the formation of dense fibrous tissue. {^By permission, frotn " Delqfigld and Prudden.") BRONCHIECTASIS 393 The chronic form generally follows a more or less protracted bronchial catarrh. Its course is one of exacerbations and remissions. Paroxysms of cough, dyspnea, and constriction occur, to be followed by temporary relief when the casts are expelled, but they recur at longer or shorter intervals for weeks, months, or years. Every grade of severity is seen in the recurrences, and months or years of perfect health may intervene. The temperature rises, if at all, during the exacerbations and does not generally reach so high a degree as it does in the acute form. The physical signs are variable and depend upon the presence or ab- sence of casts at the time of examination. In acute cases there may be all the evidences of an acute bronchitis; in the intervals of quiescence there may be no adventitious signs. The casts are readily recognized when the sputum is deposited in water, where they unfold. Treatment — It is difficult to estimate the results of treatment, since so few cases have come under the care of any one observer. Potassium iodid has been employed more than any other remedy, but its effects have not been uniformly satisfactory. Ammonium chlorid, ipecacuanha, senega, benzoic acid, apomorphin, and other expectorants have been recommended. Emetics may be employed in robust individuals to assist in the expulsion of the casts after they have become detached. Creosot carbonate in 15-drop doses is worthy of a trial. Obliterative Bronchitis. — Under the term bronchitis obliterans Lange and A. Frankel have reported three cases in which a plastic exudate in the bronchi, instead of becoming detached, underwent organization and caused a fatal obliteration of the air-spaces in a considerable por- tion of both lungs. The disease followed the inhalation of highly irritat- ing fumes. BRONCHIECTASIS. Definition. — A general or localized dilatation of the bronchial tubes. Etiology. — The disease is more common in middle life, but it has been found as a congenital condition ; men are more frequently affected than women. The direct cause is believed to be a weakness of the walls induced by inflammation involving the muscle, fibrous, and cartilaginous struc- tures, aided by the weight of accumulated secretions and probably by the expansive force of coughing. The disease is generally secondary to : («) Chronic bronchitis and emphysema, (i^) interstitial pneumonia, broncho- pneumonia, or tuberculosis, (^) compression of the bronchi by solid tumors or aneurism, (^) impaction of a foreign body, or ( of food taken in the evening. The patient should dine at noon, HYPEREMIA 397 eat a light supper, and should never eat late at night. The quantity of carbohydrates should be limited, especially at the evening meal. But many articles which agree with one patient cause great disturbance in another. Climate exerts a beneficial influence, but in this respect also patients diff'er. Some do well in the higher altitudes, but most of them, and particularly those having emphysema, generally do better near the seacoast, in an equable climate, like that of southern Cali- fornia or Florida. DISEASES OF THE LUNGS. HYPEREMIA. Hyperemia, or congestion, of the lungs may be either active or pas- sive. Both the parenchyma of the lungs and mucous membrane of the bronchial tubes are generally involved. I. Active Hyperemia.— £f/o/o5'/.— Some writers go so far as to doubt the occurrence of primary active hyperemia of the lung. There can be little doubt, however, that it sometimes occurs: (i) As a result of the inhalation of hot air, illuminating gas, or irritant vapors, and (2) sometimes in individuals whose occupation requires them to enter cold-storage vaults while actively working. (3) It is generally supposed to develop in one portion of the lung when the circulation of another part is interfered with; and it occurs (4) in the beginning of such pul- monary diseases as bronchitis, pneumonia, pleurisy, and tuberculosis. (5) It occasionally results from violent fits of coughing, (6) from too great atmospheric pressure, like that encountered by deep-sea divers and workers in caissons, or (7) from violent action of the heart, as that occasioned by athletic sports or cycling. Symptoms. — The development of an active hyperemia is generally an- nounced by a chill immediately or a few hours after its onset, with pain in the side, dyspnea, a dry cough, and moderate elevation of tempera- ture (101° — 103° F. ; 38.3° — 39.5° C). Examination reveals diminished resonance, feeble or bronchial breathing, subcrepitant rales, sometimes over the entire afi'ected lung. Death has resulted from the condition within the first 24 hours, but in most cases complete recovery occurs.^ Passive Hyperemia. — This form of congestion is of two kinds, mechan- ical and hypostatic. («) Mechanical hyperemia or congestion is caused almost exclusively by valvular lesions or dilatation and weakness of the heart which inter- feres with the normal return of blood from the lungs. It is sometimes induced, however, by the pressure of aneurisms or other tumors. The condition produced in the lung is known as brown induration. The lung becomes distended with blood, its tissues indurated and of a brown- ish red color. On microscopic examination the capillary vessels are found to be distended, the connective tissue is hyperplastic, and the alveoli contain many desquamated epithelial cells in various stages of degenera- tion and pigmentation. Symotoms. — The condition, when well marked, is indicated by dysp- nea and the expectoration of sputum containing degenerated and pig- mented alveolar cells and possibly free blood, in quantity sufficient to be 398 PRACTICE OF MEDICINE evident. Dullness may be found on percussion, and moist rales on auscul- tation. ((^) Hypostatic Congestion. — This condition is caused by weakness of the heart's action and favored, in some cases largely induced, by gravi- tation of the blood to the most dependent portion of the lung as a result of too prolonged lying in the same posture. It is most frequently encountered, therefore, in the continued fevers, notably in typhoid, and more chronic diseases. The posterior parts of the lungs are engorged with blood and become dark, often almost black. The affected portion of the lung may contain so little air that it will sink in water. This condition is often referred to as splenization. A form of hypostatic congestion, usually less pronounced than the foregoing, is met with in some cases of cerebral hemorrhage, especially in aged persons or as a result of cerebral tumors situated near the respiratory center, and some- times in cases of uremic coma or opium-poisoning. Symptoms. — The condition is recognized by dullness on percussion, the absence of the vesicular murmur, and the presence of moist rales, moderate dyspnea and cough, sometimes accompanied with blood-stained expectoration, under conditions favorable to its development. The con- gestion can be made to clear up on the affected side by changing the position of the patient. Treatment. — In active congestion, great relief may be afforded by a hot bath, by the application of wet or dry cups, a poultice, or mus- tard over the affected area. In extreme cases, general blood-letting is more certain and prompt. Aspiration of the right auricle has been ad- vised, if the blood does not flow freely from the arm. If blood-letting cannot be resorted to, the tincture of aconite in doses of a half to one drop every 15 minutes for an hour or two may be given for its action on the heart. In passive congestion the chief indication is the treatment of the cause. Remedies should be applied to strengthen the heart's action and, if possible, to overcome the dilatation. Hypostatic congestion should be treated prophylactically. It should be prevented by proper attention to the posture of the patient. When it has developed, it may be removed by changing the posture, and by careful stimulation of the circulation, preferably with strychnin. EDEMA OF THE LUNGS. Definition. — A transudation of serum into the air-cells and alveolar walls of the lungs. Etiology.— The most prominent cause of transudation is hyperemia, particularly passive hyperemia. The causes of edema are, therefore, practically the same as those of passive congestion, and the most im- portant of them is a feeble action of the heart due to dilatation, degen- eration, or chronic pericarditis. Edema occurs also in connection with chronic nephritis, hepatic cirrhosis, profound anemia, cachexias, or any condition in which there is a hydremic condition of the blood; in some cerebral affections and in some cases of acute ascending spinal paralysis. In all such conditions it is often a terminal affection, frequently occur- ring during the death struggle, a final relaxation of the blood-vessel PULMONARY HEMORRHAGE 399 walls that permits the escape of serum. A so-called collateral edema occurs in the neighborhood of inflammatory processes, infarcts, new growths, and tubercular formations. An acute angioneurotic edema is also believed to occur, similar to that which affects the larynx and various other parts of the body. It comes on suddenly, often in an individual apparently in good health, except, perhaps, for a slight gastric disturbance, with attacks of gastralgia and vomiting. The cause is supposed to be some irritant in the blood, probably an unoxidizable product of digestion which causes vasomotor paralysis and consequent dilatation of blood-vessels and transudation. Morbid Anatomy. — ^Vhen the edema is great, the lung may have a gelatinous appearance; it is heavy, pits on pressure, and, when incised, discharges a large quantity of serum, which is blood-stained when the condition accompanies congestion. The edema may be general, but it is usually most marked at the base and dependent portions of the lungs. Symptoms. — The symptoms are rapid breathing, audible bubbling or rattling, and dyspnea. There is the same sense of oppression as in asthma. The patient cannot lie down. All the respiratory muscles assist. The expectoration consists of an abundance of watery, frothy, blood-stained serum. Cyanosis often becomes extreme. Edema is usually present in other parts of the body, and the condition may be a part, usually the termination, of a general dropsy. The percussion note is dull, especially over the dependent portions of the lungs, and fine moist rales are exceedingly numerous in all parts of the chest. In secondary edema the temperature is sometimes subnormal, especially when it is the result of chronic nephritis, but in the so-called inflammatory edema there is always fever, and the condition closely resembles one of pneu- monia. Prognosis. — This is always grave, for the edema often proves rapidly fatal, sometimes within an hour. But in chronic cases several attacks of moderate severity are sometimes recovered from. The circumscribed, inflammatory edema is less dangerous. Treatment. — A severe attack of pulmonary edema calls for prompt treatment. If there is much cyanosis and the condition of the patient will permit, free venesection affords the quickest relief. Dry cups may be applied freely over all parts of the chest, thirty or more at a single application. The object is not to draw blood, but to stimulate absorp- tion. In some cases the patient is benefited by very hot fomentations, turpentine stupes, a poultice, or mustard applied to the chest. The inhalation of oxygen may assist in tiding the patient over. Strychnin should be given hypodermically, gr. 1-40 (0.0016), if the heart's action is feeble. Nitroglyerin (gr. 1-50; 0.0013) assists in equalizing the cir- culation, and a free purge should be given to aid absorption. PULMONARY HEMORRHAGE. Two very different conditions are described under this head ; broncho- pulmonary hemorrhage or bronchorrhagia, and pulmonary apoplexy or hemorrhagic infarct, sometimes referred to as pneumorrhagia. I. Bronchopulmonary hemorrhage is the form that is usually desig- nated by the term hemoptysis, or the spitting of blood. Although some 40 o PRACTICE OF MEDICINE writers include in this class of cases hemorrhages from the upper respira- tory passages, the term is generally understood to apply only to those in which the blood escapes into the bronchi. Flint restricts the term to the raising of blood, and blood only. The most important con- ditions in which this occurs are : («) In young persons apparently in good health, a more or less profuse hemoptysis, or a slight expectora- tion of blood for several days, sometimes occurs without discoverable lesion of the lungs, and is followed for many years by good health and no recurrence of the hemorrhage; (^) tuberculosis. This has been con- sidered in the chapter on that disease; (r) ulceration of the larynx, trachea, or bronchi. This form is sometimes rapidly fatal from erosion of a branch of the pulmonary artery. (^) Pure blood is sometimes expectorated in the primary stage of engorgement in acute pneumonia, in bronchitis, bronchiectasis, emphysema, abscess, gangrene, or cancer, less frequently in sarcoma of the lung. (^) Profuse and recurrent hemor- rhage sometimes occurs during the course of valvular disease of the heart, more frequently with mitral stenosis than with insufficiency or aortic lesions. (/) Aneurism of a branch of the pulmonary artery within the lung usually terminates in a fatal hemoptysis. Aneurism of the arch of the aorta sometimes perforates a bronchus and produces an immedi- ately fatal hemoptysis. But the fatal hemorrhage is sometimes pre- ceded for days or weeks by the expectoration of a small quantity of blood from pressure or erosion, and later from an oozing of blood through the laminae of fibrin which alone remain. (^) Vicarious hemoptysis occasionally replaces menstruation, especially in hysterical and anemic women, or for a time after removal of the ovaries. Hemopytsis after cessation of the menses has been known to continue for several years; but it sometimes indicates the development of tuberculosis, and deception is often practiced by this class of patients. (/?) Hemoptysis has been observed in connection with the arthritic diathesis in individuals past 50 years of age; (/) purpura hemorrhagica and malignant infections; (y) parasitic diseases of the lungs, particularly Distomum Westermanni, met with especially in China and Japan. Exertion, a blow upon the chest, or mental excitement is sometimes the immediate cause of hemoptysis in a person already predisposed to it by pulmonary disease. Symptoms.— In a majority of cases the hemorrhage comes on sud- denly, often at night and during sleep. Sometimes it follows a fit of coughing, strong vocal effort, unusual excitement, or exertion. The first indication of it is usually a welling up into the mouth of the warm, salty fluid. The quantity expectorated varies much with the con- dition leading to the hemorrhage. Very often the bleeding ceases after an ounce or less has been brought up, or a dram or less may be ex- pectorated at intervals for several days ; but in some cases of continued hemoptysis, repeated losses of several ounces occur at short intervals. When an aneurism ruptures into the lung, there is usually a sudden gush that overwhelms the patient. Only a small part of the blood is usually expectorated. In some cases, particularly in those of tubercu- lous origin, the blood is sometimes poured into a large cavity within the lung, and death occurs from the hemorrhage, without expectoration of blood. PULMONARY HEMORRHAGE 401 Coughing is generally provoked hy the hemoptysis; the patient be- comes pale, and the heart's action may be feeble, but this is usually due to the alarm that is naturally occasioned, and not to the loss of blood. After a hemoptysis it is not unusual for the patient to vomit some blood that has been swallowed; sometimes there is blood in the stools for a day or two. The sputum continues to be streaked with blood for a few days after cessation of the hemorrhage. Diagnosis. — It is not usually difficult to distinguish pulmonary hemorrhage from the other conditions in which blood is expectorated. The statement of the patient that the blood has been coughed up, and not vomited, is generally correct, and the appearance of the blood is quite different. In hemoptysis it has a bright red color and usually contains numerous small air-bubbles which may give it a frothy appear- ance. Blood from the stomach is generally dark and clotted. If doubt exists, or if the blood be not frothy, it is well to examine the pharynx, after having the patient gargle with water, for blood from the posterior nares may flow back into the throat. Auscultation of the chest reveals moist rales in the affected part of the lung, but it is of little value unless the previous condition be known, and the patient should not be disturbed for examination. Percussion should not be practiced. Prognosis. — This depends entirely upon the character of the hemopty- sis. In a majority of cases the bleeding ceases spontaneously, except when it is from a vessel of considerable size. Treatment — Rest is the most important element of treatment. The patient should be placed in a comfortable position, better on the affected side, in order to avoid aspiration of blood into the healthy lung. He should be given all justifiable assurance of recovery, and impressed with the importance of quiet and silence. No remedy is so valuable as opium, for it induces rest, quiets the heart's action, and allays the cough. Mor- phin may be administered hypodermically (gr. J^ to ^; 0.008 — 0.016), and followed with heroin (gr. 1-12; 0.005) or codein (gr. ]/^; 0.016) every four hours. Aconite is often indicated to quiet and strengthen the heart's action and to reduce the pressure in the pulmonary artery. Digitalis, ergot, styptics, are all more or less positively contraindicated. The application of cold to the chest is favored by some writers, but it is often more annoying to the patient than beneficial. Probably the best method of reducing intra-arterial tension is compression of the brachial and femoral veins by means of an elastic band, or any con- venient strap or bandage, passed around the arm and leg and drawn just tightly enough to arrest the venous circulation without compressing the artery. Not more than three extremities should be compressed at the same time, and one tourniquet should be removed every fifteen minutes, and, if necessary, placed upon the remaining limb. This method is often effective in arresting the more profuse hemorrhages which can- not be influenced by medicinal means. The diet of the patient should be light and nutritious. Stimulants should not be given, unless the patient is in an extreme condition from the loss of blood, and they should then be given hypodermically. A purge is generally indicated; repeated purgation is especially beneficial in cases of continued hemorrhage. 2. Pulmonary Apoplexy (Hemorrhagic Infarct of the Lung). — A 26 402 PRACTICE OF MEDICINE condition in which the tissue of a hmited portion of the lung is infil- trated and the air-cells more or less completely filled with blood as a result of embolism or thrombosis. Etiology. — This affection, which is not to be regarded as a hemor- rhage in the proper use of the term, results in most cases from the obstruction of a branch of the pulmonary artery with either a thrombus or an embolus. It is usually a sequel of heart disease. The emboli are septic when a result of malignant endocarditis or pyemia, and the ex- travasation of blood in such cases may be slight. In the chronic forms of heart disease the embolus usually consists of a vegetation from one of the valves, and it is not septic. It may be derived from a remote thrombus, as that of the femoral vein, after typhoid fever. Morbid Anaiomy. — The affected, wedge-shaped area is solidified, dark red in color, and a fibrinous pleurisy develops over its base. The subsequent changes are those peculiar to thrombosis. (See p. 15.) If recovery occur, the tissue is converted into a firm cicatrix. In some instances, caseation or calcification results, or, when septic, the tissue breaks down and forms an abscess or gangrene; general pyemia is possible. One or many infarctions may occur in the same lung. Symptoms. — A large embolus sometimes causes sudden death before an infarction has had time to develop. On the other hand, the vessel may be so small that its obstruction produces no symptoms. In other cases the patient is seized with a sudden, severe pain in the lung, urgent dyspnea, sometimes a chill and slight elevation of temperature. Exam- ination reveals circumscribed dullness, generally in the region to which the pain is referred, and tubular breathing. Mucus streaked with blood is usually expectorated. Diagnosis. — The differential diagnosis usually rests between hemor- rhagic infarct and pneumonia. Infarction does not occur as a primary disease. In pneumonia the initial chill is more severe, the fever much higher, the lung is more extensively involved, and auscultation reveals the characteristic crepitant rale, or the subcrepitant, over a larger area than is generally aff'ected in infarction. The treatment is directed to the relief of pain, weakness, and other symptoms as they arise. BRONCHOPNEUMONIA. LOBULAR PNEUMONLA, CAPILLARY BRONCHITIS, CATARRHAL PNEUMONIA. Definition.— An acute inflammation, probably of infectious origin, affecting the terminal bronchi, air-cells, and interstitial tissue of isolated lobules, or groups of lobules in different parts of the lungs. It usually begins in the mucous membrane of the bronchus and extends to the air- ceMs. Etiology. — The disease is regarded by many investigators as an infection, but the specific organism has not been determined. Several bacteria have been more or less regularly found, notably the Bacillus pneumoniae, the Micrococcus lanceolatus, and the staphylococci and streptococci of suppuration. A mixed infection is present, as a rule. Bronchopneumonia is peculiarly a disease of the extremes of hfe, affect- BRONCHOPNEUMONIA 403 ing most frequently and most seriously the infant and the very aged. . It is encountered, however, in middle adult life, particularly as a second- ary affection. It may occur as a primary disease, and Holt's statistics indicate that the remarkably high ratio of one case in three is primary, without previous involvement of the bronchi. It is generally secondary to bronchitis. Primary Bronchopneumonia. — This form of the disease generally oc- curs in infants and is probably due in most cases to pneumococcus infection. Cases following prolonged inhalation of ether, smoke, or irri- tant vapors are generally included in this class. Secondary bronchopneumonia follows bronchitis of the larger tubes and is a common sequel of such affections as measles, pertussis, diph- theria, scarlet fever, influenza, or erysipelas, and it not infrequently follows acute ileocolitis in delicate, improperly fed children, or those suffering with inherited syphilis or tuberculosis. Pulmonary collapse or atelectasis from any cause is almost invariably followed by it. In adults it is often encountered as a result of influenza, variola, emphysema, occasionally in the course of typhoid fever, or as a terminal affection in bronchiectasis, emphysema, chronic bronchitis, asthma, interstitial pneumonia, and tuberculosis. Rickets greatly increases the susceptibility of a child, and long confinement to bed that of an adult. Aspiration, inhalation, and deglutition pneumonia are terms applied to bronchopneumonia developing as a result of the entrance of foreign bodies into the bronchi. This occurs when small particles of food or drink enter the larynx when it is benumbed by paralysis, coma, or anes- thesia, or when the epiglottis is ulcerated by syphilis or tuberculosis. Pus or fragments of neoplasms and blood are sometimes aspirated dur- ing operations or after the rupture of an abscess in the mouth or pharynx. The exciting cause of the disease is not so much the irrita- tion caused by the foreign substance as the bacteria which are conveyed with it. J. N. Hall has observed severe cases of bronchitis and bronchopneu- monia following inhalation of sulphurous-acid gas, formaldehyd, kero- sene, smoke and other vapors. Morbid >f/7afo/w/.— Although the bronchi of all sizes may be found in a state of hyperemia, the pneumonic process is limited to the terminal tubes in small areas. It is strictly lobular in extent, but, owing to the involvement of adjacent lobules, areas of considerable size are often found to be involved, particularly along the margins of the lungs. Sometimes almost an entire lobe is involved. The affected areas do not fully collapse with the rest of the lung as the air escapes ; they are not solidified, yet they are firmer and do not crepitate so freely as the surrounding lobules. On section, they appear sHghtly more prominent, of a brighter red color than the surrounding tissue, which is also hyper- emic for a variable distance (3 to 5 mm.). Beyond these regions of inflammation the lung tissue appears normal. The medium and smaller bronchi are filled with mucopurulent matter. The air-cells are more or less filled with serum, which, on microscopic examination, is found to contain numerous leucocytes and desquamated, swollen endothelium. A few red blood-corpuscles are occasionally seen and possibly a trace of fibrin, but not to the extent that they are present in lobar pneumonia. 40 4 PRACTICE OF MEDICINE The absence of fibrin and red corpuscles is usually a distinguishing fea- ture. The air-cells nearest the terminal bronchus are the most densely filled with cellular elements. The walls of the alveoli and those of the terminal bronchi appear swollen on account of the distention of the capillaries and infiltration with leucocytes, A compensatory emphysema is generally to be noted in the uninvolved portions of the lungs. The tracheobronchial glands are usually enlarged and inflamed, a fact which explains their frequent infection with tubercle bacilH after the infectious diseases that are attended with bronchitis. In aspiration or deglutition pneumonia the infiltration is more in- tense and more liable to become suppurative. Termination. — Bronchopneumonia terminates : («) In a rapid resolu- tion; (J?) in caseation, which is generally only a form of tubercular infection; {/) in suppuration or gangrene, especially in the deglutition or aspiration form; or (^/) in a chronic interstitial pneumonia, also more commonly seen in patients who were previously tuberculous. Symptoms. — The primary form begins in a previously healthy infant with a convulsion, less frequently with a chill, vomiting, prostration, rapid respiration, often reaching 60 in a minute, and elevation of tem- perature, possibly reaching 104° F. (40° C). There may be no cough, and infants do not expectorate. The lesions are more definitely localized than in the secondary form. Cerebral symptoms, dehrium, photophobia, convulsions, and rigidity, are sometimes so pronounced as to mask the pulmonary affection, unless proper attention is given to the rapid respiration and evidences of dyspnea. The case often terminates with a crisis toward the end of a week, and rapid recovery usually follows. The mortality is slight, except in debilitated infants. The disease is with difficulty differentiated from lobar pneumonia during life. The secondary form occupies a more positive place in nosology. Following a bronchitis, perhaps during convalescence from measles or other acute infection, the temperature rises, the breathing and pulse be- come accelerated, and the cough m_ore frequent and severe. The cough is often painful and the infant cries; the respiration is often labored, the lower part of the chest is drawn in by the diaphragm, the alae of the nose vibrate, and cyanosis often develops. Percussion reveals areas of dullness in some cases, but it is more frequently negative. On auscultation, numerous subcrepitant rales are heard, particularly over the base of the lungs and on either side of the spine. The fever generally reaches 103° or 104° F. (39.5°— 40.0° C), and the skin feels hot and dry. The thirst is urgent, but the child cannot drink, and the infant refuses the breast on account of the rapid respiration and dyspnea. As the disease progresses, often within 24 to 48 hours the dyspnea and cyanosis rap- idly increase. The right ventricle is overcome in its effort to main- tain the circulation in the lungs and becomes increasingly dilated. The cyanosis rapidly deepens; the child struggles for breath, but finally sinks into unconsciousness, overcome by the accumulation of carbon dioxid in its blood; the breathing becomes less labored, the mucus is more fluid and rattles in its throat, and soon the heart ceases, from paralysis. When recovery is about to occur, the symptoms gradually ameliorate ; the fever subsides, and, usually by the end of a week, convalescence is established. It not infrequently happens, however, that convalescence BRONCHOPNEUMONIA 405 is delayed or slow. The child improves, but the cough persists and the emaciation continues. In such cases there may be ultimate recovery, but in some instances a portion of one or both lungs remains perma- nently collapsed or a chronic interstitial pneumonia is set up; some finally die of exhaustion, and others develop tuberculosis. Diagnosis. — In primary cases the differentiation generally lies between bronchopneumonia and lobar pneumonia. The former is more frequent in young infants, the latter after the third year. Lobar pneumonia is usually unilateral and confined to a definite region of one lung, which can be determined by the dullness on percussion. Bronchopneumonia affects both lungs, and there is often a general tympanitic note without recognizable dullness anywhere. The cough, pain, and fever are generally more severe in the lobar form ; yet in many cases the distinction is ex- tremely difficult. In secondary cases the diagnosis is much less obscure. The disease follows a bronchitis or an acute infection. The onset is gradual, the fever is more moderate, and the physical signs are more definite. There may be little or no recognizable dullness, but fine moist rales are heard in definite areas over both lungs. Acute tuberculosis, in the beginning, is sometimes differentiated with difficulty, although the temperature generally remains more uniformly high, with periodical sweats, especially at night. Prognosis.— The result depends largely upon the condition of the pa tient. The disease is very fatal in the extremes of life. The primary form generally terminates in recovery, but the secondary is always to be feared. Prophylaxis.— The liability to the development of bronchopneumonia should always be borne in mind in the treatment of the acute infections, particularly measles and whooping-cough. Most important, probably, is the avoidance of exposure to cold, or rather to infection. The patients should be kept warm in flannel gowns, and they should not be released from confinement until all danger has passed. The sick-chamber should not be allowed to become cold during the night. The regular cleansing of the mouth with an antiseptic solution is also important in all dis- eases which may lead to bronchopneumonia. Treatment — The patient should be confined to bed in a room kept at a temperature of 68° F. (20° C), and the air should be kept moist by the evaporation of water. The treatment is largely symptomatic. The fever should be kept within bounds by the administration of tinc- ture of aconite, TTLj (0.06) every hour or two according to the age and the effect. Cool sponging or the graduated bath serves the same pur- pose, but is often objected to and condemned as the cause of subsequent accidents. The coal-tar antipyretics should be avoided on account of their depressing effects. Opium should not be used, unless the pain and cough cannot be controlled by any other means. A hot poultice around the chest, although not now in fashion, or the more cleanly cotton jacket which may be pressed out of hot water and made to serve as a poultice, often relieves the pain, and is probably beneficial in other re- spects. The ice-poultice and cold-water jacket are rarely employed in this country. A simple expectorant consisting of ammonium chlorid, gr. i to ij (0.06—0.12), or the carbonate, gr. ^to i (o.oi — 0.06), with 4o6 PRACTICE OF MEDICINE sirup of ipecacuanha, Tll,v to x (0.3 — 0.6) in each dose, in tolu or other sirup, prevents the accumulation of tenacious mucus, providing opiurn has not been given, and thus renders the cough less annoying. An occasional emetic dose of wine of ipecacuanha may be required to clear the bronchial tubes. The strength of the patient must be maintained with nutritious food, chiefly milk, beef-juice, broths, and egg albumen. The child must be given an abundance of cold water to drink, and brandy (t1],x to xv; 0.6— I. o, to an infant) should be given at regular intervals, or strychnin may be administered hypodermically. The bowels should be opened with calomel, gr. i-io (0.006) every two hours, until it acts, and kept regular during the illness with magnesium citrate or other laxative. When cyanosis appears, every effort must be made to arouse the patient and induce coughing or vomiting. If the mucus can be removed from the tubes, an apparently hopeless case will sometimes recover. CHRONIC INTERSTITIAL PNEUMONIA. SCLEROSIS (CIRRHOSIS) OF THE LUNG, FIBROUS PNEUMONIA, CHRONIC FIBROSIS OF THE LUNG. Definiiion. — A chronic inflammation of the interstitial tissue of the lung resulting in proliferation, with subsequent contraction and diminu- tion of air-space. It may be local or diffuse in character. £f/o/o^/.— The disease may be either primary or secondary. Primary cases are generally due to the inhalation of dust. This is described in the following chapter, on Pneumokoniosis. Secondary cases occur in the course of chronic tuberculosis, syphihs, chronic bronchitis, emphy- sema, or chronic pleurisy, less commonly as a result of bronchopneu- monia or lobar pneumonia. These cases are usually classed as examples of the diffuse form. The local form of the disease is met with as a result of penetrating wounds, the presence of a foreign body, pressure of a tumor or aneurism, or the irritation of healing tubercular nodules. It is commonly met with around bronchiectatic cavities and beneath a thickened pleura. Morbid Anatomy.— The essential lesion is a firm mass of connective tissue from which lines of similar hyperplastic tissue usually radiate into the surrounding lung substance. The primary hyperplasia may take place around the blood-vessels, the bronchial walls, the interlobular spaces, around the bronchioles, or in the pleura. The resulting con- ditions are described under two forms, the massive or lobar, and the insular, diffuse, or bronchopneumonic. («) The massive form is unilateral, affecting a lobe or the entire lung and producing extreme deformity of the chest with approximation or overlapping of the ribs and depression of the shoulder in extreme cases. The heart is drawn toward the affected side, and the opposite lung is emphysematous, while the affected lung is often shrunken into an extremely small mass close to the bodies of the vertebrae. In cases of long standing the tissue has an almost cartilaginous hardness. Tu- bercular or bronchiectatic cavities are often found in the interior, and within these aneurisms of the pulmonary artery are sometimes found. (/^) In the bronchopneumonic form the areas are smaller, less indu- PNEUMOKONIOSIS 407 rated, and usually pigmented. They are found in all parts of the lung, ' as a rule, but may be confined to the lower lobes. Symptoms.— The disease is an exceedingly chronic one. The symp- toms are most pronounced in the early stage of its development ; after it has become fully established, they generally subside to a great ex- tent and the individual continues in fair health indefinitely. There is a chronic cough, and he becomes short of breath upon exertion, as in going upstairs or walking up hill. In many respects the case resembles one of bronchiectasis, especially in the periodical expectoration of large quantities of mucopurulent, sometimes fetid matter. The nutrition generally fails, and the patient then appears tuberculous, especially if hemorrhage occurs, a possible accident in nearly half the cases. But the anemia is not generally so marked. The absence of bacilli is the dis- tinguishing feature. Physical Signs. — These are exceedingly variable. In extreme cases the affected side is shrunken and immobile, often retracted until the ribs overlap and the opposite side seems to be enlarged. The shoulder is depressed, and the spine has generally a lateral curvature. Percus- sion of the affected side may reveal flatness or partial dullness, with a tympanitic or amphoric quality over existing cavities. Over the other lung the tone is one of exaggerated resonance (tympanitic resonance). The breath-sounds and voice-sounds depend upon the condition of the contracted lung. The vesicular murmur is generally replaced by a tubu- lar, cavernous, or amphoric breathing in the apex and by moist rales at the base. The disease ultimates fatally from dilatation of the right ventricle and dropsy, or from exhaustion, sometimes from amyloid dis- ease of the viscera, or earlier from hemorrhage. Diagnosis. — Interstitial pneumonia cannot be mistaken for any other disease except fibroid phthisis, in which the lesions and physical signs are virtually the same, with the additional and distinctive feature, the tubercle bacillus. Treatment. —Nothing can be done to arrest or counteract the disease. Life may be prolonged by residence in a mild climate, where the liability to bronchitis is least, and by maintaining the nutrition with tonics, the best of which in most cases is codliver oil. When the cough becomes troublesome or the expectoration fetid, the treatment is the same as for chronic or fetid bronchitis. PNEUMOKONIOSIS. ANTHRACOSIS, SIDEROSIS, CHALICOSIS, MINER'S LUNG, KNIFE-GRINDERS' PHTHISIS, ETC. Definition. — A form of fibrous induration of the lung due to the in- halation of particles of dust in various occupations. Anthracosis sig- nifies induration from the inhalation of coal-dust; siderosis, that from the inhalation of metallic dust, especially iron, as from the emery- wheel; chalicosis, that from the inhalation of mineral dust, as in stone- cutting. Etiology. — The irritant action of the particles of dust upon the con- nective tissue of the lungs is probably the only etiological factor in 4o8 PRACTICE OF MEDICINE the production of the disease. It does not, however, excite proliferation with the same degree of certainty in all individuals. Morbid Anatomy. — A large part of the inhaled dust is carried back by the ciliated epithelium of the bronchial tubes and expectorated. A smaller part is picked up by phagocytes, even from the surface of the mucous membrane. Part of these cells then pass out in the sputum, but part of them carry their burden into the lymph-channels and to remote organs, particularly the bronchial glands, liver, and spleen. In individuals who constantly breathe a smoky atmosphere, the surface of the lungs becomes deeply discolored, sometimes jet-black, as a result of the passage of particles of soot into the lymph-spaces and thence into the connective tissue beneath the pleura. The particles probably do not reach the air-cells directly, but they are often found in the alveolar epithelium, having been picked up by these cells while passing through the bronchial tubes. When the quantity of dust that gains access to the bronchi becomes greater than can be carried out or disposed of by the carrier-cells, much of it is stored in the lymph-spaces and connective tissue of the lungs, beneath the pleura, around the bronchi and air-cells. The irritation produced excites proliferation of the tissue and a fibro- sis is produced, much like that of chronic interstitial pneumonia, ex- cept that the new fibrous tissue is always deeply pigmented. Later, this tissue often undergoes necrosis, and cavities are formed in the lungs. The lesions are bilateral; the bases of the lungs are more extensively affected than other parts, but nodules and cavities are not infrequently found scattered through all parts of both lungs. Chronic bronchitis is a constant accompaniment, and there is generally emphysema. Some- times the necrotic cavities become tubercular. Symptoms. — The clinical features of the case are the same as those of chronic bronchitis with emphysema, except that there is a more pro- fuse expectoration of black or otherwise discolored mucopurulent spu- tum. This discoloration continues for a long time after the patient has abandoned his dusty employment. Examination of the sputum re- veals numerous leucocytes, bronchial and occasional alveolar epithelial cells containing dust-particles. The presence or absence of tubercle ba- cilli depends wholly upon the presence of tubercular infection. Dyspnea is often a prominent symptom, but it depends for the most part upon the emphysema. More or less pronounced asthmatic attacks occur in many cases. The chest often becomes barrel-shaped, as a result of the emphysematous condition. Treatment. — The case should be treated as one of chronic bronchitis with emphysema. The condition of the lungs cannot be modified by treatment. EMPHYSEMA. Definition. — Pulmonary emphysema is a condition of the lungs charac- terized by distention or dilatation of the infundibula and alveoli, asso- ciated, when permanent, with atrophy of their walls. Five more or less distinct forms of the disease are recognized, namely, the compensatory, hypertrophic, atrophic, acute vesicular, and interstitial. I. Compensatory Emphysema.— This condition is produced in one EMPHYSEMA 409 lung or in a part of either lung whenever some other part is prevented from expanding during respiration. It is compensatory in that it en- ables the lung, by overexpansion, to fill the space that should be filled by the part whose movement has been arrested. A temporary condition of emphysema is produced in the normal portions of the lungs : (a) In the presence of atelectasis or collapse; (^) in all the acute conditions attended with consolidation or bronchial obstruction, as in the pneu- monias; and (r) a more persistent form occurs in connection with pleuritic adhesions, hydrothorax, empyema, pneumothorax, chronic interstitial pneumonia, and tuberculosis. In the purely compensatory condition the alveolar walls are merely distended without undergoing atrophy, and return to their normal condition with the removal of the exciting cause. 2. Hypertrophic Emphysema.— The lungs in this condition are much enlarged by the distention of their air-cells. The condition is known also as substantive or idiopathic emphysema, and it is the form that was described by Sir William Jenner as the " large-lunged emphysema," in contradistinction to the atrophic or " small-lunged emphysema." Etiology. — A hereditary predisposition to the disease, in the form of a congenital defect in the structure or nutrition of the tissue of the lungs, is generally believed to exist, for the disease does not develop in all individuals, or to the same extent, under the same influences. The disease very commonly develops in early life and especially in the chil- dren of those affected with it. It is by no means uncommon, however, later in life, and may develop in the aged. The next important factor in etiology is an increased pressure within the air-cells. This may result from either inspiratory or expiratory force, but it is doubtless more readily and more commonly produced by forcible expiration, such as occurs in pertussis, asthma, chronic coughs, and in playing wind-instruments, glassblowing, and other occu- pations requiring prolonged acts of blowing. Mechanical causes are believed to be eff'ective only in the presence of a weakened power of resistance in the lung. Dilatation of the heart, a condition usually en- countered as a result of emphysema, and alcoholism are regarded by some writers as predisposing causes in some instances. The presence of adenoid vegetations in the nasopharynx is at least a probable cause in a child with inherited predisposition. Morbid Anatomy. — The chest has a barrel-shape, a condition attribut- ed by some writers to the expansion of the lungs within, by others to the action of the external respiratory muscles. The dilatation of the lungs is generally so great that the pericardium is completely con- cealed by the overlapping of their anterior margins, when the chest is opened. They do not collapse, but pit on pressure, on account of a com- plete loss of elasticity. Immediately under the pleura can be seen numer- ous enlarged air-vesicles, varying in diameter from i to 3 or 4 mm. Along the margins and over the inner surfaces, near the heart, there are bullae, varying in size from that of a pea to that of a hen's c:gg, which have resulted from a coalescing of several smaller vesicles, frag- ments of whose walls can be seen in the interior with a suitable lens or in microscopic section. Other histological changes are also to be noted. With the distention of the air-cells the capillary vessels are 41 o PRACTICE OF MEDICINE stretched longitudinally at the expense of their caliber. As a result, the network becomes imperfect and gradually disappears from the larger sacs. The elastic tissue of the distended air-cells is also lost — some regard it as congenitally defective; and the epithelium is reduced to a delicate squamous layer lining the inner surface of the bullae. As a result of the destruction of the capillary circulation, increased action is thrown upon the right ventricle. This leads to hypertrophy and in time to dilatation. In the more chronic cases both sides of the heart become hypertrophied, but the right side is most dilated. The pulmonary artery also yields to the increased tension within it and becomes en- larged. Atheromatous changes are commonly found in its walls. The bronchi also show important changes. The mucous membrane in the larger tubes is often greatly thickened and indurated. The longi- tudinal elastic fibers sometimes stand out like cords. Around the tubes there is generally a fibrous-tissue hyperplasia, a sclerosis, which leads to dilatation, particularly of the smaller bronchi. Atelectasis is some- times present, but it is not a frequent result of emphysema. The more remote organs, especially the liver and kidneys, are found in a more or less advanced stage of chronic passive hyperemia. Symptoms. — Emphysema is an exceedingly chronic disease, and its symptoms from time to time depend largely upon the existence of bron- chitis, the extent to which the circulation in the lung is impaired, and the development of comphcations. There is usually a considerable period, especially in childhood, during which the patient experiences compara- tively little discomfort. The muscular system may be well developed and strong, but the body generally becomes emaciated as the disease progresses. The most important symptoms are dyspnea, cyanosis, and bronchitis. (a) Dyspnea may be almost constant, but in many cases it is com- plained of only after a full meal or after exertion. It is at first largely expiratory in character, but later assumes, in many instances, the form of asthmatic seizures, with both inspiratory and expiratory obstruction. A distinct wheezing or rattling rhoncus is often audible to the patient, and it can sometimes be heard at a distance of several feet from him, most markedly with expiration. (<5) The cyanosis is a common and often a most striking feature of the disease. It accompanies the dyspnea, but is often severe beyond all comparison with that condition. The patient often shows little discomfort; he may be able to walk about when his face is puffy and his lips and finger-tips are blue. So deep cyanosis is not often seen except as a result of anilin-poisoning, congenital heart-lesions, or the most advanced organic cardiac or pulmonary disease, and then only in persons confined to bed. (^) The bronchitis is most troublesome in winter, often disappearing almost completely during the summer. It is excited by the slightest exposure and assumes a severity that is unusual in a previously healthy person, intensifying the dyspnea and cyanosis and often inducing severe paroxysms of asthma. With the advance of age it becomes a more dangerous condition and may ultimately lead to a fatal bronchopneu- monia. Physical Signs. —Inspection.— The appearance of the chest is so typical EMPHYSEMA 411 as not to be mistaken. It is the so-called barrel-shaped chest. The thorax is round and deeper than the normal. The anteroposterior di- ameter may exceed the transverse; the ribs are more horizontal, and the interspaces are widened. The sternum and clavicles are prominent, and fossae above them are deep. The back is rounded, the shoulders are raised and drawn forward. The respiratory muscles, including all the accessory muscles, are strong and stand out prominently. Their action during active respiration is exaggerated, and the thorax is drawn up as a solid frame; there is little or no expansion. Tranquil respiration is carried on almost entirely by the diaphragm. The expiration is pro- longed, and the thorax sinks more slowly than it rises. During inspira- tion, the upper part of the abdomen often remains fixed, or it may sink, and the suprasternal fossa is usually drawn in. A transverse curve running across the abdomen at the level of the last ribs has been noted. The veins of the neck are distended and usually pulsate. The apex beat of the heart is not visible, but there is usually a strong epigastric pulsation. Palpation reveals but slight vocal fremitus, the absence of the apex beat, a strong impulse beneath the lower portion of the sternum, and a forcible epigastric pulsation. Percussion elicits a peculiar type of resonance which is described by different authors as increased resonance, hyper-resonance, or tympanitic resonance. The quality is more or less drumlike and peculiar to the emphysematous chest. It partakes of the tympanitic quality as com- pared to the normal percussion note, but it is not tympanitic when compared with that of the abdomen. The distention of the lungs is revealed by the obliteration of the cardiac dullness and the lowering of the upper margins of the liver and splenic dullness. Attscultation. — The vesicular quality of the respiratory murmur is lost. In the absence of bronchitis, the respiration may be almost in- audible, but there is, as a rule, a distinct prolongation of the expiratory murmur, generally accompanied with wheezing and coarse, sonorous, and sibilant rales. When bronchitis is present, the respiratory sounds are replaced by the moist rales belonging to that affection. The heart- sounds can be distinctly heard and may be normal, with the exception of an accentuation of the pulmonary second sound; but in the later stages of the disease there is often a tricuspid regurgitant murmur. Diagnosis. — The disease cannot be mistaken for any other. Even when the physical signs are masked by those of bronchitis the condition is fully revealed by the appearance of the thorax, the absence of the apex beat, and the disappearance of the usual boundaries of the solid organs. Prognosis. — Emphysema is incurable; under the most favorable con- ditioris it is slowly progressive, for the elasticity of the lung cannot be restored, and the damage to the pulmonary circulation is a permanent one. Treatment. — When the disease is encountered early, as in a young child with asthma, a thorough examination should be made of the upper respiratory passages; nasal defects and pharyngeal adenoids or polyps should be removed in the hope of abating the causal influence. After the disease has been developed, nothing can be done, and the 412 PRACTICE OF MEDICINE treatment is directed, for the most part, toward the accompanying bron- chitis. The emphysematous patient should reside in a warm, dry cU- mate where he can best escape the many influences which excite bron- chitis. The diet should be regulated with reference to the prevention of constipation and flatulency. Starches and sugar should be restricted in quantity. Strychnin is a valuable tonic, assisting the weakened heart to perform its function. For extreme cyanosis, oxygen may be inhaled, but there is no better remedy in young, robust patients than free vene- section. 3. Atrophic Emphysema. — This form of ephysema is purely a senile change, a part of the general wasting which marks the closing years of a long life. It occurs in either sex and is attended with atrophic changes in nearly all other tissues of the body. These patients usuall)^ give a history of winter cough, with greater or less difficulty of breath- ing, for many years. The chest is not expanded, but small, and the obliquity of the ribs is increased. It is only the condition of the lungs that is characteristic of emphysema. In a typical case the air-cells are found to have coalesced into a series of large bullae. The blood- vessels have undergone atrophy, as in the hypertrophic form of the dis- ease. 4. Acute Vesicular Emphysema. — A condition in which the air-cells are acutely distended as a result of strong expiratory efforts in some cases of bronchitis affecting the smaller tubes, bronchopneumonia, cardiac dyspnea, angina pectoris, or asphyxia. The lungs are much en- larged after death. The condition can sometimes be recognized during life by the emphysematous resonance, increase in area, prolonged expira- tion and loud sibilant rales over all parts of the chest. 5. Interstitial Emphysema. — This form of emphysema, which corre- sponds to surgical emphysema, results from the passage of air into the interstitial tissue of the lungs. It is generally caused by an extreme expiratory effort, as in whooping-cough, bronchopneumonia, convulsions, parturition, defecation, or lifting, a rupture of air-vesicles being pro- duced. The air accumulates in minute bubbles beneath the pleura and in the interlobular spaces. Sometimes it finds its way into the medi- astinum and thence into the cellular tissue of the neck. After trache- otomy an interstitial emphysema sometimes develops from the passage of the air down along the trachea to the lungs. Pneumothorax may also result from an interstitial emphysema. PULMONARY COLLAPSE. ATELECTASIS. The term atelectasis signifies the airless condition of the lung before birth, or as a result of the failure to establish respiration after birth. Pulmonary collapse, on the other hand, applies to the collapse of a por- tion of a lung when a bronchial tube becomes obstructed by a foreign body, a plug of mucus, or from other cause, and to the occasional collapse of a portion of one or both lungs in a feeble, syphilitic child. Collapse may be caused also by the pressure of tumors, hydrothorax, empyema, or pneumothorax. The condition is then known as carnifi- ABSCESS OF THE LUNG ' 413 cation. Bronchopneumonia is a common sequel of partial collapse. A collapsed lung may regain its normal condition, especially when due to hydrothorax, after early removal of the compressing fluid, but later it becomes firmly adherent, and expansion is permanently prevented. The collapsed lung contains little or no air, and has a dark red color from engorgement with blood. The condition is usually a part or sequel of some other condition, and rarely calls for separate treatment. The only measure for its relief, in fact, is the removal of the cause, and this is rarely possible. ABSCESS OF THE LUNG. Etiology. — i. Suppuration of the lung results from septic infection after inflammation. It is sometimes a sequel of lobar pneumonia, more frequently of lobular, and exceedingly common after deglutition or as- piration pneumonia. The form of aspiration pneumonia most fre- quently leading to suppuration is that arising from the entrance of pus or septic matter of any kind during operations upon the nose or throat. Multiple abscesses varying in size from an inch to two inches (2.5 — 5.0 cm.) in diameter are generally produced, but a solitary abscess is occasionally met with. 2. Embolic or metastatic abscesses are generally a part of a pyemic infection, multiple septic emboli reaching the lungs through the circula- tion from more or less remote sources, as from a malignant endocarditis^ an endophlebitis, or pyonephrosis. The abscesses are, therefore, multiple and may be extremely numerous. They are generally found immediately beneath the pleura. The lodgment of an embolus at first produces a hemorrhagic infarction, but owing to the septic nature of the obstruc- tion the subsequent changes are suppurative. The pleura is at once afi^ected with a septic fibrinous inflammation, and perforation is not uncommon, with the production of pneumothorax. 3. Abscess results also from perforation of the lung from without, the lodgment of foreign bodies, especially bullets, or from the rupture of a subdiaphragmatic or hepatic abscess or echinococcus cyst. 4. Finally, one of the most common types of pulmonary suppuration is that associated with tuberculosis. Symptoms. — Suppuration of the lung following an inflammatory con- dition is usually announced by a return of the fever, pain, and dys- pnea, with rapid respiration. Later, pus is found in the sputum, or, if the abscess be large, a correspondingly large quantity of pure pus may be expectorated. The pus is often extremely offensive. Multiple pyemic abscesses are often unrecognizable on account of the intense general pyemic condition that is present. The discovery of pus in the sputum, with, perhaps, fragments of elastic tissue, is highly diagnostic of the condition. Prognosis. — Embolic and aspiration abscesses are almost invariably fatal, but recovery sometimes occurs in those following pneumonia or foreign bodies, after surgical treatment or a long process of spontaneous healing. Treatment. — Medicinal treatment is practically useless. The quantitj and the offensive character of the expectorated pus are sometimes mark- 414 ' PRACTICE OF MEDICLNE edly diminished after the administration of calcium sulphid, gr. j (0.06) t, i. d., but when the abscess can be reached the proper treatment is incision and the estabHshment of drainage. GANGRENE OF THE LUNG. Definiiion. — h. locaHzed or diffuse putrefactive necrosis affecting a greater or less portion of the lung. Etiology. — Gangrene is always a secondary affection; it does not attack previously healthy lung tissue. It arises from the entrance of the bacteria of putrefaction into a tissue already necrotic. It is a common sequence of: (rt;) Aspiration pneumonia; occasionally of (i^) lobar pneumonia in a previously debilitated subject ; more commonly of i^c) bronchopneumonia, (i^) bronchiectasis or fetid bronchitis, (^) embo- lism or thrombosis of the pulmonary artery, especially when the embolus is derived from a gangrenous focus, or (y) cancer. It sometimes follows (^) perforating wounds, (/^) rupture into a bronchus of an esophageal or other ulcer, (/) the perforation of an empyema or hydatid cyst, (y) the pressure of an aneurism or other tumor. (/&) As a result of tuberculosis, it is infrequent only in comparision to the prevalence of the latter disease. (/) It sometimes develops during convalescence from fevers of long duration, when the exciting cause cannot be deter- mined. After typhoid fever, it is generally due to the obstruction of a large branch of the pulmonary artery. The disease is most likely to affect elderly persons debilitated by chronic wasting disease, especially diabetes, or by alcoholism, but it sometimes occurs in the young. Morbid Anatomy. — (a) The diffuse form is rare, being occasionally met with after lobar pneumonia, or after the plugging of a large branch of the pulmonary artery. A greater part or the whole of one lung is con- verted into a dark blue or greenish black, extremely fetid, pultaceous mass, disintegrated at the center and not definitely separated from the surrounding tissue. (^) In the circumscribed form, the necrotic tissue is more clearly defined ; a distinct sphacelus is sometimes formed. The surrounding tissue is deeply congested, often solidified, and beyond this area the lung is edematous. The original embolus can sometimes be found, and it is not unusual to discover a rupture of a blood-vessel or perforation of the pleura in cases dying from hemorrhage. Bron- chitis is a constant accompaniment. Abscesses are not infrequently found also in the brain, liver, or spleen. Symptoms. — The development of putrefaction upon a previous pul- monary disease is promptly announced by the extremely fetid expectora- tion. The condition is occasionally encountered post mortem, however, in cases which gave no indication of it during life. The sputum is usually profuse, thin, greenish, containing mucus, pus, elastic tissue, fat-crystals, granular debris, bacteria of putrefaction, and sometimes altered blood. After standing, the sputum separates into three layers, the solid matter sinking to the bottom; a middle greenish fluid, and a supernatant brownish froth. Fragments of necrotic lung tissue are sometimes expectorated, and, when a blood-vessel has been eroded, a profuse hemorrhage occurs. Moderate fever is always present. The patient becomes rapidly emaciated and anemic, but does not, as a rule, NEOPLASMS OF THE LUNG 415 have much pain. The cough is almost constant, sometimes strong and ineffectual, interfering with sleep. Sepsis generally develops, with re- peated chills, increased fever, sweats, and delirium. The physical signs are not always distinctive. A severe bronchitis is invariably present, as indicated by the cough, and, when there has been great destruction of the lung, the signs of a cavity may be elicited by percussion and auscul- tation. The prognosis depends upon the previous condition of the patient and the cause and character of the gangrene. Recovery sometimes occurs in a young, previously healthy person after the case has long appeared hopeless, and after extensive destruction of lung tissue, but in the debilitated subject of diabetes or other constitutional disease a fatal result is inevitable. Treatment. — The patient must be immediately isolated in a well- ven- tilated apartment, the air of which should be charged with the vapor of carbolic acid, guaiacol, turpentine, or formaldehyd ; or one of these disinfectants may be dropped upon a respirator worn by the patient. The strength of the patient must receive especial attention. The food should be liquid and of the most nutritious quality. Whisky and strychnin should be administered freely. The advisability of surgical measures should be considered early when the gangrenous cavity is near the surface. Antiseptic solutions may be injected directly into it, or the cavity may be opened and drained as an abscess, providing the con- dition of the patient will permit. NEOPLASMS OF THE LUNG. 1. Benign neoplasms are rare. Fibromata, myxomata, enchondro- mata, osteomata, and adenomata have been encountered. Dermoid cysts have occasionally been met with. 2. Malignant growths may be either primary or secondary. The primary are extremely rare. Secondary carcinoma, epithelioma, or sar- coma is more common. Cancer reaches the lung by direct growth through the chest-wall, or through the lymph-channels from a primary source in the breast, esophagus, stomach, or liver. It usually appears in the form of multiple small nodules in the pleura of one or both lungs, which increase in size and extend deeper, sometimes giving rise to bronchopneumonia, suppuration, or gangrene. Secondary sarcoma reaches the lung by direct extension from the ribs or other adjacent tissues, or through the blood-vessels from remote parts of the body. It constitutes one of the most frequent locations of secondary growths. \\Tien a direct extension, the growth is usually single ; when metasta- tic, there may be a large number of nodules in both lungs. Pleurisy, either malignant, serous, fibrinous, or hemorrhagic, is an almost con- stant accompaniment of either form of malignant disease. Sarcoma occurs most frequently in early and middle life, but cancer is infrequent under the age of 40. The secondary form is much more commonly met with in women. Symptoms. — The clinical manifestations of malignant disease are indefinite. In many cases the disease exists for some time without producing recognizable disturbance. Dyspnea is often one of the first 41 6 PRACTICE OF MEDICINE indications of it. Cough is usually present, and it may be painful and ineffectual. There is sometimes a brownish, " prune-juice" expectoration that is regarded as highly diagnostic by some writers. Pain is usually an indication of involvement of the pleura. With the growth of the tumor, the blood-vessels are sometimes compressed in such a way as to induce turgescence of one or both arms and lividity of the face and neck. The heart may be displaced toward the opposite side, and the pneumogastric and recurrent laryngeal nerves are sometimes pressed upon. The dyspnea becomes extreme when the trachea or bronchi are compressed or their walls invaded by the growth. The subclavicular, axillary, and cervical lymph-glands are often enlarged. Auscultation and percussion give little information as to the character of the affec- tion and are of value chiefly after a source of probable metastatic infection has been determined. The development of cachexia is one of the most valuable factors in diagnosis. The duration of the disease after its recognition is generally brief. Death has occurred as early as one or two months after involvement of the lung, and it is seldom delayed longer than six or eight months. The prognosis is necessarily fatal. The treatmenf is palliative, directed to the relief of pain and the sup- port of strength. Morphin should not be withheld. PARASITIC DISEASES OF THE LUNG. Echinococcus of the lung is considered on page 286. Actinomycosis of the Lung.— A disease caused by the growth within the lung of the actinomycosis, or ray fungus. This may result either from inhalation of the fungus, or from direct extension of the dis- ease from the jaw and neck. Three more or less distinct forms are recognized, as noted on page 235, one affecting particularly the bronchi another producing bronchopneum.onia, and a third resembling tuber- culosis. The inflammatory process tliat is set up is usually modified by the accompanying pyogenic bacteria. With manifestations like those of an intense bronchitis or tuberculosis, the fibrous tissue of the lungs and pleura is proliferated, and pus-pockets are often formed within the new tissue. As the disease progresses, erosion of the ribs often occurs and the skin may finally be perforated. In some cases the perforation occurs through the diaphragm, and the pus burrows into the liver or other abdominal organ, or it may pass down the psoas or iliacus muscle. The disease was no doubt confounded v/ith tuberculosis until within the past few years. Septic manifestations are common, and a fatal pyemia is the usual termination. The extension of the disease outward and the perforation of the skin reveal the diagnosis, since the fungus can be found in the discharges. This also distinguishes the disease from a syphilitic or tuberculous abscess with fistulous opening. The disease may last for months or years, during which time metastatic infections are liable to occur, with the production of abscesses in the abdomi- nal organs, heart, and brain. The patient finally succumbs to exhaus- tion. Treatmenf.— The treatment which promises most is the administra- PLEURISY 417 tion of large doses of potassium iodid. Arsenic or iron may be advan- tageously combined with it. The declining strength of the patient calls for the most nutritious food and the free administration of alcohol or strychnin. DISEASES OF THE PLEURA. ACUTE PLEURISY. Pleurisy is classified : (^) Etiologically as primary or secondary; (^) anatomically, as plastic or adhesive (dry), and pleurisy with effusion; (^) in its course, as acute and chronic ; (^) in the character of the exu- date, as fibrinous, serofibrinous, purulent, and hemorrhagic, to which is sometimes added the so-called chylous pleurisy. (^) In addition to these, such terms as diaphragmatic, encysted, interlobular, and tuber- cular are often employed to describe differences in the location or origin of the process. Fibrinous Pleurisy. — Etiology. — The disease may be primary or sec- ondary in origin, (i) Primary pleurisy is often attributed to cold, but such micro-organisms as the bacillus tuberculosis, pneumococcus, and streptococci are often found, and are then looked upon as the exciting causes of the inflammation. (2) Secondary pleurisy generally occurs in connection with acute in- flammatory affections of the lung. It is constantly present in acute pneumonia and it is generally associated with abscess, gangrene, hemorrhagic infarction, and tuberculosis. It sometimes results from extension of inflammation from the pericardium or other adjacent struc- tures. It is generally encountered in penetrating wounds, malignant or other disease of the wall of the thorax, and caries of the vertebrae. Morbid Anatomy. — The lesions are generally unilateral. The pleura is at first hyperemic and edematous. The surface is opaque and dry, and a layer of fibrin of variable thickness, uniform and smooth, or with a granular surface, or superimposed layers of fibrin, are formed upon the surface. Within the meshes of fibrin are leucocytes and often a few red blood-corpuscles; a small quantity of serum is also exuded. Beginning on either surface, more commonly on the pulmonary, the process usually extends to the opposing layer. In the course of a few days, as a rule, the exudate becomes absorbed and adhesions are generally formed between the two layers of the pleura. These are often perma- nent, particularly when the apex has been the seat of the disease. Symptoms. — The disease often begins with a sharp stitch in the side, which is aggravated by deep breathing and coughing. The pain is generally referred to the lo.wer portion of the chest, but it may be con- fined to the apex region. A dry cough is usually present. In the more severe cases there may be an initial chill, with slight elevation of tem- perature. Tenderness is sometimes elicited by pressure over the affected region. The only physical sign belonging to the disease is a dry friction sound, a rubbing to and fro with the movements of inspiration and expiration, which gives the impression of being immediately under the ear. It is usually compared to the creaking of new leather. Sometimes there is a fine dry, crackling sound that can hardly be dis- tinguished from the crepitant rale of lobar pneumonia, but it is not 27 41 8 PRACTICE OF MEDICINE always confined to the end of inspiration, as in that disease. Many other rales are sometimes heard as a result of associated inflammatory conditions in the lung. The disease often occurs at longer or shorter intervals, especially when it is tuberculous in origin. Serofibrinous Pleurisy. — This is by far the most frequent form of the disease; it is the form commonly known as pleurisy with effusion. Etiology. — The causes are the same as those of fibrinous pleurisy. Bacteria are believed to play even a more important part in its pro- duction, and a great many cases are tuberculous. The disease sometimes occurs as a terminal affection in hepatic cirrhosis, chronic nephritis, and cancer, but it has been repeatedly found to be tubercular in these cases, and a dropsical effusion is more commonly formed. Some writers have gone so far as to attribute all cases of primary pleurisy with effuson to tubercular infection. But the pneumococcus and streptococcus are without doubt the exciting factors in some cases, and the typhoid bacillus, Friedlander's bacillus, and the diphtheria bacillus have been found in some instances. The tubercular exudate is generally sterile, but that from the streptococcus or pneumococcus is prone to become purulent. Morbid Anatomy. — The membrane is inflamed and covered with a layer of fibrin, as in the adhesive form of the disease, but the serous exu- date is much more profuse, so that an accumulation amounting to from one to four quarts (liters) is found in the pleural cavity. This is usually a clear or slightly turbid, straw-colored serum, containing flocculi of fibrin, which sometimes settle to the dependent part of the sac. It has a specific gravity of i.oio to 1.015, and faintly alkaline reaction. It is highly albuminous and usually contains, in addition to fibrin, a great number of leucocytes and degenerated epithelial cells, sometimes a itw red blood-corpuscles. It rarely coagulates spontaneously. Sugar, uric acid, and cholesterin are sometimes found in it. The lung of the affected side is compressed to the extent required to accommodate the fluid. In extreme cases the entire lung is pushed back against the upper pos- terior wall of the thorax and completely collapsed. In such cases the mediastinum with the heart is pushed over a variable distance to the opposite side. When the left side is greatly distended with fluid, the apex of the heart may reach the middle line of the sternum. Symptoms.— The disease sometimes develops abruptly with a chill, severe pain in the side, elevation of temperature, and a dry cough, sug- gesting acute pneumonia, but, as a rule, it is less severe in all its features. A great many cases, on the other hand, begin so insidiously, with little disturbance beyond a gradually increasing dyspnea, that the condition is not recognized until a large quantity of serum has accumulated. Dyspnea is usually an early symptom. It is at first due to the pain and in a measure to the fever, but later to the compression of the lung by the fluid accumulation. When, however, the accumulation forms very slowly, there is often but little evidence of dyspnea except on exertion. The pain, at first sharp and severe, is generally referred to the affected area, but sometimes to the back or abdomen. The fever seldom exceeds io3°F. (39.5°C.) and it is often intermittent in charac- ter. It may terminate at the end of a week, or it may persist for sev- eral weeks. The surface temperature is higher on the affected side. PLEURISY 419 Physical Signs.— Inspection.— The respiratory movements of the af- fected side are restricted to a degree that corresponds to the quantity of effusion. When this is extreme, it even causes that side of the chest to appear as if it were in a constant state of inspiratory expansion. The diameter is greater than that of the unaffected side, but the differ- ence is less than it appears. The intercostal furrows are obliterated and may rarely become slightly prominent. The cardiac impulse is obliterated or displaced. In a right-sized effusion, the apex-beat may be displaced beyond the left nipple, even into the axilla and raised to the level of the fourth interspace. In left-sided effusion, the apex beat is generally concealed behind the sternum. The pulsation of the right side of the heart may be seen at the right of the sternum and perhaps as high as the third or fourth interspace. Palpation. — The affected side is almost immobile, showing little or no expansion during full inspiration. The interspaces feel prominent. The tactile fremitus is diminished when the accumulation is moderate, and obliterated when it is excessive. Mensuration. — Differential measurements show a difference of from a half-inch to more than an inch (i — 2.5 mm.) between the two sides when at rest. The measurements may be about equal in full expansion. Percussion. — The percussion note over the fluid is flat; over the com- pressed lung it is tympanitic, the tone fading away into complete flat- ness as the lung becomes more and more compressed. Several points should be carefully studied in this connection : ( i ) Percussion over fluid gives a very different sensation to the fingers than that obtained by percussion over solidified lung tissue. (2) The upper boundary of the pleuritic fluid, when the patient is in the erect posture, does not follow a horizontal line, but a curve known as the Ellis or S-line of flatness. When the quantity of fluid is moderate, the lowest point is behind, near the spine. From that point it advances upward and forward in an S-curve to the axillary region, and thence declines in a straight line to the sternum. When the quantity of fluid is extreme, the upper margin behind is concave ; it may reach the clav- icle in front and extend beyond the sternum of the healthy side. In order to determine with exactness the upper boundary of the fluid, it is necessary to percuss with a light, quick stroke. (3) A peculiar tympanitic note, known as Skoda's resonance, is often heard on percussion in the infraclavicular region, and sometimes in the back just above the upper margin of the fluid. (4) The upper margin of the fluid in cases of moderate accumulation is found to change when the position of the patient is changed. If the upper margin of the fluid be marked in the axillary region when the patient is in the erect posture, the previously dull area will be found to be resonant when he lies upon the unaffected side. Atiscultatio?i. — In the beginning, when the exudation is but slight, a friction sound is heard with the respiratory movements, a dry crackling, as in the fibrinous form of the disease; but as soon as the pleural sur- faces have been separated by the fluid accumulation, the friction dis- appears. When the accumulation is sufhcient to compress the lung, the respiratory sounds become less distinct and apparently distant. With the filling of the chest, the sounds undergo many changes; sometimes 42 o PRACTICE OF MEDICINE there is tubular breathing with distinct inspiration and expiration, sometimes only a short, puffing expiratory sound; sometimes there is a metallic quality like the amphoric breathing heard over a cavity. Numerous rales may be heard as adventitious sounds, when tuberculosis, bronchitis, or other disease is associated with the pleurisy. The vocal sounds are also modified, absent, or intensified. Much depends upon the quantity of fluid, the position of the patient, and the presence or absence of adhesions. Bronchophony is not infrequently heard, and occasionally there is a more or less typical egophony. Baccelli affirms that the whispered voice can be heard through a serous effusion, but not through a purulent one, but exceptions to this rule have been repeatedly noted. The heart-sounds may be normal, but a systolic murmur is sometimes heard over a displaced heart, and a pleuropericardial friction sound is not unusual. As the fluid undergoes resorption, the respiratory sounds return. When the roughened pleural surfaces again come into contact, there is usually produced a friction sound not unlike that of the inflammatory stage, sometimes a creaking or crackling, sometimes much like fine rales, but generally described as a redux friction. These sounds often persist for months, or recur at intervals even for years, especially when there is a tubercular background. The heart-sounds also return to their normal position with the disappearance of the fluid. The duration and course of an acute serofibrinous pleursy are very indefinite. As in the adhesive form, all evidence of disease may subside within a week or ten days; a moderate exudate is sometimes absorbed within two or three days. When, however, the fluid has become excessive, compressing the lung, it is more apt to prove persistent, and in the tubercular form it often undergoes little change in quantity for many months. While the natural tendency of the serofibrinous exudate is toward absorption, there is always a liability to the development of suppuration. Spontaneous evacuation through the lung or chest-wall occasionally occurs, but less frequently than in the suppurative form. Sudden death has occurred in cases of long standing, usually in syncope, following some slight exertion or a sudden change of position. The exact cause of the accident cannot always be determined, but it has been attributed, as a rule, to embolism or thrombosis of the heart or pulmonary artery, or to a supposed twist of the great vessels. PURULENT PLEURISY. EMPYEMA. Eiioiogy.—(ia) In a majority of instances purulent pleurisy follows the serofibrinous form of the disease, but it is often primarily purulent in children. Although it is probably of bacterial origin in most cases, the pus is often found to be sterile, and no satisfactory explanation of its occurrence can be given at the time. Q^ It often develops after the acute infections, particularly scarlet fever, pyemia, som.etimes after dysentery, and it may be apparently purulent from the beginning. The same is true of its occurrence with typhoid fever, but it occurs less frequently in that connection. An important relation often exists between PLEURISY 421 the disease and pneumonia, the purulent accumulation developing either during the pneumonic attack or in convalescence. Aspiration, done with proper precautions for the prevention of septic infection, has probably no influence in the conversion of a serous into a purulent effusion. In tuberculous cases, however, the needle wound may be sufficient to produce infection under the most careful supervision, the infectious matter being derived from within, (^c^ The rupture of a tubercular cavity in the lung, and the extension of malignant disease from the lung, esophagus, or thoracic wall, excites a purulent pleurisy in some cases. (^) The disease may be established also as a result of injury, a penetrating wound, or the fracture of a rib. The micro-organisms most frequently found in the exudate are the streptococcus, staphylococcus, especially in pyemic cases; the pneumo- coccus, usually indicating a favorable termination ; the micrococcus lan- ceolatus; and the tubercle bacillus. Most cases of sterile purulent exu- dation are tubercular. The leptothrix pulmonus has been found in putrid exudates, and psorosperms have been discovered in a few cases. Morbid Anatomy. — The fluid found in the pleural cavity after death varies from a slightly turbid, seropurulent, flocculent liquid to a thick, creamy pus. In pneumococcous cases it is usually thick and creamy and has only a faint, sweetish odor. In cases associated with gangrene it may be more fluid and has an extremely fetid odor. The pleura is much thickened and is often eroded, sometimes perforated, in one or more places. The lung may be much compressed, as in a serofibrinous ac- cumulation. Symptoms. — A purulent pleurisy often develops so insidiously that it can be regarded as of rather long standing when discovered. Symp- toms of sepsis sometimes precede its recognition; they are seldom en- tirely absent. Sometimes, on the other hand, the onset is abrupt. The transition from a serous to a purulent eff'usion is marked in some cases by a rigor with rapid and pronounced elevation of temperature and pro- found prostration, often accompanied with severe pain in the side, which is aggravated by deep breathing. Cough is generally present, but it is by no means constant. Dyspnea is more uniformly present, but it may also be comparatively slight or entirely absent, except as a result of exertion. The patient sometimes sinks into a typhoid state soon after the development of pus, and more certainly after the exudate has be- come putrid. The course of the disease in the more severe cases is marked chiefly by manifestations of sepsis, with repeated chills, irregular or intermittent fever, profuse sweating, and finally delirium. Leucocyto- sis is present and often reaches a high grade. Peptonuria is observed in most cases, and indicanuria is more or less constant. Physical Signs. — All the signs characteristic of serofibrinous pleu- risy are found in the purulent form of the disease. In addition to these, however, certain peculiarities may be noted, (^a) The distention of the chest often reaches a more extreme degree, especially in children, and a bulging of the intercostal spaces is more frequently observed. (^) The heart becomes even more widely displaced, and the liver and spleen are more distinctly depressed. (<;) The subcutaneous veins are often distended over the affected side, and the chest-wall may become edema- tous. (^) Fluctuation has been noted, but generally as a result of a 42 2 PRACTICE OF MEDICINE beginning process of spontaneous evacuation and only over the region of "pointing." (^) The vocal sounds, sometimes audible over a serous accumulation (Baccelli's sign), are not transmitted through the purulent exudate. (/) In some cases a peculiar pulsation can be detected which is synchronous with the heart-beats (pulsating pleurisy). It is due probably to nothing more than the forcible action of the heart and the weakened resistance of the chest-walls. The natural tendency of an empyema is to become chronic and, ultimately, to a fatal termination. Spontaneous recovery has been observed, however, in a few instances, either through absorption of the fluid or after spontaneous evacuation through the lung or chest-wall. Evacuation through the lung, if too rapid, may terminate fatally, by suffocation, the large quantity of pus rapidly filling the lung. It is only in cases in which the pus seems to filter through an area of softened lung tissue that this accident is prevented. Spontaneous evacu- ation through the chest-wall (empyema necessitatis) usually occurs at some point in the anterior wall between the third and sixth interspaces. More than one opening may occur, and there is sometimes a fistulous tract of considerable length in the thoracic wall. Ultimate recovery is sometimes observed after a chronic discharge of many years' duration. There is always danger in these cases, however, from the possible pro- duction of amyloid disease. Perforation may occur also into the esopha- gus, stomach, pericardium, or peritoneum. Cases have been observed in which the pus passed down along the spine and psoas muscle to the iliac fossa, producing a condition resembling a psoas or lumbar abscess. Special Forms of Pleurisy.— i. Tubercular Pleurisy.— Many writers regard all cases of pleurisy with eff"usion as of tubercular origin. The clinical manifestations are the same as have been described, and need not therefore be repeated. From the standpoint of tuberculosis the con- dition has been considered in the chapter on Tuberculosis. 2, Hemorrhagic Pleurisy. — This term has been applied to cases in which the serofibrinous exudate contains blood in sufficient quantity to give it a reddish color. The condition is distinct from that already described under the head of Hematothorax. Hemorrhagic pleurisy is encountered, for the most part, in : (/^r(?w?/fl! is commonly associated with acute and chronic diseases of the throat. It is a constant condi- tion in smokers. Passive congestion is seen also as a result of obstruc- tion of the circulation in the vena cava by aneurism, neoplasm, or valvu- lar disease of the heart. It generally subsides upon removal of the cause. A 2 per cent solution of silver nitrate may be applied. (Ji) Anemia is observed chiefly in connection with general anemic conditions, as after hemorrhage and in chlorosis. (^) Ulcers sometimes result from chronic pharyngitis, but much more frequently from tuberculosis, syphihs, the general debility of long-stand- DISEASES OF THE PHARYNX 437 ing disease, as lupus, cancer, or nephritis, or from septic infection con- tracted in hospital or the dissecting-room. The treatment consists in the improvement of the general condition and the application of silver nitrate. (^) Edema of the pharynx ajid uvula occurs in quinsy, chronic ne- phritis, profound anemias, and other debilitated conditions. The enlarge- ment of the uvula may interfere with deglutition and respiration, espe- cially when there is congenital elongation. The serum may be evacuated by puncture or by snipping off the tip of the uvula when elongated. Hot gargles should be employed. Treatment of the general condition is even more important in many cases than local treatment. (^) Hemorrhage of the pharynx is sometimes associated with that of other mucous membranes. The blood may be retained and form a hematoma. Vomiting of blood (hematemesis) may occur after a large quantity has been swallowed. The condition may be mistaken also for hemoptysis, and for this reason the pharynx should always be examined in a case of moderate spitting of blood. The blood may come from granulations in the nasopharynx, and can then be seen trickling down the posterior wall. It can generally be arrested by the application of astringents or the peroxid of hydrogen. 2. Neuroses of the Pharnyx.— These occur especially as a result of neurotic conditions, bulbar paralysis, hydrophobia, tetanus, or of vari- cosity of the veins of the throat, reflex irritation of an enlarged phar3ni- geal tonsil, or growths in the posterior nares. They are manifested for the most part as hyperesthesia, anesthesia, paresthesia (altered or un- natural sensation) ; less frequently as spasms, neuralgia or paralysis, all of which conditions interfere with deglutition and sometimes impair the sense of hearing. The treatment is usually that of the underlying condi- tion. 3. Acute Pharyngitis (Sore Throat, Simple or Catarrhal Angina).— An acute inflammation of the pharynx, generally involving also the uvula and tonsils. Eiiology. — It may result from cold or the inhalation of hot or irri- tating vapors, but it is frequently a part of a general nasopharyngeal catarrh. It is doubtless due to the action of bacteria in some cases, especially when it is associated with the acute infections. Along with inflammation of the tonsils, it often precedes an attack of rheumatism or other acute disease. It may be induced by vomiting, and is thus associated with gastric catarrh. Symptoms. — It may set in with a slight chill and fever, and a burning soreness of the throat. This is sometimes followed with stiffness of the neck, glandular enlargement, tinnitus, an irritable cough, and perhaps hoarseness, from extension to the larynx. Swallowing and speaking be- come difficult. The pharynx appears red and swollen and is usually coated with viscid mucus. Treatment. — Gargling with hot milk or tea, sprays containing sodium bicarbonate or menthol, and lozenges containing alkalis afford great relief. The neck may be rubbed with volatile linament or camphorated oil, and covered with flannel. A purge is often beneficial, and laxatives should be a routine treatment with most patients in order to ward off" recurrences. 438 PRACTICE OF MEDICINE 4. Chronic Pharyngitis (Chronic Ulcerative or Granular Pharyngitis, Chronic Angina, Clergyman's Sore Throat).— A chronic inflammation of the mucous membrane of the pharynx, involving to a variable extent the other structures of the throat. Etiology. — The disease may follow repeated attacks of the acute form. In children it is associated with chronic hypertrophy of the tonsils and the presence of adenoids. It is induced by mouth-breathing, and it may be an extension of a catarrhal process from the nose. It is a common result of alcoholism and the excessive use of tobacco, but is often in- duced by voice-strain in lecturers, clergymen, and street-criers. It is probably more frequent in the rheumatic and gouty and in those pre- disposed to tuberculosis, as well as in the subjects of chronic diseases of the heart or lungs. Symptoms. — There is usually a sense of dryness or of irritation of the throat, that is most severe in the morning, and accompanied with cough or hawking, huskiness of the voice, and pain upon swallowing. The secretion is often abundant, and the enlarged follicles can be distinctly seen as prominences on the wall of the pharynx, but later the follicles may shrivel and the pharynx become dry. A few dilated capillaries usu- ally traverse the posterior wall. The mucous membrane appears relaxed and the uvula may be elongated and swollen. Chronic disease of the sphenoid occasionally produces a purulent discharge that flows down the wall of the pharynx. Treatment. — Removal of the cause is important, and the general con- dition of the patient must be improved. The enlarged follicles should be touched separately with silver nitrate or the electric cautery. The use of astringent gargles, sprays, and pastilles is beneficial, but in most cases the condition proves extremely resistant to all treatment. Chronic atrophic pharyngitis results, the mucous membrane becoming shrunken and pale, and the patient is greatly annoyed by the formation of crusts. Partial deafness often results from involvement of the orifices of the Eustachian tube. 5. Retropharyngeal Abscess.— This affection may occur in healthy infants or young children as a result of septic infection which cannot always be accounted for, or it may follow the acute infections. As a re- sult of caries of the bodies of the vertebras it may assume a chronic or recurrent form. The swelling may be so great as to interfere with swal- lowing and even to threaten asphyxia. The sound of the voice is altered. The neck may become greatly swollen. The wall of the pharynx is in- tensely red, and the abscess can generally be felt with the finger. The prognosis is grave, on account of the danger of suffocation, pneumonia from the aspiration of pus when rupture occurs during sleep, septicemia, edema of the glottis, or perforation of a blood-vessel, the trachea, or esophagus. Treatment. — An early incision should be made when the abscess can be reached through the mouth. In some cases the pus burrows and must be evacuated through the neck. 6. Acute Infectious Phlegmon. — This name has been given to a rare, malignant inflammation which begins in the side of the pharynx and rapidly passes to suppuration. The pus burrows down the neck and may reach the mediastinum. The side of the neck becomes intensely DISEASES OF THE TONSILS 439 swollen, red, and tender, deglutition painful, and respiration may be ob- structed. Severe constitutional symptoms of a septic character usually develop, and death may be a matter of but a few days. The treatment is purely surgical and consists in the evacuation of the pus when it can be reached. DISEASES OF THE TONSILS. ACUTE TONSILITIS. Catarrhal, Follicular, Lacunar, or Ulcerative Tonsilitis, or Amygdalitis. Definiiion. — An acute inflammation of the mucous membrane of the tonsils, accompanied with soreness of the throat and more or less sys- temic disturbance. Etiology. — The disease is ordinarily a part of a general pharyngitis. It is more frequent in the spring and affects particularly children and young adults. It often appears to be infectious, attacking simultane- ously several members of the same family, and it often recurs in the same individual at the same time each year. Cold and poor hygiene are doubtless influential in its production. Some writers regard it as related to rheumatism, for an attack of tonsilitis not infrequently precedes the onset of rheumatism. It is a common symptom of the acute exanthe- mata and may be associated with or follow an attack of indigestion. Morbid Anatomy. — Several forms of the disease are recognized, the most important of which are : (a) The superficial, in which only the mucous membrane of the surface of the tonsils is involved, and (/^) the lacunar or follicular, in which the mucous membrane of the crypts is also affected. The tonsils are enlarged and intensely hyperemic, and the follicles not infrequently become filled with a fetid, cheesy material com- posed of epithelium and micrococci. The exudation from several follicles sometimes blends into a uniform coating resembling the false membrane of diphtheria. Small vesicles like those of herpes have been observed on the tonsil in a few instances (herpetic tonsilitis) ; (^) a suppurative form, in which the tissues are more deeply involved and the inflammatory process rapidly goes on to suppuration. Symptoms. — The affection may begin with or without constitutional manifestations. There is often a slight chill and fever, with pain in the back and limbs. The temperature often reaches 104° or 105° F. (40.0° — 40.5° C.) in children. The throat is sore, and swallowing is painful. Fluids may be regurgitated into the nose on account of the swelling of the uvula. The tongue is furred, the tonsils much enlarged, and the crypts filled with a white or yellowish exudate. The voice is nasal, and articulation may be difficult and painful. The inflammation may extend to the middle ear and impair the hearing. The disease does not usually last longer than a week. Albuminuria is sometimes present, and endo- carditis and pericarditis have been observed; but the discovery of a systolic apex murmur does not necessarily indicate an endocarditis in a feverish child. Paralysis does not follow an acute tonsilitis unless it is of diphtheritic character. Diagnosis. —The disease is to be differentiated particularly from diph- theria. In the latter disease the membranous formation has a gravish 440 PRACTICE OF MEDICINE color, it is more uniformly spread over the surface of the tonsil, and is more firmly adherent, leaving a bleeding surface when forcibly removed, and it is not usually confined to the tonsils. Fever is not generally present at the beginning of the disease. The presence of the diphtheria bacillus establishes the diagnosis. Treatment — As a prophylactic measure the child should be isolated and confined to bed, at least until the presence of diphtheria has been excluded. The fever, headache, and joint or muscular pains are relieved by phenacetin or sodium salicylate. Aconite is highly recommended in the lacunar form. The diet should be liquid until the difficulty in swallowing subsides. Cold milk, egg-nog, and ice-cream are the most acceptable food. Hot gargles of sodium bicarbonate or borax with thymol, or astringents in glycerin and water, hot tea or milk, generally afford tem- porary relief. A folded flannel dipped in ice water should be applied to the neck at night and covered with oil-silk. In the suppurative form, hot applications are better. An incision should be made as soon as fluctuation can be detected. This is usually done with a curved bistoury guarded nearly to the point with a strip of adhesive plaster, the incision being made downward and parallel to the anterior pillars, avoiding the carotid region. Very rarely the tonsil reaches an extent that renders suffocation imminent before suppuration has occurred. The necessity of tracheotomy as the only means of saving life in such cases should be borne in mind. CHRONIC TONSILITIS. Chronic Nasopharyngeal Obstruction, Mouth-Breathing, Aprosexia. Definiiion. — A chronic hypertrophy of the tonsils and of the pharyn- geal adenoid tissue. Etiology. — The condition generally begins about the third or fourth year, but may be congenital. It is a little more frequent in boys. An inherited predisposition is often apparent, and it is favored by bad hy- giene and poor food. It often follows diphtheria, scarlet fever, or measles. Repeated attacks of acute tonsilitis produce permanent enlargement in some cases. Morbid Anatomy. — The enlargement of the tonsils is due to an in- crease of all their constituents. In many cases the hypertrophy of the lymphoid tissue predominates, while in others, especially cases of long standing, the stroma is greatly increased and the glands become quite firm. The tonsils are usually about equally affected. The enlargement of the adenoid tissue, the so-called pharyngeal tonsil, is sometimes of a papillomatous character in the more chronic cases. Symptoms. — The most prominent symptom is obstruction of respira- tion, due, in great measure, to the presence of the adenoids. The disease develops gradually. The child becomes restless at night and sleeps with the head thrown back and the mouth open. The obstruction causes loud snoring, and in severe cases the child often awakes in a fright as though at the point of suffocation. Next the child acquires the habit of keeping the mouth open during the day, and the face becomes dull and expres- sionless, the voice nasal and indistinct, especially in the pronunciation of the sounds /, r, m, and n. The hearing often becomes defective. The DISEASES OF THE ESOPHAGUS 441 secretion of mucus is increased and the breath becomes foul. Small cheesy, foul-smelling masses from the crypts are often brought up by coughing or hawking. Taste and smell are also affected in many cases. One of the most important results of the obstruction of the breathing is the production of deformities of the chest, especially the pigeon-breast, barrel-chest, and funnel-chest. While it is proljable that the deformity is more readily produced in a rachitic child, it may be independent of the latter disease. The greatest prominence of the sternum is usually in the upper part. The barrel-chest is associated especially with asthma and emphysema. Among the more remote results are habit chorea of the face, dreams, enuresis, forgetfulness, and inaptitudeTor study. Headache is a common complaint, and the children are especially susceptible to cold and other forms of infection. Diagnosis. — There is no difficulty in recognizing the condition in a well-marked case; examination of the throat reveals the enlargement of the tonsils. The adenoid vegetations may be seen through the throat mirror or they can be felt with the linger. Treatment. — An attempt may be made to reduce the enlargement by the local application of astringents, as glycerite of tannin, or, better, the compound solution of iodin in glycerin, applied with a stiff brush, but in most cases it is better to remove the tonsils. The treatment of the adenoids is of greater importance than that of the tonsils. Their removal can be readily accomplished under anesthesia, with the finger-nail, or, more esthetically, with a curette. The hemor- rhage is usually slight, but, if persistent, yields to astringents or a spray of adrenalin solution (i :iooo). It is sometimes necessary after the operation to apply a bandage or chin-strap at night, in order to over- come the habit of mouth-breathing. The child should have the benefit of fresh air, sunshine, and good food. Enlargement of the Lingual Tonsils.— Enlargement of the so-called lingual tonsils, a group of closed follicles at the root of the tongue, pro- duces the sensation of a foreign body lodged in the throat, causing repeated swallowing and hawking. It is usually associated with pharyn- gitis, and the treatment is the same. DISEASES OF THE ESOPHAGUS. ACUTE ESOPHAGITIS. Etiology. — The inflammation may be (^a) an extension of disease in the pharynx or in the stomach; (^b^ it may be produced by mechanical or chemical irritation, (<:) the passage or lodgment of foreign bodies, or (1^) the swallowing of corrosives. It frequently follows the infections, typhoid fever, diphtheria, smallpox, or pneumonia. In some instances the cause cannot be discovered. IVlorbid Anatomy. — The inflammatory process may be confined to the mucous membrance or it may extend deeply into the underlying tissues. It may be simple or catarrhal, membranous or diphtheritic, suppura- tive or phlegmonous, or gangrenous. The epithelial coat is lost, the follicles enlarged; erosions are often present, and ulcers of considerable depth, rarely perforating the entire wall, are sometimes formed as a 442 PRACTICE OF MEDICINE result of corrosive poisons. The membranous form may be due to diph- theria or the thrush fungus, and an interesting form is described in which casts of a greater or less portion of the tube are ejected similar to those of the bronchi in fibrinous bronchitis. Symptoms. — The chief symptom is pain upon swallowing, a burning sensation which may last for hours after the taking of food. A spasm is sometimes produced, with regurgitation of food. As the disease ad- vances, pus and blood may be regurgitated. Thirst becomes urgent, and emaciation results from the inability to take nourishment. A more or less constant pain beneath the sternum is usually complained of. On the other hand, there may be extensive disease of the esophagus, with ulcera- tion, unattended with any symptoms of prominence. Treatment. — The diet must be entirely fluid, or rectal feeding may be employed. Bismuth subcarbonate, gr. xv (i.o), with sodium bicarbonate, gr. V (0.3), may be given, suspended in mucilage or placed dry upon the tongue. Small fragments of ice and, as the inflammation subsides, de- mulcent drinks may be given. CHRONIC ESOPHAGITIS. This form may result from the acute or it may be produced by chronic alcoholism, irritating food, the lodgment of a foreign body, stricture, varix, cancer, or other tumor. The mucous membrane becomes greatly thickened, ulcers develop, and polyps may form. There may be pain on swallowing, and regurgitation of food, sometimes coated with mucus. The treatment consists in the removal of the cause and the administra- tion of the remedies for acute esophagitis. Ulcer is usually encountered in connection with acute esophagitis, cancer, or other neoplasms. It has been seen also after typhoid fever and in peptic ulcer of the cardiac orifice of the stomach. The condition is rarely recognized during life. The treatment is the same as that of peptic ulcer. STRICTURE OF THE ESOPHAGUS. Etiology. — Stricture, or stenosis, is produced by organic changes in the wall of the tube, by abnormal internal conditions, or through pres- sure from without. Congenital narrowing has been observed. Cicatricial contraction results from corrosive, tubercular, syphilitic, diphtheritic, or smallpox ulceration, and peptic ulcer at the cardia. The lumen of the tube may be closed by a polyp, cancer, or other neoplastic growth. The chief sources of external pressure are tumors in the neck or mediastinum, enlarged lymph-glands, aneurism, and pericardial eftusion. Morbid Anatomy. — The stenosis may occur in any part of the tube, generally near the upper or lower extremity, and rarely involves its en- tire length. It is usually single. A diverticulum may be formed, or the muscular coat above the constriction becomes greatly hypertrophied and the tube dilated. Symptoms. — A gradually increasing difficulty in swallowing is usually observed. The food seems to lodge on its way to the stomach, and for a time it must be assisted with a swallow of water. As the stenosis DISEASES OF THE ESOPHAGUS 443 becomes more complete, the food can no longer be forced down, and regurgitation occurs— immediately when the stricture is in the upper part, sometimes not for several hours when it is near the cardiac ex- tremity. The ejected matter has an alkaline reaction, unless changed by the formation of fatty acids. It shows no indication of gastric digestion. Auscultation may be of service in locating the stricture, or the esophageal bougie or stomach-tube may be employed for this purpose. The use of the esophagoscope is a more recent method. The X-ray has been suc- cessfully employed also, after giving the patient a large dose of bismuth subnitrate in order to produce a shadow. The utmost care must be exer- cised in passing a bougie or tube in a case of long standing, for the wall of an aneurism or a cancerous mass may be punctured, even when the instrument is most skillfully used. Treatment.— The patient must be nourished by rectal alimentation. Attempts may be made to dilate the stricture with graduated sounds, and in the cicatricial form this may sometimes prove successful. Elec- trolysis has been used with benefit. Esophagotomy or gastrostomy may be resorted to in extreme cases. No attempt should be made, as a rule, to dilate the carcinomatous stricture. CANCER OF THE ESOPHAGUS. Et/'o/ogy.— The disease is generally primary, and it affects most fre- quently men between 40 and 60 years of age. It is more common in alcoholic subjects, and may follow injury by a foreign body or chronic gastritis from any cause. The type of cancer is generally the epithe- lioma. /morbid Anatomy.— Some writers place the point of greatest frequency in the upper third, others at the lower extremity, of the tube ; the growth is sometimes found at the point of crossing the left bronchus. An annular mass from one to two inches in length is often formed. It may involve only the mucous membrane or the entire thickness of the wall. Ulcera- tion and perforation often result, with evacuation of the contents into the trachea, bronchus, mediastinum, or pericardium. Secondary growths develop in the neighboring lymph-glands. 5//w/7fo/77S.— Gradually increasing dysphagia is complained of, and a complete stenosis finally develops. The food, when regurgitated, is often coated with bloody mucus after ulceration has occurred, or pure blood may be brought up. Fragments of the cancer are sometimes found. Pe- riodical attacks of sharp pain are not uncommon. Laryngeal or bron- chial cough is produced by pressure. In other cases there are no symp- toms except gradual emaciation and the development of a .cachexia. Diagnosis.— The history of the case usually excludes spasm, stricture, and foreign bodies, for sudden occlusion does not occur. The emacia- tion, pain, and cachexia, in a man past middle life, with regurgitation of blood, should arouse suspicion of the disease. The tumor may be lo- cated by the careful passage of the stomach-tube. Prognosis.— The disease is invariably fatal. Death occurs from as- thenia or from perforation of the cancerous ulcer. Treatment.— This is purely palliative in most cases. The patient can generally be nourished with liquids, milk, predigested beef, egg-nog. 444 PRACTICE OF MEDICINE broths, and gruels until a late stage has been reached, when rectal feed- ing must be resorted to. Pain requires the administration of morphin. The patient's life may often be prolonged by an early gastrostomy. NEUROSES OF THE ESOPHAGUS. Spasm of the Esophagus.— This affection is generally met with in neurotic individuals, in connection with hysteria, hypochondriasis, epi- lepsy, or chorea, and sometimes in hydrophobia. It has been observed during pregnancy and in connection with ovarian or uterine disease. It may follow a choking fit or such emotional excitement as anger or fright. It is sometimes a result of gastric irritation or a reflex influence from the respiratory passages, and it sometimes occurs in persons debili- tated by neurasthenia, tuberculosis, or other chronic disease. Symptoms.— The spasm generally develops suddenly. It may affect any part, but more usually the upper or lower extremity of the tube. The food is regurgitated, and for a time all efforts to overcome the ob- struction are futile. Hiccough, pain, palpitation, and a sense of contric- tion generally accompany the attack. The spasm is sometimes caused only by certain articles of food, and fluids can generally be swallowed. The attacks recur at variable intervals, sometimes daily, sometimes not for weeks ; and the duration of each attack is equally indefinite, some- times lasting for only a few moments, sometimes for days at a time, until dilatation is finally produced. The bougie may pass without diffi- culty. The diagnosis is established by anesthetizing the patient, when the spasm will be found to have completely subsided. The affection is not usually serious, but fatal cases have been recorded. Treatment.— The treatment is that of the causative condition. The passage of the bougie often cures a hysterical case. The valerianates, asafetida, and the bromids are usually administered. The patient should be persuaded to swallow food in the presence of the physician, in order to overcome his fear of spasm. Globus Hystericus.— This name is given to the sensation of a lump rising in the throat and threatening suftbcation. It is a hysterical manifestation and is generally accompanied with repeated efforts at swal- lowing, and dyspnea. It is promptly reheved by remedies which quiet the hysterical seizure, as the bromids and the valerianates. Hyperesthesia occurs in the same class of nervous, hypochondriacal, or neurasthenic patients. It is indicated by a sense of burning or soreness in swallowing, without evidence of inflammation. It may precede or ac- company spasm. Anesthesia occurs either as a hysterical manifestation or in connection with paralysis. It is indicated, not so much by an absence of sensation, as by the slow passage of food. Paralysis is a rare condition. It may be the result of central disease, as bulbar paralysis, or of peripheral neuritis from diphtheria toxemia or metallic poisoning. It may occur in a hysterical person. It has been attributed also to myositis and adhesions. The food is regurgitated, sometimes after long intervals. Swallowing provokes coughing, and there is always danger of the aspiration of particles of food into the lungs. The patient rapidly becomes emaciated. The treatment consists in sup- DISEASES OF THE STOMACH 445 plying nourishment through the stomach-tube, and the appHcation of a weak faradic current, while the constitution is built up with bitter tonics, especially strychnin. Dilatation. — This is almost never primary, but is usually a result of stricture, and affects the part of the esophagus immediately above the constriction. Hypertrophy of the wall accompanies the dilatation. The food is regurgitated, sometimes after a considerable quantity has been swallowed, and respiration may be interfered with. Diverticula. — Saccular dilatations are of two kinds, those due to pres- sure (pulsion) and those due to traction. The former are usually found on the posterior wall at the junction of the pharynx and esopha- gus. A small dilatation is gradually increased by the pressure of food within it until a distinct pouch has been formed. Traction diverticula are generally situated on the anterior wall near the bifurcation of the trachea. They are generally produced by the contraction of cicatricial bands resulting from a previous inflammation of the lymph-glands. Foreign Bodies. — Such foreign bodies as fishbones, pins, buttons, coins, pieces of bone, false teeth, and numerous other articles sometimes lodge in the esophagus. When of a harmless character the foreign body may be carried on into the stomach with such food as bread or potatoes swallowed in large mouthfuls. Or the patient may drink a glassful of milk, and 20 minutes later take an emetic. The foreign body may be dislodged by the coagulated milk. Another method is to have the pa- tient swallow a mass of tangled thread. An hour or two later the for- eign body can sometimes be withdrawn with the thread. Rupture of the esophagus, when not a result of cancer or ulcer, is generally produced by violent vomiting. It is most frequently encoun- tered in intoxicated persons. It is always fatal. Varix. — The veins at the lower end of the esophagus sometimes become dilated as a result of hepatic cirrhosis or valvular disease of the heart; chronic esophagitis is induced, and a fatal hemorrhage often follows rupture of the vessels. Hemorrhage occurs also in connection with ulcers and cancer or from the injury inflicted in the passage of a foreign body. Profuse hemor- rhage follows the rupture of an aneurism into the esophagus. It some- times occurs also in purpura and pernicious anemia. DISEASES OF THE STOMACH. The stomach is so situated that its cardiac orifice normally lies behind the seventh left costal cartilage, one inch from the sternum and four inches from the surface. The pyloric orifice is less than three inches to the right of the cardiac when the viscus is empty, but it lies behind the left lobe of the liver when distended. The fundus rises to the level of the fifth rib. The line of the greater curvature varies, but it seldom sinks below midway between the xiphoid cartilage and the umbilicus in a healthy person. The blood supply of the stomach is received from the three branches of the celiac axis, and the residual blood is returned to the splenic and superior mesenteric veins. The nerve supply consists of the terminal branches of the two pneumogastrics, convej'ing impulses from the central system, and of branches from the solar plexus of the sympathetic sj^s- tem. The normal capacity of the stomach is from 1.500 to 1,700 c. c. (3 — 3',, pints). The gastric secretion consists of the true secretion of the peptic glands and mucus from the columnar cells found on the surface and in the mouths of the glands. The secretion proper contains, in addition to inorganic salts, hydrochloric acid and two enzymes, pep- 446 PRACTICE OF MEDICINE sin, which acts upon proteids, and rennin, which has the power of coagulating the casein of milk. It is normally almost colorless, of acid reaction and characteristic odor. Its. specific gravity is usually between 1.002 and 1.003. The acidity is chieil3^ if not wholly, due to hydrochloric acid, and amounts to 0.2, rarely 0.3 per cent. EXAMINATION OF THE STOMACH. The examination of the stomach includes the apphcation of the usual methods of physical diagnosis — inspection, palpation, percussion, and auscultation— and the chemical, microscopic, and bacteriologic examina- tion of its contents. Many mechanical devices have recently been intro- duced which render it possible to illuminate the interior of the stomach, determine its size, and outline its form with considerable accuracy. Inspection. — It is only when the stomach is distended that its outline becomes distinguishable by inspection. Peristaltic movements can some- times be recognized, and they may be induced in some individuals by applying heat or cold to the abdominal wall or by tapping with the finger. The stomach may be artificially inflated with air or carbonic- acid gas. For this purpose, the stomach-tube is introduced, and air is slowly pumped in with a small hand-pump or a Politzer bag. Disten- tion with gas may be effected by administering alternately small quanti- ties of an acid and an alkaline solution, as the two parts of a Seidlitz powder, until the desired degree of distention has been obtained. The latter method must be used with caution, in order not to produce seri- ous overdistention, and the stomach-tube should be at hand to relieve such a condition. Neither method should be employed in a case in which cancer or ulcer is suspected. The stomach may be illuminated by means of Einhorn's electric bulb introduced at the end of an esophageal sound, thus revealing its size and any inequality of its surface due to neoplasms. The X-ray may also be employed after filling the stomach with a solu- tion of bismuth subnitrate. Palpatmi.—T\\\^ method is employed chiefly for the purpose of deter- mining the presence of a tumor. The palm of the hand should be slowly but forcibly pressed upon the surface and, by having the patient relax the abdominal muscles, the neoplasm can often be felt, especially during expiration. A more certain method is to examine the patient in the knee-elbow position, with the thighs well drawn up. In many cases the size, location, outline, and firmness of the tumor may be determined, as well as the presence of tenderness, pulsation, or fluctuation. Percussion is of value chiefly in determining the size of the stomach and its relations to other organs, particularly when it is inflated. The presence of food or fluid alters the result, especially along the lower margin. Tumors may also be recognized. The normal percussion note is tympanitic, of rather high pitch, with more of a metallic quahty than that of the colon ; but it differs with the degree of distention. Ausculta- tory percussion is often more accurate. In order to accurately determine the size of the organ, percussion should be practiced first with the stom- ach empty, then inflated with gas, and finally distended with water. It is well also to examine the patient both in the recumbent and in the standing posture. Auscultation is of comparatively little value except in connection with percussion. Succussion may be produced by shaking the patient or by ACUTE GASTRITIS 447 his voluntary abdominal movements, but it affords only an indefinite idea of enlargement. The promptness with which fluid reaches the stomach may also be determined by auscultation (deglutition murmur). This should normally occur six seconds after the act of deglutition, but it may be indefinitely delayed when a tumor is present at the cardiac orifice. Examination of the Stomach-Contents. (For methods see p. 719.) ACUTE GASTRITIS. SIMPLE GASTRITIS, GASTRIC CATARRH, ACUTE DYSPEPSIA. Definition.— An acute inflammation of the mucous membrane of the stomach, Etio/ogy.— The disease is exceedingly frequent in all classes of people and at all ages, but especially in childhood. Many individuals are pre- disposed to it, and the "weak stomach" is not infrequently inherited. The idiosyncrasy may exist only toward certain articles of food. The gouty tendency, chronic valvular heart-lesions, and hepatic cirrhosis predispose to it. The same is true of many nervous affections, mental and physical fatigue and exhaustion, which favor its occurrence by im- pairing the gastric secretion. The disease is often present at the begin- ning of an acute infection. Insufficient clothing and bad hygienic sur- roundings favor it, especially in children. The immediate cause in most instances is a local irritation, which is generally produced by errors in diet. The food may be too great in quantity, irritating or indigestible in quality, or taken at too short intervals. When the food is retained too long in the stomach, as when the quantity is too great, it is liable to undergo fermentation, with the production of lactic and fatty acids, and these may be the direct cause of the inflammation. Or the food, especially beef, fish, or milk, may have undergone partial decomposition before being ingested. Excessive indul- gence in alcohol, very hot or very cold drinks, are also common causes. Morbid Anatomy. — The mucous membrane becomes red, swollen, and in places eroded, and it is covered with mucus. The submucosa is edematous, and small hemorrhages may occur in it. The cells of the gastric tubules undergo cloudy swelling, and there is often a small-celled infiltration between the tubules. The inflammation is most marked in the pyloric region, and it may extend into the duodenum. Symptoms. — The disease may occur as a mild, afebrile attack, or it may assume a severe, febrile form. In mild cases there is usually a sense of discomfort, with flatulent distention of the abdomen, followed by thirst, headache, depression, dizziness, eructations, nausea, and vomiting. The tongue is coated and there may be an increased flow of saliva. There is a disagreeable taste, and the breath becomes offensive. Tem- porary relief is afforded by vomiting. The vomited matter consists of the food last eaten, and it shows little change, although it may have remained in the stomach for several hours. In children, diarrhea, with colicky pains, commonly follows ; in adults, constipation is more common. Recovery usually takes place in twenty-four hours. The febrile form may set in with a chill and rise of temperature to 448 PRACTICE OF MEDICINE 102° or 104° F. (39.0° — 40.0° C.)- The affection has been called, gastric fever. Lebert described a special, infectious form which occurred epi- demically. The tongue is broad, pale, and covered with a heavy coat. The breath is foul. Thirst becomes extreme, and the appetite is lost. The abdomen is distended, and there is often tenderness in the epigas- trium. Vomiting is almost always present, and it may be persistent, even water being ejected. At first only food is brought up, then a bile-stained fluid containing much mucus. HCl is absent, and lactic and fatty acids are often abundant. Constipation is generally present in the beginning, but it may give place to diarrhea. An eruption of herpes occasionally appears on the lips. The urine is concentrated, the urates increased, and indican is sometimes present. The disease ordinarily subsides after from three to five days, but it may pass into a subacute or chronic form. Diagnosis. — Mild cases are recognizable without difficulty. The severe attack may, however, prove to be an initial sym.ptom of one of the infectious diseases, especially in young children. When there is high fever and much headache, the presence of meningitis is often suggested. Ex- cessive pain may arouse suspicion of biliary colic, but the pain is not over the gall-bladder. The short duration of the attack or, on the other hand,^ the appearance of other symptoms soon removes all uncer- tainty. Typhoid fever may be excluded by the sudden onset and rapid rise of temperature, without epistaxis, bronchitis, or other prodromes. Treatment. — Mild cases generally recover in a day without treatment. It is well, however, to administer a mild purge, calomel or castor oil, to remove decomposed food that may remain in the intestine. In severe cases the vomiting should not be too speedily arrested. If vomiting does not occur, it sKould be induced by the administration of warm salt water or ipecacuanha, or by apomorphin hypodermically administered. The patient should abstain from food as much as possible for a day or two. The eructation and nausea may be relieved with the aromatic spirit of ammonia, or sodium bicarbonate and bismuth, each gr. v (0.3), with a drop of oil of anise or peppermint in each powder. If a free diarrhea does not develop, a dose of calomel (gr. iij — ^v; 0.2 — 0.3) should be given in the evening, and a Seidlitz powder or calcined mag- nesia in the morning. PHLEGMONOUS OR SUPPURATIVE GASTRITIS. This is a rare form of gastritis in which a suppurative inflammation occurs in the submucous and muscular coats of the stomach. Etiology. — Idiopathic cases have been observed, but, as a rule, the disease is a complication of one of the septic infections, notably puer- peral sepsis or pyemia. The suppurative process may be diffused throughout the wall of the stomach, or it may be localized. In the former condition the pus is discharged either into the stomach or into the peritoneal cavity; in the latter, abscesses are formed. Symptoms. — The case has the appearance of an extremely severe, acute gastritis, with the addition of septic manifestations. Frequent chills and hyperpyrexia are commonly present, with a rapid, feeble pulse, abdominal tenderness, and diarrhea. The diagnosis is seldom made dur- ing life, but the localized abscess can possibly be recognized by physical TOXIC GASTRITIS 449 examination, and in the diffused form pus may be found in the vomited matter. The patient generally passes into a delirium, or a coma from which he does not arouse, and death is an event of but a few days. The disease occasionally assumes a more chronic course. Treatmenf. — Nothing can be done to arrest the disease. Morphin should be given at short intervals to relieve the suffering. TOXIC GASTRITIS. A severe inflammation of the stomach, often attended with great destruction of- tissues, as a result of the ingestion of irritating sub- stances, especially the corrosive acids and alkalis, or arsenic, antimony, phosphorus, alcohol, and other noncorrosive poisons. Morbid Anaiomy. — The corrosive poisons produce a charred appear- ance of the mucous membrane, with complete destruction of vitality, over a greater or less area. When the quantity of poison taken has been large, immediate perforation of the stomach-wall may be produced. If death do not occur within a few hours, an intense hyperemia develops around the necrotic areas, and hemorrhages and transudation of serum and round cells occur in the submucosa. Granulation may begin, yet perforation may occur after several days, producing a rapidly fatal gen- eral peritonitis. The noncorrosive poisons produce hyperemia with hemorrhages and cellular infiltration into the submucosa, with fatty degeneration of the gland-cells. Healing is effected by cicatrization, and stricture or hour- glass contraction is occasionally produced as a late result. Atrophy of the stomach and ulcers are possible results. Symptoms. — There is generally intense pain and burning in the epi- gastrium; it may extend from the mouth to the stomach, and there is constant vomiting or retching. Blood may be vomited, and later frag- ments of the slough may be ejected. The abdomen becomes distended, tender, and painful. The urine is scant and albuminous or bloody. Petechiae sometimes appear in the skin. Collapse occurs in most cases immediately after the poison has been ingested; the pulse is then feeble and the surface is bathed in a cold sweat. Convulsions often supervene, and death may occur within a few hours, or only after several days. Recovery is possible when the quantity of poison has been moderate or when treatment has been promptly instituted. The diagnosis is not usu- ally difficult, for the characteristic burns are generally to be found in the mouth, or the poison may be recognized in the vomited matter. Treatmenf. — In poisoning with acids, magnesia should be immediately given with milk, egg-albumen, flour paste, or oil. In alkali-poisoning, lemon-juice, vinegar, a dilute mineral acid, or cream of tartar should be given. When the case is seen early, the stomach should be thoroughly irrigated. Morphin should then be administered for the pain. Membranous Gastritis. — This is a rare form of gastric disease which has generally been met with in diphtheria, typhoid or typhus fever, variola, or pneumonia. A diffused or circumscribed membranous exudate is formed in which are found the Klebs-Lofiler bacilli or the pyogenic micro-organisms. Portions of the fidse membrane are sometimes vomited; otherwise the condition is seldom recognized during life. 29 45 o PRACTICE OF MEDICINE Mycotic and Parasitic Gastritis.— Fungi, especially the saccharomyces and sarcinae, in one case that of favus; anthrax bacilli; trichinae, and the larvae of insects have been recognized as causes of acute gastritis in a few cases. Tuberculosis and syphilis rarely attack the stomach. CHRONIC GASTRITIS. CHRONIC GASTRIC CATARRH, CHRONIC OR FLATULENT DYSPEPSIA, ATRO- PHY OF THE STOMACH. Definition. — A chronic inflammation of the stomach characterized by changes in the gastric juice, increased secretion of mucus, weakening of muscular power, and the symptoms of chronic dyspepsia (Pepper). Etiology. — Local Influences. — In a majority of cases the disease can be traced to repeated attacks of acute indigestion or to a more or less constant irritation of the stomach by improper food. The food may be indigestible in character or it may be rendered so by improper cooking. Many cases are to be attributed to the constant use of fried food, hot bread, pie, confections, or too highly seasoned articles. Either the fat or the carbohydrates may be in too great quantity. Eating at unsea- sonable hours, or at too short or irregular intervals, and eating too rapidly, without proper mastication, are among the more frequent causes. The excessive use of cofl'ee or tea or drinking ice-water during or after meals may gradually induce the disease. A chronic gastric catarrh al- most always accompanies cancer, ulcer, and dilatation. It may be pro- duced also by obstruction of the portal or general venous circulation as a result of cirrhosis of the liver, valvular disease of the heart, and chronic interstitial disease of the lungs, or the pressure of tumors or abscesses. Other local causes are the prolonged use of irritating drugs and nos- trums, as the mineral acids, arsenic, or "bitters"; the drinking of liquors before meals, and the excessive use of tobacco. To what extent the dis- ease may be caused by the adulteration of food has not yet been de- termined. General Influences. — An important part in the production of the dis- ease is often played by anemia, chlorosis, gout, tuberculosis, nephritis, diabetes, uterine disease, and many other affections. Morbid Anatomy. — The lesions are generally studied under two heads, those of simple chronic gastritis, and those of an interstitial or sclerotic character ; but the two forms usually represent an earlier and later stage in the same pathological process. Simple Chronic Gastritis.— The stomach is usually much enlarged and all of its layers may be thickened. The mucous membrane is pale and covered with a heavy coating of tenacious mucus. The veins stand out prominently in cases associated with retarded circulation, and there may be ecchymoses or small hemorrhages into the mucosa or submucosa, especially in the pyloric region, where the disease is usually most pro- nounced. In a large class of cases, often described separately, the most pronounced feature is the large quantity of tenacious mucus which covers the mucous membrane, especially in the vicinity of the pylorus. The mucous membrane in this region also appears mammillated or wrinkled in many instances, on account of the increase of connective tissue and CHRONIC GASTRITIS 451 beginning contraction. The condition has been described as gastritis polyposa, and by French writers as the etat mamelonne. On microscopic examination, the glands appear enlarged and saccular ; sometimes they are converted into little cysts as a result of obstruction of their mouths with desquamated, degenerated epithelium. The gland- cells are usually granular from fatty degeneration, or they may be atro- phied so that the principal and parietal cells can no longer be distin- guished. The tubules are often widely separated by the new connective tissue. Ewald describes a condition in which the inflammation extends down to the base of the glands, and the cells are often in different stages of mucoid degeneration, but he was able to demonstrate these changes only in specimens which had been placed in alcohol while they were still warm. Interstitial or Sclerotic Form. — This form is usually a late result of the catarrhal process, and its most distinctive feature is atrophy. The atrophy, however, may affect the stomach as a viscus or only its walls. In general atrophy the organ sometimes becomes so small that it will hold only an ounce or two of fluid, while its walls may be greatly thick- ened. It is often referred to as cirrhosis, or, better, sclerosis ventriculi. In the other condition, the stomach as a whole may be much dilated, but the walls become extremely thin. In the former, the wall of the stomach may be an inch thick; in the latter, it may be less than an eighth of an inch. In extreme cases the mucous membrane is often so atrophic that it is impossible to find a vestige of gland tissue in it, but cysts formed from the tubules may remain. The mucous surface is smooth and firm, almost cicatricial in appearance. The muscular coat may be hypertrophied, or it may be largely replaced by connective tissue. There may be associated with the lesions of the stomach a proliferative peritonitis, perihepatitis, and perisplenitis. Ascites is often present. Symptoms. — Symptoms more or less closely conforming to those of acute gastritis usually occur at longer or shorter intervals in the chronic form, and there are often abnormal sensations in the throat, and motor phenomena which produce rumbling noises, eructations, and possibly vomiting. The ingestion of a small quantity of food produces a feeling of satiety, fullness, and pain, or even disgust and nausea; and violent eructations may continue for several hours afterward (flatulent dys- pepsia). The gas may be odorless or highly offensive. At a later period distress is experienced when the stomach is empty as well as when it is full, and eating no longer produces satiety. When the stomach is greatly reduced in size, the food may be too rapidly carried into the intestine, and intestinal catarrh may be set up. The tongue is generally heavily coated, but the tip and edges may remain intensely red. A catarrhal or aphthous stomatitis is sometimes observed. Thirst often becomes most annoying, and the patient craves sour or highly seasoned and indigestible articles of food. The salivary and pharyngeal secretions are much in- creased, and these in turn aggravate the nausea. The so-called stomach cough, which is not infrequently present, is probably due to the catarrhal condition of the pharynx. Morning nausea and vomiting or retching are common symptoms, especially in old topers. Very often only bile- stained mucus is brought up. Vomiting may occur also with regularity either immediately after meals or several hours later; yet in some cases 452 PRACTICE OF MEDICINE it is absent, although the patient may desire it as a means of rehef. Acid eructations (pyrosis) frequently accompany the belching. The acid fluid thus brought up may be in part retained in the lower end of the esophagus and cause pain in the region of the heart, known as cardialgia or heartburn. Digestion becomes slow, and there is often little or no indication of digestion when vomiting occurs several hours after a meal or if the contents are \vithdrawn as late as six or seven hours after the ingestion of food. Abnormal fermentation is generally found to have set in, one result of which is a sour, disagreeable odor. Chemical examination reveals little or no HCl, but a greater or less quantity of lactic, butyric, and acetic acids. When the atrophy of the mucous membrane has be- come extreme, the hydrochloric acid, pepsin, and rennet ferment may all be absent. Absorption is also much delayed in most cases, so that potas- sium iodid does not appear in the saliva for a half-hour or longer after it is taken into the stomach, or twice the length of time ordinarily re- quired. The abdomen often becomes much distended with gas, producing pain and dyspnea. Severe pain in the abdomen is not common, but more or less frequent attacks of colicky pains are experienced, and there is a more or less constant sense of uneasiness. Constipation usually prevails. Headache and vertigo are common, and the patient often becomes morose or melancholic. The pulse is generally small ; it may be slow, irregular, or intermittent from the irregular action of the heart that is often pres- ent. The motor function of the stomach may not be disturbed. In the extreme atrophic form, the symptoms are variable, and, from their severity, the rapid emaciation and anemia, carcinoma is often sus- pected, a diagnosis which is apparently supported by the discover}^ of a firm mass in the region of the pylorus. But the mass is due either to the hypertrophy of the muscular coat or to the lamellated condition of the mucous membrane, and the patient long outlives the limit of cancer. In some cases the features correspond more closely to those of pernicious anemia. The urine is usually of dark color, high specific gravity, and contains a large quantity of urates and phosphates and often calcium oxalate. Diagnosis.— Ulcer, cancer, dilatation, and the neuroses must be ex- cluded before a diagnosis of chronic gastritis can be arrived at. The first three of these affections are ordinarily accompanied with gastritis, however, and for this reason the presence or absence of cancer in particu- lar cannot be determined in some cases until the patient has been under observation for several months and the effects of treatment have been observed. Cancer is characterized by a much more rapid progress, with emaciation, weakness, and cachexia, features which are seldom so pro- nounced in an independent case of chronic gastritis. Treatment — Dietetic. — In a case of moderate severity, before extreme atrophy has developed, it is often unnecessary to rigidly restrict the diet. It is sometimes sufficient to prohibit the use of certain articles. The patient generally knows better than the physician what kinds of food he can most easily digest, but he generally requires the positive direction of the physician to enable him to control his appetite. Persons present themselves, also, who have already reduced their dietary beyond reason, and these are often benefited by a more liberal allowance. In other CHROXIC GASTRITIS 453 cases, a cure can often be effected by nothing more than proper regula- tion of the food. Advice must generally be given as to the necessity of eating at regular intervals, the thorough mastication of the food, and the limitation of its quantity. Hasty eating and overeating are the two main factors in the production of chronic dyspepsia in this country, and the third element in many cases is the habit of immediately rushing back to business after a hasty meal. Both mental and physical exertion should be postponed, if possible, for an hour after a full meal. Many dyspepsias are benefited by a change of the time of the principal meal to an hour at which it can be leisurely eaten and followed by an hour's rest. Idiosyncrasy must always be regarded, however, and the form of food which is theoretically best for the patient may prove less suitable than articles which should not agree. A vast deal depends also upon the proper cooking of the food, and the physician should be capable of gi\ang instruction in this department of domestic economy. Articles fried in grease are generally unfit for a healthy stomach, much more so for one that is inflamed. In many instances it is necessary to give ex- plicit written direction in regard to the food to be eaten, and that to be avoided. In other cases, doing this only converts despondency into despair by impressing the patient too strongly with the seriousness of his affliction. Albuminoids generally agree best with the stomach. Those which are most easily assimilated should be chosen for a severe case. It is often advisable to begin the treatment by placing the patient on an absolute milk diet; but there are many individuals who cannot take milk. Some- times the objectionable feature can be removed by the addition of lime- water, Vichy or other alkaline carbonated water, and a pinch of salt. From two to two and a half quarts of milk should be consumed daily, but it should be taken in quantities of a half-pint or less every two or three hours. Skimmed milk agrees better than whole milk in some cases, and some patients can drink buttermilk who cannot take sweet milk, but they usually tire of it more readily. WTiile the patient is on the milk diet the stools should be regularly examined in order to avoid giving more of it than can be assimilated. After a few days on this diet, especially if hunger is developed by it, a soft-cooked egg, beef-juice, scraped raw or rare broiled beef, and a piece of toast or zwiebach may be added to the diet list. If it is deemed advisable to continue the liquid diet, broths, bouillon, clear soups, junket, and gruels may be employed. Farinaceous food should generally be prohibited until the patient has shown marked improvement. It is especially contraindicated in cases of dilatation, for it then remains so long in the stomach that fermentation occurs and intestinal catarrh results. Hot bread and pastry should be permanently forbidden. WTiite bread may generally be eaten in small quantity if it is not too fresh, or better after it has been toasted. Only a small quantity of butter should generally be eaten. WTien acid eructa- tions are produced, the bread should be temporarily discontinued. The same is equally true of potatoes, although a mealy baked potato is sometimes well borne. Graham or brown bread or that made from the whole wheat agrees with some individuals better than the white. Sugar should be taken sparingly, as a rule. The behavior of the stomach toward fruits and green vegetables is 454 PRACTICE OF MEDICINE very uncertain, and the permission of such articles must be based upon the experience of the individual. Cooked ripe fruit can generally be eaten, and a baked apple is an agreeable addition to the exclusive milk diet. Young peas and beans and stewed onions may prove digestible, but cabbage, cauliflower, corn, strawberries, peaches, bananas, and many other fruits and vegetables must, as a rule, be forbidden. Fat can seldom be eaten ; veal, pork, and the meat of any animal just after it has been killed are difficult of digestion. In some cases a diet consisting almost exclusively of beef, roast or broiled, but always tender and rare and freed from its coarse fiber, with an occasional roast of mutton or broiled chops, proves the most satisfactory. In severe cases, after atrophy of the mucous membrane, peptonized beef preparations and peptonized milk may be used with advantage^ When solid food is eaten, it is better to limit the quantity of fluids. A small quantity of soup may be taken at the beginning of a meal, but little or no fluid should be drunk with the food. Very hot or very cold drinks, tea, coff'ee, and alcoholic beverages should generally be forbidden. Finally, the patient should never allow himself to fill his stomach; it is much better to stop before the appetite has been fully assuaged. Hygienic. — A very important factor in the treatment of most cases is the relief of the morbid introspection which is generally present, with its resultant despondency and melancholy. When the condition is very pro- nounced, it is often better to have a change of scene, a sojourn in the mountains or a sea-voyage in the summer, or a visit to the Southern resorts in the winter. It is often better to send the patient to one of the watering-places where the dietetic treatment can be carried out. Under any circumstances he should take systematic exercise including walking, horseback riding, and outdoor games. He should always be with cheerful companions who are capable of holding his attention away from himself. Medicinal. — The objects to be attained by the administration of drugs are : (i) To supply the chemical elements of the gastric secretion which are absent; (2) to restore the secretory and motor power; (3) to pre- vent abnormal fermentation; and (4) to relieve special symptoms. To meet the first indication, dilute hydrochloric acid is usually administered in doses of TT|,xv to xx (i.o — 1.2) in two or three ounces of water imme- diately after meals. It should be taken through a tube in order to pro- tect the teeth, and the dose may be repeated a few hours later or when- ever a feeling of discomfort arises. Pepper advised the administration of quinin (gr. j; 0.06) and strychnin (gr. 1-60; o.ooi) with the acid. A few grains of pepsin may be added with benefit in some cases, but it is probably seldom necessary, and much of the pepsin that is dispensed is worthless. In cases of extreme atrophy of the mucous membrane, when the administration of the acid fails to stimulate the secretion of pepsin, an active preparation should be administered. The action of hydro- chloric acid is not uniformly beneficial. Pancreatin in doses of gr. v to x (0.30 — 0.60), with an equal quantity of sodium bicarbonate, is often of great value when given a half-hour after each meal, especially in mucous and atrophic cases. Ptyalin and diastase or a good malt extract are recommended by some writers for the same class of cases. To increase the secretory and motor power of the stomach, the gen- eral condition of the patient must be treated, especially in the presence DILATATION OF THE STOMACH 455 of anemia or malnutrition, or when the condition is due to venous ob- struction, as in connection with valvular disease of the heart or hepatic cirrhosis. Lavage is usually the most successful method of local treat- ment. (For the method, see page 719.) It should be performed with a large quantity of lukewarm water, either plain or containing i per cent of common salt or 5 per cent of sodium bicarbonate. The alkaline solution is especially indicated when much mucus is present. A 3 per cent solution of boric acid or a very dilute carbolic acid solution may be employed when there is much fermentation. The irrigation should generally be continued until the clear water returns. One treatment each day is usually sufficient, or one in two days if the patient be weak. It is best done in the morning, when the stomach is empty, but when there is much distress and flatulency during the night it may be prac- ticed just before retiring. The relief is so great that many patients are restrained with difficulty from abusing the practice. In other cases, however, the fear of the tube is so great that the method cannot be satisfactorily employed, or the patient positively and persistently refuses to submit to it. In such cases the same object may often be attained, with almost as much benefit, from the administration of sodium bicar- bonate, gr. XX to XXX (1.3 — 2.0) in a half-pint (250) or more of warm water, twenty minutes before each meal. In this way the mucus is dis- solved, and the effect is much the same as that of lavage. The subse- quent secretion of HCl is believed to be increased. This secretion is sometimes improved by an increase of the amount of salt in the food. The bitter tonics are also useful in some cases, especially to stimulate appetite, but they sometimes prove irritating. Strychnin or the compound tincture of gentian with nux vomica may be prescribed. One of the most valuable remedies is the nitrate of silver. It is some- times applied in solution through the tube, but, as a rule, it is admin- istered in pills containing also the extract of belladonna and perhaps nux vomica. It should be given when the stomach is empty, as a half- hour before mealtime. A record of the quantity administered should always be kept, in order to avoid the production of argyria. The first indication of this condition is a dark line on the gums. Electricity has proved beneficial in some cases. A mild faradic current is applied through Einhorn's electrode after the stomach has been mod- erately distended with water. Many other remedies have been recom- mended — among them, creosot, carbolic acid, magnesia, animal charcoal, bismuth subgallate, sahcylic acid, chloroform, and the essential oils— for the relief of acid fermentation and flatulency. For nausea and vomiting, the dilute hydrocyanic acid, three drops; serium oxalate, camphorated tincture of opium or cocain, gr. Ys (0.008), may be given. The regular action of the bowels must be secured by laxatives. DILATATION OF THE STOMACH. GASTRECTASIA, GASTRECTASIS. Definition. — An acute or chronic enlargement of the stomach, with re- laxation and weakness of its walls. The term megast7-ia is applied to the 4s6 PRACTICE OF MEDICINE condition in which the stomach is abnormally large, but still capable of discharging its contents into the duodenum. Etiology. — Acute dilatation is rare, in this country at least, and usu- ally results from a too hasty ingestion of an enormous quantity of food or drink; occasionally from the rapid evolution of gas. The sudden dilatation produces a paralytic condition of the walls, which sometimes proves fatal. Chronic dilatation may occur at any time of life, but it is more frequent in men of middle age, especially in beer-drinkers. It is not uncommon, also, in rachitic children. The principal causes are narrowing or obstruc- tion of the pylorus or duodenum, and deficiency of muscular power. (dt) Narrowing of the pylorus is seen in the rare congenital stricture and as a result of cancer, the cicatrization following ulcer, toxic or phlegmonous gastritis. It is produced also by the nonmalignant hyper- plastic thickening of the pylorus in chronic gastritis. Among the other recognized causes are pressure from without, by tumors, rarely by a floating kidney ; or obstruction from within, as by polypi. A sharp bend or twist caused by adhesions to the liver or gall-bladder or by the dragging weight of a distended stomach (volvulus of the stomach) has been observed in a few instances. Obstruction by foreign bodies, as balls of hair, or coins, has been the cause in some cases. (^P) Deficiency of muscular power may result from habitual overfilling of the stomach with food and drink or from atony of the muscle due to malnutrition in the course of such diseases as chronic gastritis, anemia, tuberculosis, or cancer, or following nervous exhaustion or an acute infection, as typhoid fever. It may follow degeneration of the muscle occasioned by amyloid disease, constipation, or peritonitis; and hernia has been named as a cause which might operate through restraining the movements of the stomach. Morbid Anatomy.— The degree of dilatation is exceedingly variable. Extreme cases have been reported in which the stomach held from i o to 1 6 pounds of fluid. When the dilatation is moderate, there may be com- pensatory hypertrophy of its walls ; but when it is extreme or of long duration, the walls become thin through stretching and atrophy. The greatest dilatation is found in the fundus, and the greater curvature sometimes sinks two or three inches below the umbilicus. Gastroptosia, or downward displacement of the entire stomach, may accompany the dilatation, and the right kidney is sometimes displaced downward. The mucous membrane is usually hyperemic and, on microscopic examination, shows atrophy of the secretory glands, as it does in chronic gastritis. Symptoms.— The clinical manifestations vary greatly with the severity of the disease and the nature of its cause. Symptoms are ordinarily present which resemble closely those of an aggravated chronic gastritis. There is a feeling of fullness or distress in the stomach, with epigastric tenderness, especially after eating. Large quantities of gas and sour fluid are eructated. The appetite is variable, sometimes ravenous; the tongue is heavily coated and the breath is usually foul. The most nearly pathognomonic symptom, however, is periodic vomiting. This may occur several times a day in the beginning, but as the dilatation increases it becomes less frequent until it occurs only at intervals of two or three days, and an enormous quantity of food, liquid, and gas is brought up. DILATATION OF THE STOMACH 457 As much as a gallon (4 liters) is sometimes vomited at one time. The vomited matter is generally frothy, from abnormal fermentation, and it has a characteristically sour odor. It separates, on standing, into three layers. The lowest contains the food, the middle a dark gray turbid fluid, and the upper a brownish froth. HCl is often absent, but it may be present in normal, increased, or diminished quantity. Lactic, butyric, and acetic acids and various gases, especially hydrogen sulphid and marsh gas, are present. Different molds and bacteria, the yeast fungus and sarcina ventriculi, are found on microscopic examination. Constipa- tion results from the obstruction to the passage of food and fluid into the intestine; and anemia and emaciation, with marked dryness of the skin, commonly follow. When the stomach finally becomes unable to con- tract with sufficient force to discharge its contents through vomiting, the patient's discomfort is extreme. The abdomen becomes so much dis- tended that he cannot lie down with comfort, and the nausea and gase- ous eructations become almost constant. The absorption of the products of decomposition gives rise to such nervous phenomena as numbness, vertigo, and insomnia; tetany and epileptiform spasms may be induced. Fat-necrosis has been reported in at least one instance, probably as a result of pressure on the pancreas. Physical Examinaiion. — Inspection.^T\i& outline of the dilated stom- ach is often distinctl}^ visible, especially after artificial distention. The greatest prominence is in the left h3'pochondrium, and below the um- bilicus when the patient is standing, but the epigastrium, right hypo- chondrium, and umbilical regions are prominent. The peristaltic move- ment from left to right can sometimes be observed, and rarely there is a reversed peristalsis. Palpation, — A tumor-like thickening in the region of the pylorus can often be felt in the nonmalignant as well as in cancerous cases. The sensation obtained from pressure on the stomach is peculiar and not unlike that of palpating an air-cushion. A splashing sound which can be heard at some distance (clapotage) may often be produced through bimanual examination or by shaking the patient. It is significant of dilatation only when it can be elicited several hours after a meal. The gurgling of gas passing through the pylorus can sometimes be felt. Percussion. — The outline of the stomach can be accuratel}^ mapped out by this method, but the examination should be repeated with the patient in different positions, in order to avoid error in the lower boundary. This can be more definitely made out with the patient hang on his back. The percussion note is tympanitic and rather high-pitched when the stomach is distended with gas or air, but flat when distended with water. The latter method of distention is of little value for determining the outline. Auscultation is of limited service. The succussion sound may be readily determined in most cases, but it is not of much value. A fine sizzling sound can sometimes be heard, which is believed to be due to the evolution of gas in the decomposition of the food, since the same sound can be heard after the administration of an effervescent powder. \Mien the stomach is distended with gas, the heart-sounds are transmitted with unusual distinctness and they often have a metallic quality. Auscultatory percussion also aftbrds an accurate means of determining the outline. 458 PRACTICE OF MEDICINE Diagnosis. — This is usually quite simple. It is based upon : (a) The periodical vomiting, ((^) the enormous quantity ejected, (r) the gaseous eructations, and (/) the enlarged outlines of the distended stomach. The condition cannot well be mistaken for any other, although some re- markable blunders have been recorded. In gastroptosia the stomach is displaced downward and may be somewhat enlarged, but the food does not stagnate in it, and vomiting is not present. In megastria the en- largement in not strictly pathological, since the stomach is capable of performing its normal function. Prognosis. — The prognosis is hopeless in a case due to cancer, and very unfavorable in other forms of stenosis. When the condition is due to overdistention with food and drink or to chronic gastritis, and pro- viding that it is not extreme, great benefit can be obtained from treat- ment, but it is seldom possible to control the patient's habits outside of a hospital. The results of surgical methods in nonmalignant stenosis have been brilliant in some cases. Treatment. — This comprises relief from the source of distention through removal of the fermenting stomach-contents. The best means of accomplishing this is lavage. The second object is to increase the mus- cular power of the organ, and the third to select the most suitable diet for the patient. (^a) Lavage is not only the most useful method, but it has its great ■ est field of usefulness in this condition. By it the weight of the accumu- lating food is removed from the stomach, and the expansive force of the gases developed in it is taken away. At the same time the mucous mem- brane is cleansed and disinfected, and any ptomains or toxins that may have been formed are gotten rid of. (For the method of lavage, see page 719.) The stomach should generally be washed out once a day, but in extreme cases it may be done twice. It is customary to use luke- warm water or an alkaline or antiseptic solution. The reduction of size obtained in a few weeks is sometimes remarkable. The patient can generally be taught to use the tube without assistance. ((^) To increase the muscular power, strychnin is the best remedy. A tablet containing gr. 1-30 (0.002) should be given three or four times daily. Iron and ergot are also of benefit in some cases. The faradic current may be applied through the Einhorn electrode introduced into the stomach, the opposite pole being applied to the epigastrium. E. G. Marshall has obtained better results by applying a large sponge elec- trode to the epigastrium, and a smaller one, connected to the same pole by means of a V-shaped cord, to the neck, over the course of the pneu- mogastric nerve. The wearing of an elastic abdominal band is a source of relief from the dragging weight. (r) Diet.— The important indication is to administer the food in a concentrated form, in order not to produce distention or downward trac- tion. The food must be of a character that will not produce gaseous dilatation. It should be taken in small quantities at short intervals. In the beginning, it should consist principally of raw or rare broiled or roast beef and other tender meats; soft eggs with a little toasted bread or zwiebach. Very httle fluid should be taken; the milk diet is con- traindicated. Water may be drunk an hour before each meal, or in the morning upon rising, and before retiring at night, but not with the meal. PEPTIC ULCER 459 After the size of the stomach has been considerably reduced by treat- ment, thoroughly cooked vegetables may be carefully added to the diet- list. In cases of stenosis that are known to be nonmalignant, and in those that are doubtful, the resort to surgical means of diagnosis and treatment should not be too long delayed, for a condition has not in- frequently been revealed upon the post-mortem table that might have been remedied. The principal methods will be found in the works on surgery, under the heads of Loreta's method of digital dilatation of the pylorus, gastroenterostomy, and pylorectomy. PEPTIC ULCER. SIMPLE, ROUND, PERFORATING, OR RODENT ULCER OF THE STOMACH. Definition. — A round or oval, usually single, sharply defined loss of tissue caused by the digestive action of the gastric juice on a portion of the mucous membrane of the stomach or of the duodenum whose nutri- tion has been impaired. The process of its formation is one of necrosis rather than of ulceration. Etiology. — Two factors are generally regarded as operative in the production of the so-called ulcer ; first an impairment of the nutrition of a small portion of the mucous membrane, second the action upon this area of a superacid gastric juice, favored, perhaps, by an alteration in the composition of the blood. The disturbance of nutrition is probably due to such vascular change as the plugging of a small blood-vessel, through thrombosis or embolism, or to a diminished circulation in the vessels. The interference may be caused by mechanical or thermal irri- tation of the mucous membrane, as by blows or pressure upon the epigastrium or by hot food. The embolus may originate in a diseased heart, or it may consist of bacteria which have gained entrance to the circulation. And, since duodenal ulcer frequently follows burns, it has been suggested that an embolus may be caused by such injury. The superacidity of the gastric fluid is regarded by some writers as a result of the ulcer. If not active in its production, it doubtless retards its heahng. Cystic dilatation of Brunner's glands has been suggested also as a cause of the duodenal ulcer. It is probable that more than one of these causes is operative in most cases. It is also highly probable that the true cause of many cases remains to be discovered. Age and ^^x.— Gastric ulcer is about twice as common in women as in men. In women it generally occurs between the ages of 20 and 30, in men between 30 and 40. It is not infrequent in children and old persons, and it has been found in the fetus and new-born infant. It is doubtless more common than is usually recognized. Heredity is thought to be a causative influence in some instances. Ulcer of the duodenum is more frequent in men. Occ7ipatio7i IS an important factor, since the disease is very frequent among servant girls and cooks, probably as a result of improper food and consequent anemia; and in shoemakers and tailors, as a result of pressure over the stomach. The history of such injury as a blow is often obtained. Anemia and chlorosis are recognized as frequent causes, operating, 46o PRACTICE OF MEDICINE perhaps, by reducing the acidity of the blood, or in some other way impairing the power of the mucous membrane to resist the action of the gastric juice. Such affections as tuberculosis, syphilis, disease of the heart or liver, and arteriosclerosis have been regarded as favoring the production of gastric ulcer. Morbid Anatomy. — The ulcer is usually single, but a large number (in one case 34) have been repeatedly found. Several ulcers may coalesce to form an irregular destruction of tissue. They may occur in any region, but in three-fourths of the cases they have been found near the pylorus, generally on the posterior wall near the lesser curvature. In the duodenum they are much less frequent than in the stomach, and they are always found above the biliary papilla. Their diameter is usually about y^ inch (6 mm.), but they may be. as large as four or five inches (10. o— 12.5 cm.). The appearance of a recent ulcer is as though the tissue had been removed with a punch, so uniform and clean-cut are its edges. The shape is that of a truncated cone, the apex of which may rest upon the submucous, muscular, or peritoneal coat. In very acute cases, especially when located in the anterior wall, the peritoneum may be perforated, with fatal general peritonitis as the inevitable result. In some instances a sinus is formed which communicates with the colon, pleura, pericar- dium, even with the left ventricle of the heart. Localized abscesses sometimes result, and when air penetrates these a condition known as subphrenic pyopneumothorax is produced. In very chronic ulcers the clean-cut appearance may be lost. A striking feature is the absence of inflammatory reaction in the vicinity of the ulcer. The scars of former ulcers are not infrequently discovered, and a recent ulcer is often found in close proximity to an old cicatrix. Deformities of various kinds may be produced by the contraction of the cicatrices of large or numerous ulcers. Hour-glass contraction is occasionally ob- served, but a much more common result is the narrowing of the pylorus, which may lead to dilatation. Deformity may result also from the ad- hesions formed between the peritoneum immediately over an ulcer and a neighboring organ, as the liver or spleen. These adhesions, however, often prevent perforation into the peritoneal cavity. A gastrocutaneous fistula is a rare, though relatively fortunate, result of perforation. It usually opens near the umbilicus. Emphysema of the subcutaneous cel- lular tissue has been observed as a result of perforation. The erosion of a blood-vessel in the stomach-wall produces hemorrhage, a not un- common symptom. The hepatic and splenic arteries and the portal vein have also been opened. Symptoms.— The early symptoms are usually those of indigestion, with discomfort after eating and gaseous or acid eructations. The appe- tite sometimes remains normal, but nausea frequently develops, and vomiting may occur. The patient rapidly becomes anemic, and the dyspeptic symptoms gradually or suddenly increase until the discomfort becomes pain. This is usually limited to the region of the ulcer. It may be an almost constant, gnawing sensation, but it is generally sharp. It is aggravated by eating and relieved by vomiting, sometimes also by a change of position which allows the contents of the stomach to gravi- tate away from the ulcer. Pressure on the painful spot elicits tenderness, but it is often found to afford relief, and the patient bends over a chair PEPTIC ULCER 461 or lies with a pillow under his abdomen. The pain commonly radiates to the back, sometimes also to the sides. It is generally felt in the back at a point a little to the left of the tenth dorsal vertebra. It may be continuous for weeks, but occasionally ceases for a variable interval. Attacks of intense gastralgia sometimes occur independently of the local condition. This is generally at a point an inch or two below the ensi- form cartilage and a little to the right of the median line. Vomiting sometimes occurs without much nausea, either immediately after meals or at irregular intervals of several days. The vomitus is usually] highly acid, the free HCl sometimes reaching 0.5 per cent. The ferments are not generally altered in amount. Hemorrhage occurs in nearly or quite half the cases. It may be slight, but it is generally profuse and may induce syncope or convul- sions. Unaltered blood, bright red and fluid, is brought up in these cases. Hemoptysis is, indeed, one of the most characteristic symptoms. A free, even fatal, hemorrhage sometimes results from a small superficial ulcer or a scarcely recognizable erosion. After the blood has remained in the stomach for a short time, it becomes altered and mingled with the food. Blood from either a gastric or a duodenal ulcer can generally be found in the stools after a hematemesis, and sometimes in cases which have not been attended with hematemesis. The blood appears in the stools as black, tarlike matter. The stools should always be examined in a case of suspected ulcer. Perforation occurs in about 6 per cent of cases. It may follow undue pressure or the ingestion of food. It is more common in women. Its occurrence is announced by a sudden severe pain which is generally con- fined to the epigastrium, but may radiate over the abdomen or be referred to another region. Collapse quickly follows; the abdomen be- comes distended and tender, the pulse small and rapid. The Hippocratic facies, shallow respiration, and other manifestations of peritonitis rapidly develop. The evidences of perforation are occasionally the first indica- tion of the existence of the ulcer. Complicaiions. — The most important of these are pylephlebitis, with abscess of the liver; chronic peritonitis; and suppurative parotitis. Dilatation of the stomach follows narrowing of the pylorus from cicatri- zation, and sclerosis of the walls is not uncommon. Diagnosis. — The cardinal symptoms are the peculiar localized sensa- tion of discomfort or of pain and tenderness, vomiting, especially hema- temesis accompanied with pronounced anemia. Ulcer is to be differenti- ated from gastralgia, hyperchlorhydria, acute gastritis, and cancer, and the hemorrhages from hematemesis of other character. Gastralgia is a neuralgic pain which is not limited to a definite area, and it is, as a rule, neither relieved nor intensified by the taking of food. The patient does not become anemic ; digestion may be normal between the attacks; vomiting seldom occurs; hematemesis is absent; and if there is tenderness, it is difi'use. Superacidity may be present. In hyperchlorhydria the pain is diffuse, and it usually occurs two or three hours after the ingestion of food. ■Acute gastritis is generally accompanied with fever and evidences of toxemia. Blood is absent from the vomited matter, or present in only trifling amount. The condition does not usually last more than a week. 462 PRACTICE OF MEDICINE Carchioma almost always occurs in individuals past 40. The pain is irregular, sometimes absent; tenderness may not develop until late. Vomiting occurs irregularly or it is absent ; hematemesis is not profuse, and the blood usually has the coffee-grounds appearance. A tumor can generally be felt, and the patient acquires a cachectic appearance. The free HCl is usually diminished and sometimes absent. The gastric crises of locomotor ataxia sometimes simulate the par- oxysms of pain from ulcer before the more characteristic symptoms of the disease have developed. They are usually associated, however, with the lightning pains, ocular symptoms, and absence of the patellar reflex. Chlorosis. — Hematemesis sometimes occurs in chlorotic girls, which cannot always be attributed to an ulcer, on account of the rapidity of the recovery which follows. It is believed to be due to simple vascular engorgement of the gastric mucous membrane. The diagnosis is difficult, but the localized pain and tenderness of ulcer are generally absent, and there may have been no previous indigestion. Gall-stone colic can generally be recognized by the location and char- acter of the pain, its sudden onset and sudden termination, as well as by the enlargement and tenderness of the liver, sometimes accompanied with distention of the gall-bladder and jaundice. The hemateinesis due to cirrhosis of the liver accompanies the charac- teristic symptoms of that disease. The liver is small, and jaundice and ascites are usually present. The differentiation between gastric and duodenal ulcer is often impos- sible. The latter location of the ulcer may be suspected, however, when a sudden intestinal hemorrhage (melena) takes place in a previously healthy person, or when there is a history of pain in the right hypochon- drium two or three hours after meals. Prognosis. — Recovery usually follows appropriate treatment, but re- currence is common. It is never safe to give a favorable prognosis, for the course of the disease is exceedingly uncertain. The danger of perforation is always to be regarded, and the hemorrhages sometimes prove fatal. A chronic ulcer may terminate unfavorably through inani- tion and exhaustion. Treatment — The first indication is to give the stomach complete rest. This may be accomplished in severe cases by confining the patient to bed and resorting to rectal alimentation for at least the first week. In ordinary cases, however, it is sufficient to give easily digestible, unirri- tating food in small quantities at regular intervals. It is generally best to give only milk at first; 4 ounces every two hours. It may be plain or peptonized, and buttermilk often agrees better than sweet milk. Beef- juice or peptonized beef, and egg albumen, may be allowed after a few days, and the diet should be restricted in most cases to such articles as these during the first month. It may then be extended so as to include rare beef, the white meat of chicken, poached eggs, toast, and well-cooked farinaceous articles. Pain is rarely so intense as to require the administration of morphin. Relief can generally be obtained from alkalis, as sodium bicarbonate, the compound spirit of sulphuric ether, camphor-water, or a few drops of chloroform. When vomiting is persistent, it may be necessary to adopt rectal ali- CANCER OF THE STOMACH 463 mentation. Mustard may be applied to the epigastrium, or a few quick strokes may be made with the cautery. The vomiting is sometimes checked by bismuth, with or without opium, by dilute hydrocyanic acid, chloroform, or by sipping a carbonated water or champagne. Lavage with a warm alkaline solution has been recommended, but it should be performed with the utmost care. The action of the bowels must gener- ally be regulated by either a saline laxative or enemata. Thirst is best relieved by enemata of salt water. The powder of Stockton and Jones often proves an excellent remedy for the pain, vomiting, and constipation. Each powder contains : Of cerium oxalate, gr. ij (0.13); light magnesium carbonate, gr. x (0.65); and bismuth subcarbonate, gr. xx (1.30). It should be administered from three to six times a day. A grain or two of reduced iron should be added to each powder, for the anemia. For the healing of the ulcer, large doses of bismuth subcarbonate,, gr. xxx to Ix (2.0 — 4.0) three times a day, are of unquestionable benefit. The nitrate of silver in doses of gr. ]/l (0.016), combined with opium, was highly recommended by Pepper. When hemorrhage occurs, the patient should be immediately placed under the influence of morphin, given hypodermically at such intervals as will insure complete rest for several days. Ergotin, gr. ij (0.13), may also be administered hypodermically. Astringent remedies per os are useless. In extreme cases the subcutaneous injection of saline solution should be resorted to. During convalescence iron should be administered freely in a nonirritating form. The reduced iron is probably best. Surgery has accomplished excellent results in a few instances after per- foration or persistent hemorrhage. The source of the bleeding cannot always be discovered, but ligature of the artery in the stomach-wall which supplies the region has resulted in arrest of the hemorrhage and healing of the ulcer. CANCER OF THE STOMACH. Etiology. — Sex and Age. — The sexes are about equally affected. More than half the cases occur between the ages of 40 and 60; the disease is rare under 30, but cases have been observed in children, and a few con- genital cases have been reported. Next to the uterus, the stomach is the most frequent location of cancer. Race. — The disease is much more frequent in the white race than among negroes. Heredity is regarded as a strong predisposing factor, but in many cases no such influence can be traced. Previous Disease and Habits. — That previous irritation of the stomach is influential is inferred from the frequent location of the growth in the pyloric region as well as from the frequent history of long-standing catarrh before its onset. In about 6 per cent of cases there is a more or less definite history of ulcer, or of injury to the region of the stomach. A considerable proportion of cancer patients have been addicted to free indulgence in alcohol. But in general no great importance can be at- tached to previous disease, habits, occupation, or station in life. Bacteria. — Cancer is regarded by many authorities as a specific infec- tion, but the microbe has not been identified. It is possible that some 464 PRACTICE OF MEDICINE one of the micro-organisms recently demonstrated in the growth, and cultivated with more or less success, will prove to be the cause of the dis- ease. Cancer of the stomach is usually primary, but it is sometimes secondary to cancer of one of the adjacent organs. Morbid Anatomy. — The different types of cancer are found in the fol- lowing order of frequency : (i) Cylinder-celled epithelioma, (2) encepha- loid, (3) scirrhous, (4) colloid. The epithelioma is much the most common. The soft encephaloid or medullary and the colloid are the most rapid in growth and invasion of tissues, and the hard scirrhous is least so. The epithelioma and scirrhus are usually found as compara- tively small masses, while the encephaloid and colloid frequently invade almost the entire wall of the stomach. The growth most commonly originates near the pylorus, next in the lesser curvature, then at the cardia, the posterior wall, the greater curvature, and finally in the fun- dus. Multiple tumors are occasionally encountered. The stomach is dilated as a result of cancer at the pylorus, and much contracted when the growth is located at the cardiac orifice. The esoph- agus is much dilated above a tumor at the cardia. In some cases of pyloric scirrhus, however, the stomach is contracted, although marked stenosis may have been produced. The stomach may be displaced down- ward by its weight, and it may drag with it the surrounding viscera. In some cases the tumor is remarkably movable, while in others adhesions are formed between the stomach and colon, liver, or anterior abdominal wall. Metastatic growths are often found in the lymph-glands, liver, gall-bladder, peritoneum, omentum, intestine, pancreas, spleen, pleura, and lungs, or elsewhere. Small subcutaneous cancers are sometimes found in the epigastric and hypogastric regions. Symptoms. — There is great diversity in the symptoms of different cases. There may be no manifestations by which the disease can be recognized until a comparatively late period. The history that is gener- ally obtained is that of indigestion during several months, increasing in severity, and attended with anemia and emaciation. The disease is sometimes discovered post mortem in those dying from other causes. In another class of cases the s)anptoms appear comparatively early and are characteristic. The disturbances caused by the metastatic growths, especially in the liver, are occasionally more prominent than those of the primary disease. The early symptoms in an ordinary case are loss of appetite, impaired digestion, pain, nausea, and vomiting. Later there are loss of weight and strength, anemia, emaciation, cachexia, and finally prostration, and death from toxemia or exhaustion. The early symptoms are not typical ; they indicate only a disturbance of the function of the stomach. The loss of appetite is an early symptom, and it is one of the most constant. The tongue becomes heavily coated and dry. Nausea and distress soon develop after meals; then the feeling of oppression in the stomach be- comes more constant, and it is aggravated into a distinct pain by the ingestion of food. Eructations become a prominent feature, and then occasional vomiting, Votniting. — In some cases neither nausea nor vomiting is present throughout the disease, but in others they are extremely troublesome symptoms, especially in the last stages. Vomiting is more frequently CANCER OF THE STOMACH 465 present when the cancer is situated at the pylorus, and more frequently absent when it is at a distance from this region. It is observed, how- ever, early or late, in about four-fifths of all cases. It often bears no relation to the taking of food. The vomitus may consist only of food and mucus, or it may contain adventitious matter, particularly blood. It has a sour odor and in some cases becomes distinctly fetid or fecu- lent, especially as a result of the separation of gangrenous sloughs from the tumor. The food may show but little digestion, after having re- mained in the stomach many hours. Hemorrhage. — Free hematemesis is rare. The blood is sometimes so small in quantity that it can be discovered only by microscopic or chem- ical examination. Altered corpuscles can often be recognized; hemin crystals may be obtained, or the guaiacum test may be applied. In other cases the blood appears as coffee-ground matter, which is regarded as highly pathognomonic of cancer. Large ulcerating cancers are most liable to be attended with free hemorrhage ; scirrhus often runs its course without it. Pain is a prominent symptom in about three-fourths of the cases and often occurs early. It is usually confined to the epigastrium, but may be referred to the shoulders, sides, or back. It is generally of a burning, gnawing, or dragging character; distinct cardialgia rarely occurs. It is generally constant, but increased by ingestion of food. Tenderness is usually elicited by pressure over the region aff'ected, sometimes also over the back between the fifth and twelfth dorsal vertebrae. Anernia and cachexia are often early symptoms and almost invariably present. The number of red corpuscles often sinks below 3,000,000, occasionally below 2,000,000, and the hemoglobin may fall below 50 per cent. The anemia is one of the chief elements in the production of cachexia, but, in addition, the skin acquires a pale yellow tint, often associated with brownish discoloration of the face, neck, and backs of the hands or other regions. The skin appears firm and inelastic, some- times slightly edematous. When the anemia is extreme, there is often edema of the lower extremities and sometimes a more general dropsy. Emaciatio7i often begins early, but in a large proportion of cases there is little loss of weight until a late period of the disease. The degree of emaciation is often remarkable, the body being literally reduced to " skin and bones." The decline of strength usually keeps pace with the loss of flesh, but a remarkable degree of vigor is sometimes retained to the end. Fever is not a prominent symptom, but there is usually some eleva- tion of temperature during the course of the disease. It may not occur until late, and may never exceed 101° F. (38.5° C), but toward the end it often rises to 103° F. (39.5° C.) or higher. When suppuration occurs at any time, in the growth or near it, fever is commonly produced. The pulse becomes weak. Thrombosis of one of the femoral veins, rarely of other vessels, has been encountered. The iirine often remains unchanged. Indican may be present, however, and sometimes a small quantity of albumin. Aceton, pepton, and glu- cose are occasionally found in it. Constipation prevails in most cases, rarely diarrhea. Blood may be occasionally found in the stools. The tumor can usually be recognized at some time during the course of the disease when it is situated at the pylorus; less frequently when at 30 466 PRACTICE OF MEDICINE the cardia or lesser curvature. The diffuse carcinoma seldom produces a prominence that can be felt. It is usually recognized by palpating deeply into the epigastrium just to the right of the median line. It is at first slightly movable, sometimes freely so, but later it ma)'- become adherent. It may be firm and smooth or nodular. As it enlarges it usually transmits the pulsations of the aorta wdth distinctness. Som.e- times it drags down the stomach and other viscera to a lower position in the abdomen. In most cases, a pyloric cancer causes obstruction, consequent increase of the peristaltic movement, and, later, dilatation of the stomach. Occasionally, however, the pyloric orifice is held open, permitting a regurgitation of bile into the stomach. The motor efficiency of the organ is impaired in nearly all cases, ex- cept those involving the cardia or in the presence of small tumors of the fundus. It is most reduced when a large portion of the stomach-wall has been invaded by the growth. WTien the tumor is located at the car- dia, the stomach generally becomes contracted, and in other respects the symptoms are the same as those of cancer of the esophagus. Physical Examinaiion. — Inspection. — From this we learn the general condition of the patient as to nutrition ; his color, whether anemic or cachectic, and the presence of abnormal pigmentation. The abdomen usually appears prominent, and the lower intercostal spaces may be widened. Small subcutaneous nodules in the epigastric or umbilical region are often of diagnostic value, \^^len the tumor is large it may protrude slightly, and the transmitted aortic pulsation may become visible. Exaggerated peristaltic movements are often seen comparatively early. They are more readily recognized after the stomach has been inflated with air, but this method should not be practiced in a case of extensive involvement or after hemorrhage has occurred. Palpation affords more positive means of recognizing the tumor. In some cases it can be recognized by examining the patient in a recumbent posture ; in other cases by placing him in the knee-elbow position. Some- times the tumor can be felt only during inspiration. The mobility of the growth is often of diagnostic value ; not only the extent to which it can be displaced with the hand, but also the extent to which it moves during respiration and with peristalsis or with inflation. Tumors of the pylorus are occasionally extremely movable, so that they can be displaced into either hypochondriac region or drawn down to the umbilicus. Through palpation, also, the escape of gas through the narrowed pylorus can be discerned, as in other forms of stenosis. Percussion is seldom of much value, and auscultation reveals nothing characteristic. Examination of the Stomach-Contents. — (Y ox methods see p. 719.) HCl is not invariably absent, but its persistent absence is regarded as highly pathognomonic of cancer, especially that of the pyloric region. It serves also to distinguish cancer of the stomach from that of adjacent organs. Lactic acid is often, but not invariably, found. Its constant presence is regarded as of greater diagnostic importance than the absence of HCl. The rennet, or milk-curdling ferment, is generally reduced in quantity. On microscopic examination, various micro-organisms are ordinarily found, among them the Boas-Oppler bacillus, a long, non- motile rod, which is supposed to be operative in the production of lactic acid. Yeast fungi are usually found, and sarcinai may be present. CANCER OF THE STOMACH 467 The course of the disease seldom exceeds a year or eighteen months, and cases are occasionally reported which apparently run their course in three or four months. Comp/icaf/ons.— Such more or less direct results as dilatation or per- foration, and such pressure symptoms as occlusion of the bile-ducts or blood-vessels, and the development of metastatic growths are often re- ferred to as complications. The metastases are most commonly encoun- tered in the liver, lymph-glands, omentum, mesentery, pancreas, occasion- ally in the spleen, lungs, pleura, axillary glands, the pelvic organs, or other parts. Diagnosis— The early recognition of cancer of the stomach is often extremely difficult, especially its differentiation from chronic gastritis and ulcer. It is to be suspected especially when it develops pronounced symptoms of gastritis in a person who has always been healthy, and more particularly when anemia and cachexia become apparent and when, in an elderly person, the indigestion is accompanied with pain. The methods of examination already referred to may render the recognition of the disease possible. When a tumor is discovered, it strongly supports the diagnosis. The diseases from which cancer is to be particularly differentiated are chronic gastritis, ulcer, and the severe primary anemias. In chronic gastritis there is usually a history of long-continued indiges- tion, without tumor or cachexia, and the blood-changes are less pro- nounced. Lactic acid is not generally found after a test-meal. Ulcer is to be distinguished especially by the presence of hyperchlor- hydria, the gastralgic attacks, and the profuse hemorrhages. It usually occurs in younger subjects. Anemia. — Grave anemia is often suggested by the appearance, espe- cially when the digestive disturbances are of only moderate severity and when tumor is absent. In countries where profound anemia is a common result of animal parasites, the differentiation may be especially difficult, until examination of the feces is made. In pernicious anemia the blood- count shows a more profound diminution of the red corpuscles than is observed in cancer. In cases of doubt, an exploratory incision is to be recommended. In many cases, without such examination the case must remain in doubt until the development of characteristic symptoms, possi- bly several months after the first examination. Prognosis. — The disease is invariably fatal. The only exceptions are the few cases in which early removal of the tumor has more or less permanently arrested the disease. Treatment. — The most important question is, Can anything be done by surgical measures? If not, the treatment is wholly palhative. The management of the digestive disturbances is that of chronic gastritis, and perhaps that of dilatation. When HCl is absent or greatly deficient, it should be supplied by the administration of the dilute acid. When stenosis occurs, the patient may be nourished by the rectum, but usually only for a very short time. Previous to this the most easily digestible and most nourishing food must be given, as finel}^ chopped meats, soft vegetables, salads, eggs, rice, custards, and the like. When the tumor is at the cardia, the diet must be entirely liquid in most cases. Much benefit and prolongation of life have followed in some instances the in- troduction of the gastric canula. Milk is often the best food. When 468 PRACTICE OF MEDICINE vomiting interferes with the nutrition, the food will sometimes be re- tained if introduced through the stomach-tube. Predigested milk or beef, egg-nog, beef-juice, broths, and gruels can usually be taken. When the tumor is located at the pylorus, lavage often gives marked relief from the suffering and assists nutrition. It should usually be practiced in the morning, and always with great care. The most successful surgical measure has been gastroenterostomy. The pylorus and in some in- stances the entire stomach have been removed, but in most instances extreme measures for prolonging life result in little more than prolonga- tion and aggravation of suffering. Marked temporary improvement has repeatedly followed an exploratory incision or any other measure which awakens a strong, though false, hope of improvement. OTHER TUMORS. The nonmalignant fibromata and papillomata and the malignant lymphosarcomata have been found in the stomach. They are seldom diagnosticated during life. Foreign bodies may also assume the char- acter of tumors. A not infrequent form is the hair tumor, which re- sults from the swallowing of hair, especially by hysterical women. These sometimes acquire enormous size and cause more or less complete ste- nosis of the pylorus. Large masses of fruit-seeds and rinds and numer- ous other substances have been found and successfully removed through surgical operations. HYPERTROPHIC STENOSIS. This rather rare condition is due to a hypertrophy of the muscular and submucous coats of the stomach, which may form a mass recogniza- ble on palpation. It is sometimes congenital, but is generally recog- nized later in life, at any time after the twelfth year. The causes which produce it in adults are not known. The principal symptoms are those of dilatation. The diagnosis is seldom made during life. The treatment is purely surgical, and the usual operation is that of gastroenterostomy. HEMORRHAGE OF THE STOMACH. GASTRORRHAGIA, HEMATEMESIS. Bleeding of the stomach (gastrorrhagia) and vomiting of blood (hematemesis) are symptoms of a variety of conditions. Etiology. — Hematemesis sometimes results from the entrance of blood into the stomach from other sources, as when swallowed in hemorrhage of the upper respiratory tract, pharynx, or esophagus, or when, it flows in through the cardiac orifice after rupture of a varicosed vein in the lower extremity of the esophagus in cirrhosis of the liver, or very rarely from the rupture of an aneurism into the stomach or esophagus. It occasionally results from the passage of blood through the pylorus from the intestine in cases of duodenal ulcer. The causes of gastrorrhagia may be either local or general. I. The most frequent local causes are: (<7) Peptic ulcer and cancer; HEMORRHAGE OF THE STOMACH 469 (^) passive congestion due to obstruction of the portal circulation, as in hepatic cirrhosis, pressure of a tumor, thrombosis of the portal vein, chronic valvular disease of the heart, and fibrosis or emphysema of the lungs; (<:) enlargement of the spleen. (^) Traumatic hemorrhage also occurs as a result of blows and wounds or the introduction of the stom- ach-tube or sounds, and it may follow the action of corrosive poisons, phosphorus, or alcohol, or the injury occasioned by a foreign body. (^) A toxic cause is sometimes recognized, when it occurs in connection with such acute infections as measles, smallpox, yellow fever, pernicious malaria, and dengue, or in acute yellow atrophy of the liver. 2. The general conditions causing it are (a) chlorosis, pernicious anemia, leukemia, purpura, scurvy, and hemophilia. (^) Vicarious menstruation from the stomach has been observed. (^) Hemorrhage of the stomach alone or in connection with the bleeding of other mucous membranes occasionally occurs in the new-born infant. (^) Hemateme- sis is sometimes feigned by hysterical women who vomit blood or col- ored fluids that have been previously swallowed. Morbid /Inatomy.— In the absence of such definite lesions as ulcer, cancer, corrosion, or other injury, the source of the blood may be de- termined with difficulty, if at all, since it often comes from numerous small erosions which are not recognizable after death, or from the rup- ture of a miliary aneurism or a small vein in the submucosa which oc- casions so slight lesions of the surface as not to be discovered on careful examination. When death has resulted from the hemorrhage, the mucous membrane participates in the general anemic condition and appears ex- tremely pale. Symptoms. — The blood may be retained in the stomach, even in cases of fatal hemorrhage. The quantity vomited in other cases may vary from two or three ounces to as many pints or even more. Fatal hem- orrhage most frequently results from ulcer or the rupture of varicose esophageal veins in cirrhosis ; death may ensue from a single hemorrhage, but more commonly as a result of repeated hemorrhages during several days. Free hematemesis often brings up bright red arterial blood, but if the blood has been retained in the stomach for a short time it assumes the character of coffee-grounds or chocolate-colored masses, which become bright red on the surface after exposure to the air. The blood may be mixed with food, mucus, or pus. Melena is also a com- mon symptom. Such other symptoms of hemorrhage are observed as pallor, restlessness, rapid feeble pulse, accelerated respiration, cold per- spiration, subnormal temperature, syncope, or convulsions. Diagnosis.— When a large quantity of blood is retained in the stom- ach, the fact that a hemorrhage has occurred can generally be recog- nized by the pallor, cardiac weakness, rapid respiration, and other in- dications already referred to. The percussion note over the stomach is fiat. The statement of the patient that blood has been vomited can- not always be accepted, for deception is sometimes practiced by the h3^s- terical, and errors have occurred from the staining of the stomach con- tents with fruit-juices or red wine or from the black discoloration caused by bismuth or iron. Such stains can generally be recognized by mere ocular inspection, but microscopic or chemical examination is sometimes necessary. The most important distinction is usually to be made be- 47 o PRACTICE OF MEDICINE tween hematemesis and hemoptysis. In hematemesis there is usually a history of gastric, hepatic, or splenic disorder, an acute infection, toxic or mechanical injury, and the blood is brought up by vomiting in a more or less changed condition and often mixed with food, mucus, or gas- tric juice, which gives an acid reaction. In hemoptysis there is the his- tory of cough or other evidence of pulmonary or cardiac disease ; the blood is raised by coughing and it is bright red and frothy, of alkaline reaction, rarely clotted, but sometimes mixed with mucus or pus. Vom- iting may accompany the hemorrhage, and hence the presence of stom- ach-contents cannot be regarded as evidence against hemoptysis. Aus- cultation generally reveals numerous moist rales or coarse bubbling in one of the lungs. Following hematemesis, tarry stools commonly occur, and after hemoptysis the sputum continues to be blood-stained for several days. Prognosis. — The hematemesis of ulcer or cancer is not commonly fatal; that from cirrhosis of the liver, splenic enlargement, the rupture of an aneurism, or penetrating wounds is generally so. For the treatment of hematemesis see that of gastric ulcer. NEUROSES OF THE STOMACH. NERVOUS DYSPEPSIA. Definiiion. — This term has been applied to a group of functional dis- orders which occur without discoverable anatomical lesions. They are in nature either secretory, motor, or sensory. Etiology. — Underlying all cases of true neurosis there is a disordered state of the nervous system. This may be inherited or acquired. It often happens, however, that the gastric symptoms are so prominent as for a time to overshadow the general nervous condition. The inherited form often shows itself in different members of the same family. The ac- quired neuroses result from nervous excitement, worry, overwork, espe- cially in a confining occupation, and are favored by neglect of hygiene, irregular or hurried meals, and loss of rest. Eyestrain, especially that due to astigmatism and errors of refraction, has been adduced as a cause. The neuroses sometimes develop in the course of the acute infections or as a sequel to them. The gastric crises of locomotor ataxia are regarded as a neurosis. More than one form of neurosis is often pres- ent in the same case, and the severity of the condition varies within broad limits. I. NEUROSES OF SECRETION. (flt) Supersecretion or Superacidity. — This is a rather rare condition, but is sometimes seen in connection with neurasthenia, locomotor ataxia, and other nervous affections. The entire quantity of the gastric juice is increased, its acidity remaining normal or undergoing increase. In most cases the condition is constant, but it may be periodic, lasting for sev- eral days at a time. Symptoms.— The periodic attack usually sets in with a gnawing sen- sation in the stomach and headache. Vomiting soon follows, with the ejection of a large quantity of watery fluid, which is so highly acid in most instances that it irritates the throat and leaves it raw and sore. NEUROSES OF THE STOMACH 471 The secretion of the fluid is remarkably rapid. One of the principal re- sults of constant superacidity is spasm of the pylorus from the irrita- tion produced by the highly acid juices constantly bathing it. Dilatation commonly follows. There is a sense of weight and oppression in the epigastrium, and the digestion is impaired. Vomiting at night or early in the morning is a characteristic feature in many cases. (/^) Hyperchlorhydria (Superacidity, Acid Dyspepsia). — In this con- dition the percentage of HCl is increased during digestion. The condi- tion is generally seen in young neurotic girls and often in connection with chlorosis. Sympioms. — Pain of a burning character, or a sensation of weight and pressure, is the most common and most characteristic symptom. It occurs, as a rule, from one to three hours after the ingestion of food. Acid eructations generally occur, and sometimes vomiting. There is also tenderness in the pit of the stomach, as in ulcer, a disease in which superacidity is commonly present, but not as a neurosis. The patient is often aroused from sleep by the distress or by the sensation of hunger, which is almost constantly present. Temporary relief is gen- erally afforded by vomiting or the ingestion of food, particularly by animal food. Treaimeni. — In superacidity or hyperchlorhydria the patient should be placed on an exclusively milk diet for the first few days. Then beef, fish, eggs, and dry toast may be added to the list. Alcoholic drinks should be excluded, and the use of tobacco would better be abandoned. Relief from the pain and eructations is afforded by sodium bicarbonate, magnesium carbonate, and other alkalis. They should not be admin- istered, however, until the distress is felt. The compound spirit of sul- phuric ether and chloroform-water give temporary relief. Atropin has been employed to reduce the quantity of secretion. (r) Hypochlorhydria (Subacidity).— In this condition the quantity of HCl is reduced below 0.14 per cent. It is generally believed to re- sult from deficient innervation. Sympioms. — The symptoms are those of chronic gastritis, without, however, an arrest of the secretion of pepsin and rennin or the excessive secretion of mucus. Treatment. — The normal secretion can generally be restored by the administration of bitter tonics, as the compound tincture of gentian, with the tinctures of nux vomica and capsicum, immediately after meals. Dilute hydrochloric acid is also beneficial. Some cases recover more promptly on the administration of an alkaline solution, as sodium bi- carbonate, gr. XX (1.30) in a half-pint of hot water twenty minutes before each meal, and the dilute hydrochloric acid, gtt. xx in water immediately after the meal. The diet should consist chiefly of farinaceous food, as well-cooked cereals, and very little meat. ((/) Achylia Gastrica (Nervous Anacidity). — A condition in which the gastric secretion is permanently absent. As a true neurosis it is usually due to some reflex irritation, as that of eyestrain in asymmetrical as- tigmatism. The term is commonly applied, however, to conditions in which the gastric juice fails of secretion on account of atrophy of the peptic glands, as in some cases of chronic gastritis, a condition in which it is not truly a neurosis, but depends upon anatomical lesions. The 472. PR.\CTICE OF MEDICINE absence of HCl in cancer and sometimes in tabes is regarded as a neurosis. Symptoms. — In many cases there are no subjective symptoms, and the condition may be first recognized on chemical examination of the stomach-contents. In other cases there is dilatation with its accom- panying symptoms, or in the absence of dilatation there may be flatu- lency, eructation, hiccough, gastralgia, nausea, and vomiting. Intestinal indigestion may also be present, with diarrhea, anemia, and nervousness. When the motor activity of the stomach remains normal and the intes- tinal digestion active, the condition may persist for years without greatly impairing the health or producing emaciation. Diagnosis. — After the usual test-breakfast, the stomach-contents show an entire absence of HCl, the ferments and proteoses. The salivary digestion is sometimes found to have progressed in the stomach. The administration of HCl with the test-meal of meat is not followed by evidence of digestion, since no pepsin is secreted. Treatment— The diet should consist chiefly of vegetables and starchy food. They should be well cooked and thoroughly masticated, or arti- ficially divided into small fragments. Well-hashed sweetbreads, raw oysters, and chicken may be occasionally allowed in small quantities. A large quantity of food should be eaten in order to maintain the nourish- ment of the patient, since he depends solely upon intestinal digestion. The bitter tonics and hydrochloric acid may be of benefit. An active pepsin may also be given. Lavage with a weak salt solution, followed by faradization, has been recommended. 2. NEUROSES OF MOTION. (^) Relaxation .of the pylorus, or pyloric incontinence, permits the too early escape of the gastric contents into the intestine. The food is sometimes passed into the duodenum immediately after entering the stomach. 474 PRACTICE OF MEDICINE (/) Atony of the Stomach. — This condition, which signifies a relaxed or enfeebled condition of the muscular coat of the stomach-wall, occurs as a neurosis in debilitated or neurasthenic conditions of the general system. It is more frequently a result of organic disease, produced by habitual overdistention with food or drink, or a general wasting of the tissues of the body from chronic disease. It sometimes occurs also in connection with the acute infections, especially typhoid fever. The symp- toms are generally those of dilatation, especially eructations and a feel- ing of distention and weight. Treatment of Motor Neuroses. — In addition to the general treatment to be considered, little is usually required. When the activity is too great, the diet must be of the mildest kind, free from irritating or stimulating properties; but deficient motility calls for highly seasoned food and preferably a meat diet, with the administration of bitter tonics. The spasm and persistent vomiting sometimes require careful treatment, ab- stinence from food for a day, followed by the administration of small quantities at short intervals and the treatment recommended for the vomiting in gastric ulcer. The treatment of atony is practically the same as that for dilatation of the stomach. 3. NEUROSES OF SENSATION. («) Hyperesthesia. — In this condition the patient complains of more or less distress in the stomach, with a burning pain in the epigastrium after the ingestion of food or drink. In all other respects the function of the stomach is normally performed. A colored fluid taken as medicine may not occasion discomfort. The aff^ection is met with in the same class of neurasthenic or hysterical individuals, mostly women, who are the subjects of the other neuroses. It may follow a violent emotion, as fright or anger, shock, or a severe illness, as the influenza or an infec- tious fever. The gastric irritability may be so extreme that the patient becomes greatly emaciated. (^) Gastralgia, or gastrodynia, may occur as a pure neurosis, inde- pendent of organic disease or the ingestion of food, and often seizing the patient at night. In other cases it is associated with other neurotic manifestations. They sometimes accompany menstrual disorders, possi- bly at puberty, but more particularly at the menopause. It is some- times associated with superacidity or supersecretion and may occur in neurasthenic men. Malaria is regarded by some writers as a possible cause. The gastric crises occurring in the course of nervous diseases, notably in locomotor ataxia, belong to this group of affections. Symptoms. — The pain is often excruciating. It is generally most severe in the epigastrium, but often radiates to the shoulders, sides, and back, resembling the pain of ulcer. It is usually independent of the ingestion of food, and often recurs at more or less definite intervals, frequently awakening the patient from sleep. Tenderness may be elicited on deep pressure, but moderate pressure affords relief. Eructations, restlessness, and other nervous or hysterical manifestations commonly accompany the attack. Vomiting seldom occurs, and the ingestion of food may give relief, as in hyperchlorhydria. Diagnosis.— The diagnosis is often difficult, especially at the first ex- NEUROSES OF THE STOMACH 475 amination of a patient not previously known. The seizure must be differentiated from gastric ulcer and cancer, bilious and renal colic, and angina pectoris. Ulcer is excluded by the greater periodicity of the attacks, perhaps by the absence of anemia. Hematemesis is not present; the pain radiates over a wider area, and the taking of food relieves, rather than aggravates, it. Ca?tcer usually occurs at a more advanced age, the pain does not radiate so widely, and the symptoms are not so constant. The presence of a cachexia favors cancer. In hepatic colic the pain is even more extreme, and it is confined to the region of the gall- bladder, where tenderness is also found. The presence of jaundice and clay -colored stools is highly significant. In retial colic the pain is lower in the abdomen and radiates along the ureter to the bladder or thigh. The urine is highly acid and often contains sand or gravel. In angina pectoris the pain is in the precordial region, often radiating to the left arm. There is marked dyspnea with a sense of suffocation and impend- ing death. Treaiment. — If the attack comes on soon after the ingestion of a full meal, an emetic may afford relief; if during the night, it calls for the application of hot fomentations, the hot-water bottle, or a mustard-leaf, and internally chloroform, TTLxv (i.o), or the compound spirit of sul- phuric ether. Morphin must sometimes be given hypodermically, but it should be avoided if possible, for this class of patients are especially susceptible to the habit. Atropin should be combined with it. It is sometimes necessary to keep the patient on a milk diet for several weeks, with the administration of the general remedies for the neurotic condition in order to overcome the tendency to the attacks. ((t) Anorexia, or the absence of appetite, is associated with so many conditions, as a neurosis or otherwise, that it requires no special con- sideration. It is a common result of febrile disease, but it is also met with in hysteria and neurasthenia. The administration of the bitter tinctures, or strychnin and arsenic, is generally beneficial. (^.— The purely catarrhal type, in which the inflammation is limited to the mucous membrane APPENDICITIS 491 of the appendix, is little known except by its results. Its existence has been sufficiently established, however, as an early stage of the processes which lead to more profound changes. In it the mucous membrane is hyperemic and greatly thickened. The surface epithelium is desquamated and the follicles of Lieberkiihn may be entirely destroyed. The entire mucous membrane is sometimes removed, and the inner surface is made up of granulation tissue. If, through external pressure or other means, the surfaces are brought into contact while in this condition, they more or less completely unite. The process then constitutes appendicitis obliterans. Its result when complete is a permanent obliteration of the lumen of the tube, and the disease cannot recur. In such an appendix the entire wall is generally found to be thickened and the organ becomes firm and stiff as rubber owing to the extensive hyperplasia of the con- nective tissue. But complete obliteration occurs in only about 2 per cent of all cases. When it is incomplete the canal is often closed at the cecal end by a constriction, and the appendix becomes thickened to the size of the thumb or larger, constituting a cyst, the contents of which may be either a clear fluid or pus. Or the distention may be due to fecal concretions, or to mucus containing desquamated epithelium, leu- cocytes, and mucous-membrane debris. The lumen is sometimes divided into numerous compartments through the formation of cicatricial bands. This condition is always liable to pass on to suppuration and perforation. In some instances, although the distention is not great, the obliterative adhesions are prevented by the rigidity of the thickened wall. Repeated attacks of colic and other manifestations are a common result. In either of these conditions the peritoneal covering may become involved, although neither suppuration nor perforation has occurred. It is then covered with a layer of fibrin, and adhesions are generally formed. Ulcei-ative Type. — Ulceration may result from the presence of concre- tions, foreign bodies, or the pus-forming micro-organisms, and sometimes it appears to be due to the typhoid or tubercle bacillus. Actinomy- cosis of the appendix has also been described. An ulcerative inflamma- tion sometimes follows the catarrhal. Single or multiple ulcers may be found, and they may be quite superficial or so deep as to cause perfo- ration. They may form at any part of the tube. As the inflammatory action reaches the surface, an adhesive peritonitis is developed, uniting the appendix with a loop of the intestine, the bladder, right kidney, ovary, liver, abdominal parietes, or any surface with which it may come in contact. UTien the appendix is of unusual length, it may become adherent to the sigmoid flexure, the gall-bladder, or other remote structiu^e. But although perforation may thus be prevented for a time, a suppurative peritonitis is usually developed. In a large percentage of cases the adhesions are incomplete and permit the escape of the contents into the peritoneal cavity, with production of a general peritonitis. In some instances a localized abscess is formed; its most frequent location is midway between the umbilicus and the anterior superior spinous proc- ess. A common location of smaller abscesses is over the psoas muscle at the angle between the ileum and cecum. They may be found, how- ever, high up in the region of the umbilicus, near the promontory of the sacrum, or down in the pelvis. When the perforation has occurred in a part of the appendix not covered with peritoneum, an extraperito- 492 PRACTICE OF MEDICINE neal abscess is formed and the peritoneum may not become affected. An occasional result of the adhesive inflammation is the constriction or bending of a loop of the intestine in such a manner as to produce tem- porary or permanent obstruction. Necrotic Type. — This is usually an advanced stage or consequence of one of the preceding types. It is perhaps primary in some instances. It may affect the entire appendix or only a limited portion, a single small area or several. Perforation more commonly follows the limited necrosis. In either case, a severe localized or general peritonitis is the usual result. The localized gangrene with consequent perforation is more frequently found at the base, close to- the cecum, but it may occur at the tip or at any point in the wall. The appendix often sloughs oft", and is then found as a highly necrotic mass in the abscess cavity. When still adherent it may be dark red, black, or greenish, corresponding to the degree of necrosis. In all cases of this type, micro-organisms are found in great numbers in the extremely fetid pus. It is more probable that the pus-forming streptococci and staphylococci are the active agents, particularly the streptococci in the more virulent cases, but in a large number of cases the Bacillus coli communis has been the only organism found. This fact has been explained by Welch, however, as due to the ability of this bacillus to outlive the other organisms in the presence of inflammation. Remote Effects of Perforation. — These are due, for the most part, to ab- scess-formation or the burrowing of pus and its erosive action. When the perforation is extraperitoneal, a retroperitoneal abscess is formed. The pus may pass beneath the iliac fascia and even perforate the skin in the region of Poupart's ligament, or it may pass beneath the liga- ment. It sometimes travels along the psoas muscle, and may reach the hip joint, the scrotum, or, by passing through the obturator foramen, form as abscess in the gluteal region. It sometimes burrows upward to form a perinephric abscess, or still further to erode the liver or per- forate the peritoneum in this region. It has also passed through the diaphragm and pleura into the lung. More common avenues of perfo- ration, especially for the intraperitoneal abscesses, is into some portion of the intestine, the urinary or gall-bladder, vagina, or rectum; and in a few instances the pus has penetrated a hernial sac or found an external exit through the abdominal wall. An occasional result of perforation is the erosion of a blood-vessel, with severe or fatal hemorrhage. The internal iliac artery, portal vein, and smaller vessels in the walls of the intestines or other viscera have been perforated. Phlebitis of the mesenteric vein and abscess of the liver are occasional results. Symptoms. — There is scarcely another disease in which the symptoms are so diverse or in which they may be so little significant of the real pathological condition as this. It is better, therefore, not to attempt a classification of them into types, but to study the disease in its en- tirety, for the mildest onset often precedes a rapidly fatal course, and the severest cases may subside with surprising rapidity. In some cases symptoms are absent, or they are so mild as to attract little attention. Many cases begin gradually with manifestations which may be regarded as prodromal. These are generally characterized by colicky pains and APPENDICITIS 493 tenderness more or less confined to the right ihac fossa, with malaise, loss of appetite, constipation or diarrhea, sometimes also with nausea and vomiting. With or without these early manifestations, however, there is ordinarily a sudden paroxysm of severe pain. This is followed with fever, gastrointestinal disturbances (constipation, nausea, and vomiting), and tenderness or pain on pressure over the region of the ap- pendix. Pain. — The pain is usually violent and begins suddenly, without obvi- ous cause, or it may follow one of the recognized causes of the disease, an error in diet, a blow, strain, or jar. It may amount only to a sense of discomfort, but it is often sharp and agonizing. It is generally per- sistent, but subject to paroxysmal exacerbations. It is often referred at first to the umbilical, epigastric, or hypogastric region, or it may be diffused over the abdomen, but it becomes localized in most cases within twenty-four to forty-eight hours, in the right iliac fossa. Extremely sharp pain usually denotes an involvement of the peritoneum with great danger of perforation, or that this has already occurred. On the other hand, no positive deduction can be made from the character of the pain, for, although severe, it is sometimes transitory, and sometimes, it is thought, significant only of appendicular colic, occasioned by violent peristaltic action in attempts to expel mucus from the interior of the appendix. Fever. — Elevation of temperature is one of the most significant symp- toms, since it indicates an inflammatory process as the source of the pain. It not only serves to exclude appendicular colic, an afebrile con- dition, but it is highly indicative of the severity of the inflammation or the presence of suppuration. It usually develops within twenty-four hours after the onset; it may be preceded by chilly sensations, but sel- dom by a distinct rigor. In a mild case it may never exceed ioi° F. (38,5° C), except in children, when it is usually higher. In severe cases it frequently rises rapidly to 103° or 104° F. (39.5° — 40° C.)- It gener- ally pursues an irregular course. But fever fails to prove a trustworthy sign in many cases and can never be implicitly relied upon, for even in the presence of abscess it may be absent, and in some of the severest cases, when general peritonitis is present from the beginning, the tem- perature is subnormal. The pulse is usually accelerated in ratio to the temperature. The respiration is often superficial or irregular on account of the pain. Gastrointestinal Disturbances. -^T\\q tongue is coated, though usually moist. The appetite is lost, and thirst is generally excessive. Nausea and vomiting are more uniformly present in severe perforative cases; they may be absent in the milder types. Obstinate constipation is the rule after the onset. Hiccough is often an annoying symptom. Great irritability of the bladder is often complained of. The urine is scant, often albuminous, and indican is generally present. Physical Examination. — Inspection. — The facial expression, general con- dition and attitude, of the patient are of much value in arriving at a diagnosis. As the Hippocratic or abdominal fascies indicates extensive involvement of the peritoneum, so its absence may signify the reverse. In cases having a mild beginning, the patient may continue at his vocation for a day or two, but in walking he assumes a shght stoop 494 PRACTICE OF MEDICINE and leans to the right. In most instances, however, he at once takes to his bed. Here he hes on his back or possibly on the right side, with the right knee drawn up. There is usually nothing peculiar in the ap- pearance of the abdomen unless the disease has progressed unfavorably for a few days. After abscess-formation or perforation it becomes dis- tended, and the right side may be sHghtly the more prominent. Three valuable signs are elicited by palpation and percussion, namely, rigidity, tenderness, and dullness. Rigidity. — Abnormal resistance to pressure over the right iliac fossa is usually an early sign. It is due chiefly to rigidit}- of the right rectus muscle, which is unmistakable when compared with the normal tension of the left. In from twenty-four to forty-eight hours, sometimes earlier, a distinct swelling can often be felt in the region of the cecum. It is sometimes concealed, however, by the abdominal rigidity or by the dis- tention of the intestine, unless the patient be anesthetized. Tetiderness.—T\\^^x^ is usually from the beginning great tenderness or acute pain on pressure in the right ihac fossa. In a majority of cases the most acutely sensitive spot is found at " McBurney's point." This is situated on a line drawn from the umbilicus to the right anterior superior spinous process, where it intersects the outer margin of the right rectus muscle. The pressure should be made with the tip of one finger pressed deeply and firmly into the abdominal wall. In some cases, owing, perhaps, to an unusual position of the appendix, the greatest tenderness may be found in another location, or it may be diff'used over a wider area. Rectal or vaginal palpation is sometimes of value in such cases, for a characteristic point of tenderness, the swollen appen- dix, or more certainly an abscess of large size, may be felt. Fluctua- tion can sometimes be obtained by palpation of an abscess of considera- ble size. Dullness.— ?txz\x%%\OTv elicits a dull tympanitic note over the region when there is tumefaction of considerable extent. While all these signs are of value when well marked, the absence of any one or more of them does not preclude the presence of appendiceal disease. They are often less distinctly recognizable or altogether ab- sent after perforation has occurred, although there may be extensive burrowing of pus, Blood-Count.— L^ViQ.ocyto%\?> is usually present, especially after suppu- ration has occurred, when it may exceed 50,000. Cot/rse.— Mild cases, in which pus is absent or so small in quantity that it can be absorbed, usually ameliorate after three or four days. The pain subsides, the fever declines, the constipation yields; all the symptoms abate, and recovery is complete in from ten to twenty days. Sometimes the recovery is less rapid, and slight fever persists during a week or two. Recovery occurs, however, in a majority of all cases. It is sometimes permanent, but too often it is of only short duration. Recurrence is to be anticipated, particularly in cases in which induration or tumefaction remains in the region of the appendix. Chronic Appendicitis.— This term is sometimes given to cases in which the induration fails to subside with the other symptoms. The patient usually suff'ers from a more or less constant uneasiness in the ileac re- gion, or occasional attacks of pain, with or without other symptoms. APPENDICITIS 495 Recurrent Appendicitis. — In another large class of cases an apparently- complete recovery takes place and the induration subsides, but in the course of three or four months, often much earlier, a relapse occurs, accompanied with all the symptoms of the original attack. This may also be recovered from, and another relapse may follow, and thus the disease may run on for several years. Ultimate recovery sometimes occurs in these cases, probably as a result of obliterative inflammation or from the evacuation of a pus cavity into the bowel, but any of the attacks may prove fatal, and the condition is an exceedingly dangerous one. Cases that are characterized by a sudden, violent onset usually cor- respond to the suppurative or ulcerative type of the disease. The ini- tial symptoms in many cases do not correspond to the actual beginning of the disease. The inflammatory process may have been going on for an indefinite time, and the sudden pain, tenderness, and fever indicate the beginning of suppuration, the rupture of the distended appendix, or possibly the giving way of an abscess that has formed insidiously. Although the symptoms may ameliorate after three or four days, as in a mild case, the improvement is generally of short duration. The fever, as a rule, assumes a remittent course from the beginning, and after a few days the symptoms of sepsis become clearly marked. Death may result from septicemia, pyemia, or pyelophlebitis, without rupture of the appen- dix, but it is more frequently a result of general peritonitis, which may be produced through the action of bacteria, either before or after rup- ture. Peritonitis, as just stated, may result from infection without rupture of the appendix, but it is more commonly a result of that accident. The pus is sometimes shut off" from the general peritoneum by adhesions, producing a localized abscess. The abscess may rupture later and set up a general peritonitis. In many instances the general peritoneal in- volvement has been established before the appearance of acute symptoms, and herein lies the greatest danger of the disease. The initial sudden, sharp pain often means the onset of peritonitis and the termination of a previously unrecognized appendicitis. It is then usually followed within a few hours by an extension of the pain and tenderness more or less generally over the abdomen, with distention, tympanites, and rigidity of both sides. The pulse becomes rapid and feeble, the respiration cor- respondingly fast, often irregular or stertorous, the voice weak, and the face anxious and pinched. The tongue is dry and the bowels are con- stipated and vomiting persistent, while the urine becomes scant or sup- pressed. The temperature is variable, sometimes not over ioo° F. (37-5° C.), sometimes over 105° F. (40.5° C). Death is inevitable. Diagnosis.— K sudden attack of violent pain in the right iliac fossa, in a person who was previously healthy, especially in one under 30 years of age, and yet more positively if associated with abdominal rigidity, tenderness on pressure in this region, vomiting, constipation or diarrhea, is almost invariably due to appendicitis, for this is the most common of all inflammatory diseases of the abdomen in early life. The diag- nosis becomes difficult only when some of the symptoms are absent or when unusual manifestations appear, as when the pain is referred tct a distant region. The greatest cause of error is, no doubt, too great 496 PRACTICE OF MEDICINE haste in reaching a conclusion. To avoid this, the complete history of the case should be carefully obtained and carefully studied ; then a thor- ough examination should be made with a view to excluding all possible sources of error. Many affections enter into the consideration. 1. Colic. — Severe intestinal colic may for a time cause confusion, but the absence of distinctive signs in the appendix region is generally sufficient. Diarrhea is more common than constipation. In hepatic colic the conditions usually found in the right iliac fossa are absent; the pain generally radiates toward the right shoulder and back ; the ten- derness is confined to the region of the liver and gall-bladder if calculi are present, and jaundice commonly appears. Gall-stones may be found in the feces. Renal colic is excluded by careful palpation of the abdomen and examination of the urine. Pain radiating to the bladder and penis or scrotum is more common than in appendicitis, and gravel is fre- quently passed. Dietl's crises, due to movable kidney, are relieved by restoration of the organ to its proper position. Gastrointestinal dis turbances are less common. Lead colic is less likely to be mistaken for appendicitis than the reverse, for without careful examination the pain of the latter condition may be referred to lead colic when it occurs in a subject of lead-intoxication. 2. Perforation of Ulcers. — The symptoms arising from the perforation of gastric, duodenal, or typhoid ulcer may be mistaken for appendicitis, but can usually be excluded by the history of the case and the absence of the local signs of the latter disease. 3. Intestinal obstruction, intussusception, fecal impaction, internal strangulation, and other obstructive conditions can generally be ex- cluded, but not always without difficulty. Fecal impaction of the cecum is of slower onset, the pain is moderate at first and of a colicky char- acter, the tumor is usually large and hard, sometimes doughy, and there is less tenderness ; the right rectus is not generally so tense. Bloody mucous evacuations usually accompany intussusception. Fecal vomiting is common to nearly all obstructions. The tympanites develop rapidly and may be confined to the upper part of the abdomen. Pericecal abscess cannot be differentiated from that due to appendicitis without incision, but the differentiation is unimportant, since both conditions call for operative treatment. 4. Psoas Abscess.— F\u.ctVia.t\on can be more uniformly obtained, and examination of the spine reveals the source of the pus in most cases. 5. Renal Disease.— The pain of pyonephrosis, perinephritic abscess, or tumor of the right kidney is often excluded with difficulty. Exami- nation of the urine may reveal the condition, but in perinephric abscess the differentiation cannot be made without exploratory incision. 6. Hemorrhagic pancreatitis may be mistaken for appendicitis, in part on account of its rarity, but the pain is usually different in character and location. 7. Female Disorders.— T\\e colicky pain of the menstrual period is sometimes a source of error. A neuralgia of the right ovary is more likely to cause difficulty in diagnosis. In both conditions, however, the absence of tumefaction or rigidity of the rectus, with the history of the case before the attack and during the few days succeeding it, gener- ally reveals the true condition. Pyosalpinx, pelvic hematocele, and pelvic APPENDICITIS 497 peritonitis can generally be recognized on careful examination, but the differentiation from a ruptured appendix is extremely difficult except Avith a clear history of the case. Extrauterine pregnancy may rarely be a source of confusion. The signs of pregnancy are usually to be found in the breast; and the location of the tumor, pain, and tenderness, seldom corresponds to that of the appendix. 8. Typhoid fever does not occasion confusion when the history of the case is obtained. The iliac pain is seldom so severe at an early period of the disease; the tumor is not present; the rectus muscle is not so rigid, and the fever is higher and more regular in its course. The presence of leucocytosis speaks for appendicitis, the Widal reaction for typhoid fever. 9. Enteralgia, mucous colitis, and other painful affections occurring in neurasthenic, h_ysterical, or hypochondriacal persons often closely simulate appendicitis on account of the strong conviction in the mind of the patient that the disease is present. In an individual who is fa- miliar with the symptoms of the disease the picture may be so accu- rately drawn that unless the most careful physical examination be made without regard to the subjective manifestations, the most skillful diag- nostician may be misled. Prognosis. — A large majority, estimated at 80 to 90 per cent of all cases, recover spontaneously or under treatment. Nevertheless, a favor- able prognosis should not be too -early pronounced, for the most favor- able condition may be converted into the most unfavorable within a very few hours. The outlook becomes less hopeful, as a rule, with each succeeding attack of the disease, not only because each attack brings the patient into greater danger of perforation, but because a condition is ultimately reached which is exceedingly unpropitious for operative measures. No deduction can be safely drawn from the experience of the patient, the physician, or, indeed, from medical and surgical statis- tics. Every case has peculiarities of its own and it must be regarded as fully liable to the most unfavorable results. We have no means of recog- nizing the obliterative appendicitis, although it may be assumed to have been present when the disease finally ceases spontaneously after a series of attacks. Treatment — The patient should.be strictly confined to bed and made as comfortable as possible. For the relief of the pain an ice-bag should be placed over the region of the appendix. Opium should be avoided if possible, for it often masks the real condition, but in extreme cases morphin must be given hypodermically in doses only sufficient to render the suftering bearable. Full doses of sodium salicylate often afford relief without producing profound insensibility to pain and tenderness. Relief sometimes follows a copious enema of warm soap-suds, but the internal administration of laxatives is objected to by most authors. The diet should be exclusively liquid. The most important question to be determined is the advisability of resorting to surgical measures. It is only in a case that runs a mild course from the start, and shows distinct improvement bv the third or fourth day, that this question can be decided in the negative. The neces- sity of an operation should be urged upon the patient: i. If he has passed through one or two previous attacks; 2, in every case of severe 32 498 PRACTICE OF MEDICINE onset with violent pains; 3, in every case in which a tumor can be rec- ognized; 4, whenever a mild case shows a sudden increase of severity, with rise of temperature, severe pain, or the development of a tumor ; 5, in every case in which there is evidence that suppuration or perfora- tion has occurred, providing that the patient's condition admits of im- mediate operation. In all cases of uncertainty, the surgeon should be called without avoidable delay, and, when the indications are distinct, the operation should be performed without the delay of an hour, for the mortality after early operation is inconsiderable, and the chances of recovery rapidly diminish with each day of procrastination. INTESTINAL OBSTRUCTION. ILEUS, OBSTIPATION. 1. Strangulation (Constriction of the Bowel, Intra-Abdominal Her- nia). — The exhaustive investigations of intestinal obstruction by Fitz have given us the best analysis of the condition. Strangulation consti- tutes about 35 per cent of all cases of obstruction. It may be partial or complete. It is much more frequent in males, and nearly half the cases occur between the ages of 15 and 30. The small intestine is in- volved in nearly 90 per cent of cases and usually in the lower part of the abdomen; often in the right iliac fossa (67 per cent). Etiology. — The causes in the order of their frequency are : bands, cords, slits, and fissures in the omentum and mesentery, diaphragmatic hernia, and peritoneal pouches. Rare forms of strangulation are the duodenojejunal hernia of Treitz, in which a loop of the intestine slips into the duodenojejunal fossa ; and the hernia of the omental bursa, in which the loop passes through the foramen of Winslow. The condition producing the strangulation, unless a congenital defect, is generally a consequence of previous peritonitis. This is particularly the cause of the formation of adhesive bands between the intestine and the abdominal wall, as after a surgical operation, between loops of intestine or between persistent vitelline remains, as a prolongation of Meckel's diverticulum or obliterated vitelline blood-vessels and other abdominal viscera. In the same manner the tip of the vermiform appendix may become at- tached and cause constriction of a coil of the intestine, which slips through the unnatural opening. 2. Intussusception (Invagination).— In this condition, which consti- tutes over 30 per cent of the cases of obstruction, a constricted portion of the intestine is forced into a relaxed portion immediately below it. Nothnagel believes that the lower bowel is drawn up over the constricted upper portion. It is a condition peculiar to early life, a majority of cases occurring in males before the tenth year and fully one-third in the first year. Eiiology.—ln a majority of cases diarrhea or habitual constipation precedes the invagination, but in some cases no more definite cause can be assigned than irregular or excessive peristaltic action. An invagina- tion sometimes occurs at the time of death, but it can be distinguished at autopsy by the absence of adhesions or other evidence of inflammation. Morbid Anatomy.— Ks a result of intussusception, a cylindrical tumor INTESTINAL OBSTRUCTION 499 is produced, which varies in length from a few inches to a foot or more. In extreme cases the ileocecal valve has been found in the rectum. The intussusception consists of three layers of intestine. The outer, known as the intussuscipiens, or receiving layer, is continuous with the bowel below, and the innermost, or entering layer, with the bowel above. The middle or returning layer joins the two. The mesentery attached to the entering layer is also drawn in, and as a result the opening at the lower extremity of the invaginated part has the appearance of a slit. The invaginated portion has a dark red or purplish color due to congestion, and the veins are distended with blood. Hemorrhages are commonly found within or upon the walls. The peritoneal surfaces of the entering and returning layer, lying in contact with each other, show the changes of acute peritonitis, being covered with fibrin and more or less firmly united by adhesions. In some cases the invaginated portion becomes separated and is discharged as a slough. Union may then take place between the upper and lower portion of the bowel at the mouth of the invagination. Fibrous stricture is apt to form, but complete recovery has occurred in many cases. 3. Twists (Volvulus) and Knots.— These constitute 14 per cent of all cases. A majority (68 per cent) of twists are encountered in men, and about one-third of them between the ages of 30 and 40. The large in- testine is involved in nearly 90 per cent of cases, most commonly the sigmoid flexure, next the cecum. The condition is favored by an unusual length of the mesentery, elongation of the intestine by hernia, the trac- tion of adhesions, or an accumulation of feces. Rarely a loop of the intestine is twisted about another portion. The bowel may be twisted on its long axis a half-turn, a whole turn, or more, complete strangula- tion being produced. The intestine below the constriction is distended and deeply congested. A fatal peritonitis is usually developed. Knots are extremely rare. 4. Stricture and Tumors. — Stricture of the intestine sometimes exists at birth, or more commonly the canal is completely obliterated in a part of its length, as is usually the case in imperforate anus or when the duodenum is separated from the stomach. Acquired strictures are generally a result of the cicatricial healing of ulcers. These may be stercoral, syphilitic, or tubercular, or they may result from a localized peritonitis, the repair of an intussusception, or very rarely from dysen- tery or typhoid fever. Tumors cause obstruction either through oblit- erating the lumen of the intestine when within it, or by compressing or drawing upon the bowel from without. Cancer is the most frequent cause, and it is generally located in the large bowel, very often in the sigmoid flexure or rectum. It is more common in women after the for- tieth year. Papilloma, fibroma, adenoma, and lipoma occasionally cause occlusion. Pelvic abscess may compress the bowel. An accumulation of feces in one portion of the bowel, as in the sigmoid flexure, sometimes closes an adjacent loop of the intestine by compression. 5. Abnormal Contents.— The most common cause of obstruction by foreign bodies is an accumulation of gall-stones, A majority of the patients are women, all are adults, and six-sevenths are over 50. The next most common cause is impaction of feces. This may occur in either sex and at any period of hfe, often in young children. Enteroliths not 500 PRACTICE OF MEDICINE infrequently occur. These generally have as a nucleus some undigested substance, as hair, thread, fragments of bone, or the pits or husks of fruit, and an external coating of calcium or magnesium phosphate. They are often as large as a hen's egg. Foreign bodies of every description may be swallowed and pass to the intestine, or they may be introduced into the rectum and produce obstruction. The most common of these are coins, nails, stones, pins, buttons, and artificial teeth ; but spoons, forks, arid other large articles have been found. Symptoms. — ((^) Acute Obstruction. — The usual symptoms of acute obstruction are constipation, abdominal pain, tympanites, and tumor. At the beginning of the obstruction, several loose dejections often occur, but a complete stoppage follows, often so complete that neither fluid nor gas can pass it. Pain in the abdomen is an early symptom and often develops suddenly. It is at first colicky, but soon becomes intense and continuous. In intussusception the pain is more gradual in onset and it may have the character of tenesmus. Localized tenderness may be present, but it is not characteristic. Vomiting is a constant symptom and it generally follows immediately after the initial pain. It may be preceded by eructations of gas. The contents of the stomach are first brought up, then a greenish, bile-stained fluid, and finally, by the third day, a feculent, brownish liquid (stercoraceous vomiting). The solid contents of the large intestine are probably never carried up, but the fluid contents may pass the ileocecal valve and appear in the vomit. There are frequent efforts at the evacuation of the bowel, with the dis- charge of only a little blood-stained mucus. Tympanites and abdominal distention become extreme when the large bowel is obstructed. They are less pronounced in intussusception or when the obstruction affects the upper part of the small intestine. A palpable tumor is more character- istic of intussusception than of other forms of obstruction. The tumor may be felt in the rectum or through the abdominal wall, often in both locations, and, as a rule, during the first two or three days of the ob- struction. It has the form of an elongated cylinder or sausage-like mass. When it reaches the rectum, a peculiar relaxation of the anus is often observed. Constitutional symptoms are generally well marked. There may be slight fever after the first day of strangulation, but collapse is common, and the temperature may then be subnormal. When peritonitis develops, the temperature generally rises, the pulse becomes rapid and feeble, there is incessant thirst, and the tongue becomes parched. The urine is of high color and scant when vomiting is excessive; it may be suppressed when the obstruction is in the upper bowel. , It often contains albumin and indican. Hiccough is sometimes a troublesome symptom. (<^) Chro7iic Obstruction. — Constipation of long duration is a constant symptom in this condition. When the obstruction is due to fecal ac- cumulation, the dejections usually become less and less frequent for a period of several weeks, possibly for months. The obstructing mass is sometimes channeled in such a manner as to permit a part of the con- tents of the bowel above to pass through, and the patient may thus have evacuations at regular intervals. The bowel may become extensively eroded or ulcerated, and a fatal perforation or peritonitis may occur without complete obstruction. Sometimes an evacuation does not occur INTESTINAL OBSTRUCTION 501 once in a week, especially in old persons, and yet little discomfort is ex- perienced. There may be frequent mucous discharges and attacks of nausea and vomiting. Finally the abdomen becomes much distended and severe pain develops. Feculent vomiting ensues as the obstruction be- comes complete. The hardened mass of feces may be felt through the rectum or abdominal wall as a large, slightly movable tumor. \^^en the obstruction is due to stricture or tumor, the pain corresponds to the location of the obstruction. Anemia and emaciation are common. The case generally terminates fatally with the symptoms of acute obstruc- tion, but of more than the usual duration. Death may, however, result from exhaustion, without complete arrest of alvine evacuations. Diagnosis. — An early diagnosis of the condition is important. It is necessary to take into consideration the situation of the obstruction, its nature, and the exclusion of other conditions which lead to error. The situation of obstruction is revealed, as a rule, by the history of the case, inspection and palpation of the abdomen, and examination of the rectum. Inspection may reveal the part obstructed through the character of the distention and the location of peristaltic movements when visible. When the obstruction is low in the large bowel, the colon may stand out prom- inently and a tumor may sometimes be felt, but the entire abdomen is often distended. Feculent vomiting is absent, at least until late. With the obstruction in the region of the ileocecal valve, the distention is greatest in the umbilical region, as a rule, and the feculent vomiting ap- pears early. The folds of the small intestine may be thrown into ladder- like prominences by the increased peristalsis. When the duodenum or jejunum is obstructed, the distention is usually confined to the upper part of the abdomen, the urine is suppressed, fecal vomiting does not occur, but collapse develops early. In obstruction involving the large bowel, digital examination of the rectum may reveal it. Examination through the vagina is often useful. When these methods fail, the bowel should be distended with warm water, with the aid of an anesthetic if necessary, the patient lying on his back or right side with the hips well elevated. The water should be allowed to flow in slowly, especially after the first or second day, from a fountain syringe at a height of not more than three feet, for the bowel may be ruptured by too great pressure. The quantity of fluid that can be introduced sometimes reveals the situa- tion of the obstruction. The adult colon should hold six quarts, the rectum three pints. The capacity of the infant colon is about three pints. Inflation with air is sometimes practiced, but it is a less satisfac- tory method. The nature of the obstruction is usually more difficult to determine than its location. The statistics already given are of much service in this respect. The character and location of the pain and the presence or absence of fever are of little diagnostic importance. A majority of cases are due to strangulation or intussusception. The former is a condition of adult life, the latter of childhood. In strangulation the history is important with reference to former attacks of peritonitis or a laparot- omy; a tumor is seldoni present. Intussusception is characterized par- ticularly by tenesmus and frequent small, bloody, mucous dejections. The sausage-shaped tumor is usually felt in the region of the trans- verse colon. Acute obstruction of the large intestine is generally due to 502 PRACTICE OF MEDICINE intussusception, volvulus, a tumor, or stricture. The first of these is practically eliminated after childhood. Volvulus can seldom be diagnosti- cated, but its frequent location at the sigmoid flexure should be remem- bered. Tumors may be recognized by rectal examination or abdominal palpation. Stricture is of slow formation, giving a history of increasing constipation for a week or more. Impaction of feces is more common in old persons, and the mass can be felt in the rectum or along the course of the colon. Its shape can generally be altered by external pressure. Obstruction by gall-stones is usually indicated by a history of repeated attacks of gall-stone colic. Vomiting occurs early and jaundice is some- times observed. Hernia. — Careful examination should always be made to exclude pos- sible hernial strangulation, even when no external signs exist. Appendicitis sometimes simulates obstruction, but it is generally recog- nized by the intense localized pain and tenderness, with fever. Peritonitis is characterized by great abdominal tenderness, an eleva- tion of temperature, but tumor and feculent vomiting are absent. Blows on the abdomen and prolonged laparotomy are sometimes fol- lowed by obstinate constipation, but the other symptoms of obstruction are absent and the history of the case explains it. Persistent constipatio7i occurring in connection with floating kidney, renal or hepatic colic, and other conditions, especially when tympanites also develops, may arouse suspicion of obstruction, but the history of the case, the character of the abdominal distention, the absence of tumor, and the action of large enemata usually remove all uncertainty. Prognosis. — This depends largely upon the character of the obstruc- tion and the promptness of the treatment. Obstruction from strangula- tion is usually fatal unless an early resort to surgery is had. Relief sometimes occurs spontaneously or follows treatment. Intussusception generally proves fatal from the third to the fifth day, but recovery is sometimes secured. Obstruction by gall-stones or fecal accumulation is much less fatal. Treatment. — General. — Purgatives must never be administered. The vomiting and pain may be greatly relieved by lavage of the stomach. When the suffering is intense, however, morphin should not be withheld, although it is claimed that it obscures the diagnosis. It sometimes renders a thorough examination less difficult, because less painful. The tympanites may be reduced by turpentine stupes. All food should be withheld, except as it can be administered by the rectum. Special Treatment. — The treatment of nearly all cases of acute ob- struction is surgical, but, to be of benefit, the operation must be made within the first three days, on the first or second day if possible. When the diagnosis cannot be determined so early, an exploratory incision is generally indicated. Intussusception can sometimes be overcome on the first day without operation, through the injection of a large quantity of water or olive oil. The patient should be anesthetized, and his body held in an inverted position. The colon is then filled, and the reduction of the invagination may be assisted by kneading the abdomen or by shaking the patient violently. The method may be repeated if necessary, but after the first day it is not devoid of danger, and the case should be submitted to the surgeon. CONSTIPATION 503 Chro7iic obstruction, before it has become complete, may be treated by irrigation and the administration of the mildest laxatives. When it has become complete, it should be treated as an acute case, and an operation may be required. Enterectomy or the establishment of an artificial anus may be found necessary. CONSTIPATION. COSTIVENESS. Definition. — Prolonged retention of feces, or the habitually difficult or infrequent evacuation of the bowels. Etiology. — In many cases there appears to be a constitutional prone- ness to constipation, and an entire family is often thus affected. It is probably a result of a similarity in habits of life and disregard of hy- gienic and dietetic rules acquired in childhood, and not a result of heredi- tary influences. Age and Sex. — Constipation may occur at any age, but it is especially frequent after middle life, when the vital functions become sluggish and muscular exercise is neglected. It is not uncommon in infants, even from birth. Women are much more subject to it than men, probably to a great extent on account of the greater capacity of the pelvis, which permits distention of the rectum without discomfort. It is often caused by retroversion of the uterus and tumors within the pelvis. Repeated pregnancy and the menopause favor its development. Habits. — Sedentary habits and mental application induce constipation largely through inducing neglect of the natural calls for evacuation. Neglect of physical exercise removes one of the influences which maintain the flow of bile and increase the peristaltic movements of the intestine. Railroad travel often induces constipation. Diseases. — Any condition of ill health is liable to produce constipation. It is generally associated with anemia, often with neurasthenia, hysteria (nervous constipation), chronic disease of the heart, stomach, intestines, or liver. Stricture of the esophagus or at the pylorus induces it by pre- venting the passage of the food into the intestines. Central nervous and mental diseases, especially insanity, chronic myelitis, and destructive lesions of the cord, are commonly attended with obstinate constipation. The condition prevails in the acute fevers, except those which affect di- rectly the intestinal tract, as cholera and typhoid fever. Diet is one of the most important factors. Food which leaves too little or too much residue, improperly prepared or insufficiently masti- cated food, particular articles, as cheese, nuts, raw vegetables, and cer- tain beverages, as milk, tea, and some of the sour wines, induce constipa- tion to a greater extent in some individuals than in others. The drinking of an insufficient quantity of water is a common cause. The loss of fluid by profuse sweating in hot weather, and lactation, are regarded as influential in many cases. Diabetics are usually constipated. Symptoms.— Const\\)a.t\on often exists for a long time without produc- ing other abnormal manifestations than the condition itself, but sooner or later in most cases definite symptoms arise. These have been attrib- uted by some writers to copremia, the absorption of poisonous matter 504 PRACTICE OF MEDICINE from the retained feces. Different individuals are affected quite differently. Some experience much discomfort from constipation of a day's duration, while others are not at all inconvenienced by retention for a week, and complain of illness only on the days on which the bowels move. The most constant symptoms are headache, lassitude, physical and mental debility, and inaptitude for work. Hypochondriasis, hysteria, melan- cholia, seminal emissions, enuresis of children, and many other disorders have been attributed to constipation. The appetite is generally lost, the tongue becomes heavily coated, the breath foul, and the patient suffers from a sense of abdominal weight and distention. Periodic attacks of slight fever are not uncommon. Neuralgia is often complained of, espe- cially that of the sacral nerves due to the pressure of the fecal accumu- lation in the sigmoid flexure. In women the distention of the rectum is often a cause of painful menstruation. Hemorrhoids are often induced by the pressure of the hemorrhoidal veins; ulcers, by the pressure and infection of the intestinal mucosa; and fissures, by the passage of the hardened masses. Attacks of cramps and abdominal distention usually occur at variable intervals, and diarrhea not infrequently alternates with the constipation, especially when a hardened fecal accumulation becomes channeled in such a manner as to permit the escape of the contents of the upper bowel. The patient often acquires a sallow, muddy complexion, and acne or eczematous eruptions may appear. Constipation in infants is often due to improper food, milk that is too rich in casein or deficient in fat. Failure to give the infant an occa- sional drink of water is a common cause of it. Sometimes, no doubt, it is a result of feeble digestive power. It has been caused in some in- stances by congenital stricture, a constricting band or other structural defects. The condition is common and often very difficult of relief The principal symptoms are colic,' abdominal distention, and sometimes vomiting. Prognosis.— T\A% depends chiefly upon the cause and duration of the afi"ection and the physical condition of the patient. Serious results are generally due to gross neglect on the part of the patient. Constipation of infants usually disappears immediately upon the commencement of a mixed diet. Treatmeni. — General. — Constipation seldom develops in those who have acquired the habit of evacuating the bowels at a fixed hour every day. The importance of this habit is not sufficiently recognized. And there is no more important measure for the cure of constipation. The patient should retire to the closet at a stated time, even when there is no desire. He should sit and wait, without straining, for probably ten minutes. If a spontaneous movement does not then occur, an enema of cold water, a weak salt solution, or soap-suds may be employed. Gly- cerin, 3 j in a pint of water or in a suppository, is more active. Individ- uals of sedentary habits should resort to systematic exercise, walking in the open air, or moderate horseback or bicycle riding. Those with pendulous or relaxed abdomens should wear an abdominal band, and practice calisthenics with especial reference to the strengthening of the abdominal muscles, swinging the arms upward and bending to touch the floor. If a gymnasium is accessible, they should use the overhead pulleys and the pumping apparatus. Massage of the abdomen is useful in most HEMORRHOIDS 505 cases, and the "cannon-ball," weighing 5 or 6 pounds, may be rolled over the abdomen, following the course of the colon. Dietetic— The diet must be regulated to suit the individual case. Persons whose food has been too coarse should modify it so as to avoid such articles. In many persons coarse food, as Graham or brown bread and oatmeal, act as laxatives. Fruit, especially an orange or an apple before breakfast, and such vegetables as lettuce, spinach, onions, and to- matoes are beneficial in many cases. Salads containing much oil are wholesome. Molasses and honey are laxative, and some persons can regulate the bowels by eating a piece of taffy every day. An important element of treatment in some cases is the regulating of the time of meals and the taking of sufficient time for thorough mastication of the food. The patient should learn to drink plenty of water. A glass of cold water immediately before retiring and on rising in the morning is often bene- ficial. Hot water is more serviceable in some cases if taken morning and evening or before each meal. Strong coffee, beer, cider, and carbonated waters are laxative to some persons. ■Medicinal. — Drugs should be avoided if possible. When they are deemed necessary, a small dose of a saline laxative, sodium or magne- sium sulphate or sodium phosphate, should be given in the morning be- fore breakfast, or the fluid extract of cascara sagrada, 3 ss to j (1.8—3.6), or the compound licorice powder, 3 j (^z-^^ ^ at night. The 3-grain cascara pill is usually preferred to the bitter fluid extract. Many other drugs, singly or combined, especially aloes, colocynth, rhubarb, and podophyllin, are employed, and the addition of the extract of belladonna, gr. 1-12 (0.005), and nux vomica, gr. 14; (0.016), to the prescription is recom- mended. Constipation in infants can often be overcome by giving an occasional drink of water, allowing the infant to suck a few drams from a linen rag, by administering two or three drams of cream in water before each nursing time, or by adding it to the artificial food. Barley-water or oatmeal-water acts well in some cases. A small glycerin or soap sup- pository is generally efficient for moving the bowels, or a small injection of cold water may be employed. For older children the effervescent magnesium citrate solution is generally agreeable, but there is no better laxative than castor oil. Children old enough to eat fruit seldom require drugs. HEMORRHOIDS. PILES, EMERODS. Definition.— A. varicose condition of the external hemorrhoidal veins, producing painful swellings just within or around the external margin of the anus. When the swelling affects the veins beneath the mucous mem- brane within the external sphincter, the protrusions are known as inter- nal hemorrhoids ; when those beneath the skin, they are external hemor- rhoids. £f/o/o5'/.— Hemorrhoids occur most frequently in middle and advanced life; they are rare before puberty. Both sexes are affected, but men more frequently than women. The common cause is venous stasis. This may be due to a local condition, especially to the pressure of accumu- 5o6 PRACTICE OF MEDICINE lated feces in habitual constipation, to stricture of the rectum, to tumors of the rectum, prostate, uterus, or ovaries, or to more remote obstruc- tion as that of the portal vein in cirrhosis of the liver, or general venous stasis in the chronic dilatation of valvular disease of the heart. Preg- nancy often induces them. Excessive indulgence in alcohol, and, more remotely, all the influences which lead to constipation, favor the develop- ment of hemorrhoids. Symptoms. — These vary with the character and severity of the disease. Internal piles often exist without causing inconvenience and may not be recognized until an erosion and bleeding occur in the passage of a hard- ened mass. In many cases, however, the hemorrhoidal mass is extruded with every act of defecation. Free bleeding often occurs, and this, in severe cases, produces anemia. Rarely, hemorrhage takes place indepen- dently of defecation. A considerable quantity of blood may be lost ex- ternally, or it may be retained within the rectum and discharged with the stool without the patient's knowledge. Such cases may be recognized only in a search for the cause of an obscure anemia. As a rule, how- ever, only a small quantity of blood is lost, perhaps only enough to streak the fecal mass as it passes. A sense of fullness, itching, burning, or pain often accompanies severe cases, especially during and after defeca- tion. In the worst cases the pain may be reflected to the loins or it may radiate down the thighs and legs to the soles of the feet. In cases of long standing an anesthetic condition of the anus is sometimes pro- duced which renders the patient unable to recognize the completion of defecation, or there may be a constant desire for evacuation. Vesical irritation is sometimes an aggravating symptom. Constipation is usu- ally kept up through the patient's dread of defecation. No little distress is often occasioned by the inability to retain the hemorrhoidal mass within the sphincter ; the slightest exertion, even walking, a cough, or a sneeze, will sometimes cause it to protrude and possibly to bleed. Vari- ous reflex symptoms, as hypochondriasis and melancholia, are more or less directly a result of the condition in some cases. External hemorrhoids cause inconvenience more than suffering, except when they become eroded through friction. Prognosis. — Serious results are seldom produced, but when the condi- tion is attended with profuse hemorrhage, the patient's health may be greatly impaired and a coexistent disease may be aggravated. Treatment.— Tht curative treatment of internal hemorrhoids is surgi- cal, and every case should be submitted to the surgeon unless the condi- tion of the patient precludes the administration of an anesthetic. Such cases are often encountered by the physician. The indications are, to overcome the constipation and to relieve symptoms as they arise. Relief of the irritation is generally afforded by suppositories containing opium extract and powdered nutgalls with iodoform or ichthyol. A condition of comfort almost amounting to cure may then be obtained from the habitual use of an enema of cold water, or very hot water immediately before defecation. This should be done at a fixed hour every day. The best time in many cases is just before retiring, since protrusion of the hemorrhoids may otherwise follow. The quantity of water should not exceed a pint, as a rule; just enough to relieve venous engorgement and stimulate peristalsis. It should not flow from a height of more than DILATATION OF THE COLON 507 three feet, for rectal dilatation may be induced by too large a quantity or too great pressure. The patient must sometimes be taught to reduce the protrusion. This is generally done without difficulty, after bathing it with cold water, by pressing it upward with the fingers while making an expulsive effort. When, however, the piles become strangulated, cocain or general anesthesia is sometimes necessary if permissible. Ex- ternal piles are often cured by an ointment of gallic acid, gr. x in an ounce of vaselin. Incision and evacuation of the clot are better. ENTEROPTOSIS. GLENARD'S DISEASE. Deffnition. — An abnormal descent of the intestines in the abdominal cavity, usually associated with prolapse of the other viscera (visceropto- sis). The terms used to describe the descent of the individual organs are : Gastroptosis, descent of the stomach ; splenoptosis, descent of the spleen; coloptosis, descent of the colon. Displacement of the liver is very rare. Etiology. — The condition may be due to congenital laxity of mes- enteric attachment, but it is more common in young women, especially in anemic neurasthenics; and in another class of cases, it is due to a removal of the support of the abdominal wall as a result of constipa- tion, pregnancy, ascites, or ovarian cyst. Symptoms. — In some cases there is little or no disturbance, while in others the patient experiences a constant abdominal discomfort. Con- stipation and digestive disorders are present, and these may lead to emaciation, debility, and melancholia. The transverse colon can some- times be felt just above the pelvis, and the acute bending of it may occasion more or less complete obstruction. Its location can readily be determined by artificial inflation. Treatment. — This is directed to (i) the relief of constipation, (2) support of the abdomen by a properly adjusted abdominal bandage, and (3) the general condition of the patient, particularly the relief of the neurasthenic state. When the abdominal walls are much relaxed, massage and calisthenics are advantageous. DILATATION OF THE COLON. Etiology. — The causes are (i) increased pressure, distention, from within the bowel, (2) diminished resistance on the part of the intestinal walls, and (3) obstruction. Congenital dilatation is also recognized (Hirschsprung's disease). 1. The increased pressure from within may be produced by either gaseous or solid contents. The dilatation is at first temporary, but, often repeated, it leads to permanent enlargement. 2. The diminished resistance on the part of the abdominal wall may result from (^) the acute distention, (/-) a paretic condition of the muscular coat which may have originated in a general enfeeblement of the system through anemia and malnutrition, or (<:) a prolonged use of cathartics. 5o8 PRACTICE OF MEDICINE 3. Obstruction is generally due to Qa^ congenital narrowing of the lumen, (Z^) acquired stricture, (r) foreign bodies, (^) impaction of feces or gall-stones, (,?) incomplete twist, especially at the sigmoid flexure, or (/") pressure from without, by tumors or displaced organs. Morbid Anatomy. — The colon is sometimes enormously dilated and its wall may be extremely thin. In less pronounced cases, the walls may appear normal or the muscular layer may be hypertrophied. In the case of the "balloon man" recorded by Formad, the colon was from 15 to 30 inches in circumference and with its contents weighed 47 pounds. Symptoms. — These are more prominent when the dilatation is acute; when the dilatation is gradual, it may occasion comparatively little discomfort. In a severe case cardiac palpitation and dyspnea or fatal embarrassment of the heart and lungs may result from the upward pressure. Obstinate constipation is the rule, and in cases caused by obstruction frequent spells of vomiting occur. Percussion reveals an in- creased area of colon tympanites, particularly after artificial distention. Diagnosis. — This is determined by the history of the case and a careful examination as to the cause of the abdominal distention. The condition is to be differentiated, as a rule, from gaseous distention of the peritoneal cavity due to perforation of typhoid, gastric, or other ulcers. Such perforation, however, is announced by sudden acute pain and collapse. The tympanites extends over the area of normal hepatic dullness. Perito- nitis is quickly developed, with elevation of temperature and diffuse tenderness. Treatment. — i. Acute gaseous distention can often be relieved by the passage of the rectal tube, giving vent to the gas. Turpentine stupes are beneficial. 2. When due to fecal accumulation, enemata containing ox-gall, and restriction of diet, especially the exclusion of starchy food, may overcome the condition. Laxatives should be regularly adminis- tered, and antifermentatives, salol, bismuth subgallate, or betanaphthol, may prevent a recurrence. 3. When anemia and malnutrition are pres- ent, the administration of iron and strychnin is indicated, and abdominal massage may prove beneficial. 4. Cases due to obstruction often require surgical treatment — the making of an artificial anus or excision of a portion of the bowel. NEUROSES OF THE INTESTINE. NERVOUS DIARRHEA. Definition. — A functional motor disturbance of the intestine, producing diarrhea. Etiology. — The condition is encountered in either sex and at any age, but it is more common in nervous or hysterical women at the menopause or in connection with disease of the generative organs. It is not infre- quent, however, in young women. Anemia, malnutrition, and disordered gastric digestion are predisposing causes. Back of the disorder there is very frequently a strong emotion, as of grief, hope, or fear. Disappoint- ment, bereavement, fright, anger, and pain induce acute attacks, which may prove persistent. The aftection is sometimes observed in connection with nervous affections, as exophthalmic goiter and locomotor ataxia. NEUROSES OF THE INTESTINE 509 In the latter disease it sometimes assumes the form of persistent crises. Cases in which diarrhea follows the eating of certain articles of food, harmless to other people, are probably of this nature. Symptoms. — The only symptom in many cases is diarrhea. This is often limited to two or three watery, pasty, or scybalous passages in the morning. In other cases the ingestion of food is immediately followed by an imperative demand for evacuation. Intestinal rumbling or gur- gling is often present and a cause of embarrassment to the patient. The affection often runs an intermittent course, improvement being broken by the occurrence of any nervous irritation or worry. Diagnosis. — This is based on the history, the character of the diarrhea, and the nervous condition of the patient. It is to be differentiated chiefly from acute enteritis. In the latter affection, the attacks often occur at night, they are attended with pain and numerous evacuations, often with vomiting, and usually follow a definite error in diet. Treatment. — All treatment is useless which fails to remove the cause. On this account a change of scene, removal from the cause of worry, and diversion from sorrow are more important than drugs. Relief of the neurasthenic condition, by whatever means, is promptly followed by ar- rest of the diarrhea. Astringents are seldom beneficial, and opiates should not be employed. The bromids, ammonium valerianate, or asa- fetida is beneficial in some cases. ENTERALGIA. Colic, Intestinal Neuralgia, Intestinal Cramps, Enterospasm, Enterodynia. Definition.— A disturbance of the sensory filaments of the intestinal nerves, producing sharp pain, often accompanied with localized spasm of the muscular coat of the intestine. Etiology.— T\it condition occurs at any age, very frequently in infancy and childhood, and it is more common in women. 1. Fredisposi/ig Influences. — As in gastralgia, there is often a consti- tutional disorder back of it, sometimes apparently a hereditary pre- disposition; a neurotic temperament, improper hygiene, poor health, chronic disease or gastric indigestion, business care and worry, or mental strain. 2. The exciting causes are : Irritating intestinal contents, toxemia, or reflex excitation. (rt;) In the infant, the meconium, if too long retained, may cause irritation (colica meconialis) ; in the adult the food may be coarse and irritating in quality, or decomposed, or the chyme may lack gastric digestion. Unripe fruit, cold and acid drinks and food, are common causes. Retained scybalous masses, foreign bodies, or an accumulation of gas may cause colic through pressure or stretching of the intestinal wall. (Ji) The blood may contain bacterial toxins which are irritating, as in cholera and malarial cachexia, or such poisons as uric acid, lead, copper, or arsenic. (r) The reflex causes are many. They include organic disease of the brain or cord and the crises of locomotor ataxia, hypochondriasis, and 5IO PRACTICE OF MEDICINE hysteria. Chilling of the surface of the body produces enteralgia in some persons. Symptoms. — Pain is the principal symptom. This is usually referred to the umbilical region, from which it may radiate. Sometimes it begins in several locations at the same time. It is generally periodical and it may be a dull aching or of a sharp, lancinating character, usually with increasing intensity. Tenderness may be complained of, but pressure may give relief, and the patient often lies on the stomach or with the knees drawn up, or bends over a chair. The abdomen is either tympanitic or retracted. The peristaltic movements of the bowel may be visible. Rum- bling noises often accompany the attack. In severe cases the body is bathed in a profuse sweat and the face becomes pale. Nausea is some- times complained of; vomiting is unusual. The pulse is generally tense, but slow. Reflex symptoms may be observed, as palpitation, dyspnea, hiccough, rectal or vesical tenesmus, strangury, priapism, vertigo, syn- cope, cramps of the voluntary muscles, occasionally convulsions. The attack may last only a few minutes, or it may continue for hours or days, finally ceasing suddenly or gradually. Diagnosis. — The condition is to be differentiated : (i) From peritonitis by the absence of fever and marked abdominal tenderness; (2) from appendicitis by the absence of tenderness at McBurney's point, rigidity of the right rectus, fever, and induration; (3) from intestinal obstruc- tion by the absence of localized tenderness, obstinate constipation, and stercoral vomiting; (4) hepatic and renal colic by the different char- acter and different location of pain. (5) Rheumatism of the abdominal walls is rare; the pain is superficial and aggravated by pressure or movement. (6) In lumboabdominal neuralgia the pain is unilateral and there are generally characteristic tender points. The prognosis is generally favorable, but relapses usually occur, unless the cause can be removed. Treatment. — This is directed to the relief of pain and to the removal of the cause. In severe cases, morphin must be injected hypodermically. Mild cases are generally relieved by the administration of spirit of peppermint or compound spirit of sulphuric ether, with camphorated tincture of opium, chloroform or tincture of ginger, capsicum or camphor, or various combinations of these remedies. Hot poultices, fomentations, turpentine stupes, and the hot-water bag are serviceable in the intervals. Removal of the cause embraces : Qa) Relief of constipation by enemata and laxatives; (/;) exclusion of irritating articles from the diet; (r) remedies to assist digestion, when any of these causes are present. (^) WTien a tendency to neuralgia is recognized, arsenic or quinin should be employed. (^) A gouty, rheumatic, neurotic taint and the various diseases named as predisposing causes must be treated. MUCOUS COLITIS. Membranous Colitis, Mucous Colic, Mucous or Tubular Diarrhea. Definition.— A. chronic secretory neurosis of the intestine characterized by the discharge of mucous shreds or long tubular mucous casts of the interior of the colon. DISEASES OF THE MESENTERY 511 Etiology. — This rather rare affection may occur at any period of life, from childhood to old age, but is more prevalent in women, particularly neurotic, hysterical, or neurasthenic subjects and those debilitated by organic nervous disease. The attack is commonly induced by mental emotion or the eating of improper food. Morbid Anatomy. — No anatomical lesions are present. The mucous shreds and casts, when detached, leave the surface of the mucosa in a normal condition. The casts consist of mucin, not fibrin. Symptoms. — The disease is generally marked by periodical attacks of enteralgia accompanied with abdominal tenderness most marked at the splenic flexure of the colon, and tenderness, during or after which the characteristic shreds or casts are discharged. These may accompany defecation or pass independently of it. Pain and tenesmus often occur during the course of the disease, without the discharge of casts. Disor- dered digestion sometimes precedes the attack for a few days. The pain may be severe, and pronounced nervous manifestations, hysterical in nature, may accompany the attack or develop upon the discovery of the casts. Constipation is usually present. Slight hemorrhage rarely ac- companies the extrusion of the casts. Fever is absent. Emaciation results from long-continued colitis. The attack may last from a day to a week or longer, and the disease may persist, with variable intervals, for many years. Diagnosis. — The casts should be carefully examined, microscopically if necessary, in order to exclude fragments of tapeworm or undigested remnants of food, as the skin of sausage, husks of various vegetables, or the pulp of orange or other fruit. The differentiation from the other painful affections of the abdomen is the same as that of enteralgia. Prognosis. — Complete cure can sometimes be secured through improve- ment of the general health, but the disease is a stubborn one. Death has occurred during the attack. Treatment. — The treatment is for the most part that of the underlying condition. The painful attack should be relieved, if possible, with the carminatives and local applications recommended for enteralgia. Mor- phin should not be given, for a habit is readily acquired by these pa- tients. Constipation is to be relieved and the diet so regulated as to avoid irritation. Intestinal Sand (Sable Intestinale).— It occasionally happens that large quantities of material resembling sand or gravel pass from the bowels. The sandlike particles generally consist of vegetable sclerenchy- matous matter, sometimes of the seeds of such fruit as raspberries or blackberries. Very rarely biliary sand is discharged. True intestinal sand, consisting of the carbonates and phosphates of calcium and mag- nesium, has been observed. C. H. Bedford, England, reports a case of this character, associated with colitis and constipation, in an extremely gouty woman of 44 years. DISEASES OF THE MESENTERY. The mesentery is seldom the seat of primary disease. The secondary affections are considered in connection with the diseases that bear a causal relation to them, (i) Hemorrhage is rare and usually associated 512 PRACTICE OF MEDICINE with hemorrhagic pancreatitis. (2) Embolism and thrombosis of the mesenteric arteries are occasionally encountered. (See Hemorrhagic In- farction of the Intestine.) (3) The mesenteric artery is one of the least frequent sites of aneurism. (4) The mesenteric glands are enlarged in typhoid fever, tuberculosis, syphilis, and occasionally in Hodgkin's dis- ease and other affections. (5) Malignant growths, hydatid, chylous, and other cysts sometimes occur. DISEASES OF THE LIVER. ANOMALIES OF FORM AND POSITION. Malformation may be congenital or acquired, (i) Congenital mal- formation is rare. The only examples of it are seen in livers showing ((2) disproportion in the size of the lobes, or (/;) lobulation, which is generally a result of hereditary syphilis. (2) Acquired malformation results from a great variety of influences, as: ((1:) The corset or lacing liver of women. It is characterized by a trans- verse groove running across the right lobe in a position corresponding to the lower margin of the ribs. In extreme cases the furrow is narrow and deep and the compressed portion is transformed into fibrous tissue with hardly a vestige of hepatic structure. The blood-vessels are to a great extent obliterated. The lower margin of the organ may rest be- tween the umbilicus and crest of the pubis. Occasionally the liver has a pyramidal shape, with the apex downward. ((^) Deformity of the verte- hrae or ribs, and tumors of the surrounding organs or structures, frequent- ly cause an alteration of the shape of the liver, (r) The alterations of size and form due to disease will be referred to in their proper relations. Symptoms may be absent. In some cases there is a sensation of drag- ging or pressure. The part of the liver below the constriction becomes inflamed, swollen, and painful. Vomiting, prostration and jaundice oc- casionally occur, especially after unusually tight lacing. The prominent lower portion of the liver may be mistaken for a neoplasm, amyloid disease, or passive hyperemia. Malposition. — The liver may be displaced upward, downward, or lat- erally, and the displacement may be congenital or acquired. (i) Congenital displacement is met with : (^?) In the rare condition of transposition of the viscera, when it occupies a position on the left side corresponding to its normal position on the right. (^) The organ may be found in a hernia of the diaphragm or abnominal wall. There ma,y be no interference with its function in these cases. (^) The so- called suspensory ligament may be of unusual length, permitting descent or lateral movement. In extreme cases the organ lies in the epigastric region or sinks to the lower part of the abdominal cavity, (2) Acquired Displacement.— (^a^ The liver may be raised by ascites, abdominal tumor, or intestinal distention, (Ji) It may be lowered by pleuritic effusion, emphysema, or an intrathoracic tumor of large size, rarely by extensive pericardial effusion or subphrenic abscess. Symptoms.— Tension and dragging are the usual symptoms. There may be occasional attacks of pain, which is often referred to the right shoulder. DISEASES OF THE LIVER 513 Diagnosis. — The condition is apt to be confounded with various neo- plasms of the stomach, ovary, uterus, kidneys, or with hydronephrosis or pyonephrosis. The diagnosis is generally based upon the absence of hepatic dullness in the usual place, but this sign may mislead when cir- rhosis or fatty degeneration is present. Treatment. — The liver can generally be replaced without much diffi- culty. A suitable bandage should then be worn in order to prevent recurrence of the displacement. DISTURBANCES OF THE HEPATIC CIRCULATION. Anemia. — It is assumed that anemia of the liver accompanies the general deficiency of blood after profuse hemorrhage and in the primary anemias. The liver is found to be almost bloodless after death in these conditions as well as in amyloid disease, fatty degeneration, and other conditions. There are no clinical manifestations, however, through which the condition can be recognized. Hyperemia of the liver is a condition common to many diseases. It may be either active or passive. 1. Active Z(>;^^/-^?«/« (Active Congestion). — (^d) A physiological hyper- emia of the liver is believed to occur after every full meal, owing to the increased activity of the portal circulation, especially if alcohol be ingested. In either case the condition is transitory, but in the gor- mand or drunkard it leads to permanent changes, especially to cirrhosis. (/') Other causes of the hyperemia are the toxins of disease, espe- cially those of malaria, dysentery, typhoid or typhus fever, erysipelas and yellow fever, exposure to cold, amenorrhea, and the suppression of habitual hemorrhoidal bleeding, and (^) the toxic products of intra- intestinal fermentation and such intoxications as accompany gout and diabetes. The symptoms are generally due to associated catarrh of the stomach, duodenum, or bile-ducts. There may be a sense of fullness or pain, slight enlargement, and tenderness of the liver; less commonly, slight jaundice, enlargement of the spleen, and a bilious diarrhea. Treatment. — For the local condition a calomel or saline purge is in- dicated. Hot or cold applications to the hepatic region relieve the abnormal sensations. Beyond this the treatment is that of the under- lying disease. 2. Passive Hyperemia (Chronic Congestion of the Liver, Nutmeg Liver). — Etiology. — This condition results from obstruction of the flow of blood from the liver, (iz) The common seat of obstruction is in the heart. Any form of uncompensated valvular disease may excite it, but diseases of the right heart act more directly. It may result also (J)) from obstruction of the pulmonary circulation as in emphysema, chronic interstitial pneumonia, or from deformity of the spine or exten- sive pleuritic effusion ; (r) from obstruction of the ascending vena cava or the hepatic vein when compressed by an aneurism or other tumor situated anywhere in its course. (^) The condition has rarely been caused by valves or other projections within the veins or by the presence of constricting bands. Morbid Anatomy.— The liver is uniformly enlarged, of a dark red or 33 514 PR.\CTICE OF MEDICINE purple color, and blood flows freely from a cut surface. In a case of long duration, however, the organ may appear but slightly, if at all, enlarged, owing to contraction of the new formed connective tissue (atrophic nutmeg liver). Microscopic examination reveals dilatation of the central vein with thickening of its walls, hyperlasia of the fibrous tissue, with pigmentation of the cells in the internal zone and fatty infiltration or degeneration of those in the outer zone. The spleen is usually enlarged, the pancreas larger and firmer than normal, and the kidneys may be in a state of passive congestion. Symptoms. — The condition seldom attracts attention until late in the history of the case. There may be a sensation of weight and full- ness or even pain in the hepatic region. Gastrointestinal disturbances are common, and jaundice may develop. Hematemesis is occasionally observed. Clay-colored stools and dark urine containing bile pigments usually accompany the jaundice. Ascites and anasarca are common, but rather as manifestations of the cardiac than of the hepatic con- dition. Palpation reveals tenderness and enlargement of the liver. In extreme cases the entire organ pulsates. Treatment. — The treatment is directed solely to the affection causing the passive congestion, as a rule. It may sometimes be necessary to deplete the liver by purgation or to relieve pain through the methods referred to under Acute Hyperemia. DISEASES OF THE BLOOD-VESSELS OF THE LIVER. Hemorrhage.— Hemorrhage into the substance of the liver may result from (ecially after fatigue. Severe pain or reflex symptoms sometimes arise, apparently from a sudden change in the position of the aftected kidney. 2. Reflex Symptoms. — The reflex manifestations may be confined to the abdominal region, or they may be general. They are intermittent, as a rule, and may be intensified by any influence which aggravates the abnormal condition, as by a sudden change of the location of the organ. Reflex gastrointestinal disturbances are common. Nausea, MOVABLE KIDNEY 553 vomiting, indigestion, and constipation can often be distinctly traced to the renal displacement; but such conditions as gastric dilatation and icterus are probably no more than coincident conditions. Cardiac palpitation, anasarca, intestinal obstruction, and functional disorders of the uterus have been attributed to the pressure of a dislocated kidney. Dietl's crises are almost distinctive. They consist of sudden, sometimes periodical, attacks of sharp abdominal pain, with chill, fever, nausea, vomiting, and collapse, probably due, as Dietl thought, to compression or twisting of the ureter. They may be induced also by overindulgence in food or strong drink. During the attack the urine usually becomes highly colored and charged with uric acid and oxalates, sometimes con- taining also blood and pus. Albuminuria or hemoglobinuria may be present. The displaced kidney becomes swollen and tender. The com- pression of the ureter sometimes leads to permanent or intermittent hydronephrosis. The general reflex symptoms usually assume the form of hysteria, neurasthenia, or simple nervousness, with anxiety and melancholia, es- pecially pronounced for a time after the discovery of the tumor. Physical Examination. — The patient should be placed on the back, v/ith the head low and the abdominal walls thoroughly relaxed. Bi- manual palpation is then practiced with the left hand over the lumbar region behind the last ribs, and the right over the hypochondriac re- gion. The kidney, if sufficiently displaced, can be felt, as a firm, globular body, just below the margin of the liver. Sometimes it is possible to feel the lower edge of the kidney only when the patient takes a full inspiration. This is called a palpable kidney. If the entire organ can be felt and the finger passed above the upper margin of it during in- spiration, it is known as the movable kidney. If the organ can be de- pressed below the level of the umbilicus, it is designated a floating kid- ney. To this class belong those rare instances in which the kidney sinks into the pelvis. Diagnosis. — Few conditions are likely to be confounded with this after careful, thorough examination. A floating kidney is often momentarily suggested by a movable cancer of the pylorus, fibromata, or secondary carcinomata of the omentum or intestine, fecal impaction, tumors of the gall-bladder or ovary, and movable spleen. But the peculiar kidney shape, with notched edges, can seldom be mistaken, and still more sig- nificant is the peculiar feeling of nausea that is induced by pressure upon it. Treatment.— It is often advisable to withhold from the patient the na- ture of the condition, especially when the displacement is so slight as to be classed with the palpable or movable kidneys, and when it pro- duces no serious disturbance. When, however, painful crises occur, more or less radical measures may become necessary. Sometimes the organ can be replaced by taxis, and nothing more is necessary than rest in bed until the pain has subsided. Morphin must sometimes be administered. After a paroxysm the patient should avoid jolts and jars, lifting and other possible causes of the crises. It is often necessary to treat the neurasthenic condition of the patient rather than the renal condition. Relief often follows a decided gain of adipose tissue. Surgical measures are required in extreme cases. The kidney capsule may be stitched to 554 PIL\CTICE OF MEDICINE the abdominal wall (nephrorrhaphy), but the result is not always per- manent. Extirpation of the kidney is a more serious operation, often successful, sometimes fatal, and the loss of one kidney in itself is not always free from injurious effects. HYPEREMIA OF THE KIDNEY. Hyperemia may be active or passive, acute or chronic. Etiology. — Active hyperemia is always present in the early stage of acute paren- chymatous nephritis, and it is not always possible to distinguish clearly between a simple hyperemia and that of Bright' s disease. The former condition is frequently induced, however, by : (^a) The toxemia of the acute infectious diseases, probably the most frequent cause, or (^F) such irritant drugs as turpentine, cantharides, copaiba, carbolic acid, potassium chlorate, phosphorus, arsenic, and alcohol, (i-) It is supposed ,to occur in one kidney after sudden arrest of the function of the other. Morbid Anatomy. — The kidney is large, of dark red color, the cap- sule is tense, but not adherent, and blood flows from the cut surface. The columnar epithelium is cloudy and desquamating, as in acute ne- phritis. Symptoms. — The urine may be increased and of low specific gravity, or diminished and of higher specific gravity. Albumin and oxalates, sometimes blood, are found in it. The treatment consists in removal of the cause if recognized, rest in bed and milk diet for a few days. When the hyperemia is extreme, and especially if strangury or anuria develop, the hot pack and dry cups to the region of the kidneys are beneficial. Internal medication is not usually necessary, and diuretics may prove injurious. Passive Hyperemia. — Etiology. — This condition is induced ( attributes the disease to the presence of an excess of uric acid in the blood and tissues, and its deposit in the tissues to a deficient alkahnity of the blood-plasma and other fluids which normally hold it in solution. In an acute paroxysm this accumu- lation of uric acid is shown by a gradual diminution of the quantity eliminated by the kidneys for several days before and during the attack. The inflammation is beheved to result from a sudden deposit of urates in crystalline form in the tissues of the joints. Some writers believe that there is increased formation of uric acid as well as deficient elimina- tion. Ebstein concludes that the acid may be formed in unusual places, as in the muscles and in the bone-marrow. Kolisch thinks that the kidneys normally form uric acid, and that the disease develops only when the function of these organs is impaired. And, since he has found that ths xanthin bases are also increased in gout, he attributes the func- tional impairment of the kidneys to their action. Garrod, accepting the theory of uric-acid formation in the kidneys, holds that when uric acid is found in the blood it is as a result of its absorption from the kid- neys. It has been found, in support of Kolisch's theory, that the in- jection of xanthin and hypoxanthin into the blood is followed by struc- GOUT 589 tural changes in the kidneys similar to those of interstitial nephritis, certain nervous disturbances, high arterial tension, and ultimately arterio- sclerosis. Other recent investigators maintain, however, that the uric acid is derived from the nucleins, and that it is not an intermediate product in the formation of urea from the proteids. And from this theory some have inferred that the increased production is due to a destruction of leucocytes. It is unfortunate for all these theories, that attempts to produce the disease by the injection of uric acid into the blood or by preventing its elimination through the kidneys have been unsuccessful. It is well known that uric acid alone is harmless, even when in greater quantities than have ever been found in the blood of gouty persons. It is probable, therefore, that some other influence is also at work in the production of the disease. (2) The Theory of Nutritive Disturbance. — Ebstein in advancing this theory argues that there is a nutritive disturbance in the tissues, with necrosis, especially in the muscles, which leads to the production of uric acid in them and favors its deposit in the cartilages and connective tissue. Von Noorden attributes this tissue-change to the action of a special ferment. (3) Nervous Theory. — This theory supplements the uric-acid theory by attributing the faulty metabolism of the proteids to a failure of the nervous system to regulate the nutritive processes. Some writers go so far as to assume a derangement of certain hypothetical nerve- centers controlling the nutrition of the joints or the action of the liver. Some regard the disturbance as due to a neurosis, others to a neuritis. The chief arguments advanced in favor of the nervous theory are : («■) The hereditary nature of the disease; ((5) the effect of such psychical disturbances as anger, grief, and fright in provoking an acute attack; (r) the common occurrence of neuralgia and myalgia in gouty per- sons; (^) joint involvement which is common to many nervous affec- tions ; and (i?) the frequent occurrence of neurotic disturbances in mem- bers of a gouty family. Morbid Anatomy. — (i) The Blood. — The excess of uric acid in the blood is generally accepted, but it cannot always be demonstrated. Garrod's test is made by placing a thread in serum obtained from a small blister, after adding to each dram of it six drops of a 28 per cent solution of acetic acid. In from 18 to 48 hours crystals of uric acid may be found upon the thread. But the test, when successful, is not peculiar to gout. The only other change in the blood which has been demonstrated is an increase of the fibrin in acute cases, since the perinuclear basophilic granules of Neusser are found not to be charac- teristic. Oxalic acid has also been found in the blood in some cases. (2) The Joints. — Wntn death has occurred during an acute attack, evidences of inflammation are found in the joints. There is also a deposit of sodium biurate, even at the earliest stage. After repeated attacks the signs of inflammation become less prominent and the deposits more abundant until masses of considerable size have been formed. 4^11 the structures composing the articulation may have been invaded. This deposit begins a short distance beneath the free surface of the articular cartilages and extends more deeply as the disease progresses. It at first forms a whitish opacity, but later incrusts the cartilage and pro- 59° PRACTICE OF MEDICINE duces an appearance which Duckworth has compared to splashes of white- paint. The synovial membrane sometimes contains the white splotches^ but its fringes escape. The synovial fluid in the larger articulations sometimes becomes thickened and may contain tufts of crystals. The fibrocartilage and ligaments are later involved, and there are generally the distinct masses of deposit known as tophi or chalk-stones. The tissues covering these masses frequently become eroded, and the tophi finally protrude through the skin. Ulceration of the surrounding skin and sometimes necrosis ensue. The articulations most frequently af- fected are the first joint of the great toe, then the ankles, knees, and the small joints of the hands and fingers. The joints of the upper extremity escape in many cases. Tophi are commonly found in the cartilage of the ear, at the margin of the helix, less frequently in the cartilages of the nose, eyelids, and larynx. Rarely they are met with also in the substance of the muscles, in the sclera, or in the cerebral and spinal meninges. Lesions are more or less regularly found in other localities, notably in the kidneys and blood-vessels. The renal changes correspond to those of interstitial nephritis, with the addition of the so-called uric-acid infarcts both within the tubules and in the epithelial cells and inter- stitial tissue. The deposits are found especially in the region of the papillae and on the bases of the pyramids. In the blood-vessels various changes are seen, but most frequently an arteriosclerosis, sometimes a hypertrophy of the muscular coat or an atheromatous deposit. Hyper- trophy of the heart usually accompanies the change. Chalky concre- tions in the valves have been described. Symptoms. — The clinical manifestations are generally described under the three heads of acute gout, retrocedent gout, chronic gout, and gouti- ness or irregular gout. (i) Acute Gout.— Theacute attack usually begins with premonitory indigestion, restlessness, headache, and often melancholia, with occasional twinges of pain in the joints of the hands or feet. The urine becomes scant, dark, and strongly acid, and shows a deposit of urates on cool- ing. It may contain traces of albumin or sugar (gouty diabetes). The uric and phosphoric acid ingredients are generally diminished shortly before and during the attack, but much depends upon diet. A chill sometimes occurs. As a rule, however, the patient is awakened in the early morning with an intense pain in the distal joint of the right big toe, possibly in the left. The pain increases during the next two or three nights; it may subside to a great extent during the day. Such parox- ysms last six or eight days ; they may be prolonged by the involvement of additional joints. It is described as a burning, throbbing, lancinat- ing pain that seems to wedge the bones apart or to press them to- gether as in a vise. At first the veins about the joint become distended^ then the skin becomes uniformly swollen, red, and glazed; the slightest motion, a touch, or the weight of the bedclothing causes intense pain. Fever is often present, reaching 102° or 103° F. (38.9° — 39.5° C). The inflammation subsides gradually ; suppuration does not occur. Desqua- mation of the skin over the affected joint is sometimes observed. Re- currence is common; some patients have three or four attacks every year. GOUT 591 (2) Retrocedent Gout.— This term has long been appHed to such phenomena as violent gastralgia, precordial distress, dyspnea, vomiting, and collapse when they occur at a time when the acute symptoms of gout are subsiding. They sometimes follow the application of cold to the affected joints. Fatal pericarditis, apoplexy, and uremic coma are sometimes included in this class of manifestations. (3) Chronic Gout.— This is the outcome of repeated acute attacks. Its distinctive feature is the formation of tophi. These are seen espe- cially at the sides of the joints, then in the ligaments and other struc- tures, until marked deformity and immobility or ankylosis are produced. They are seen first in the hands and feet, later, perhaps, in the elbows and knees, the tendons, particularly on the dorsum of the hands, in the bursce, and elsewhere. After ulceration of the skin they become visible. Indigestion is a prominent symptom in most cases, with flatulence, acid eructations, and constipation. Irritability, moroseness, and mental depression are often observed, but not in all cases. The disease has always been notable for its prevalence among men of prominence and scholarly attainments. As Sydenham expressed it, " More wise men than fools are victims of the affection." Many conditions described under the head of Goutiness are more or less uniformly present, and uremia, inflammation of the serous membranes or meninges not infre- quently develop as terminal affections. (4) Goutiness or Irregular Gout.— These terms, as well as gouty or lithemic diathesis, are appHed to ill-defined groups of symptoms which occur in the members of gouty famihes. They are often the only manifes- tations of acquired gout. Acute attacks are often absent. Unfortunately, there is a tendency to attribute to the diathesis every disturbance which occurs in an individual bearing the inherited taint, whether it aff'ects the joints, skin, nervous system, or other parts. Prominent among these aff"ections are : (^?) Cictaneous Ef-uptions. — Urticaria is common in early life; chronic eczema in later life. Burning and itching of the feet at night are regarded as gouty indications. (^li) Digestive Disorders. — Flatulence, hyperacidity, with pyrosis and " bihousness," with coated tongue, fetid breath, and constipation, gingi- vitis, tonsilitis, enlargement of the uvula, congestion of the liver, hemor- rhoids, headache, colic, neuralgia, and intestinal catarrh, are encountered in some instances. (r) Respiratory Disorders. — There is often a tendency to catarrh, pro- ducing attacks of coryza, pharyngitis, laryngitis, or bronchitis. Em- physema and asthma are common, and uric-acid crystals have been found in the sputum. (^) Circulatory System. — Arteriosclerosis is a common change. Owing to the high blood-tension, changes are produced, not only in the vessels, but in the heart and kidneys. The right ventricle is hypertrophied, but later yields to dilatation and becomes feeble in action. Dropsy then ensues. Aneurism may be developed or a cerebral vessel may rupture, and thrombosis of the coronary arteries is often a cause of death. (/) U'ri?ia?y System. — Nephritis may develop early or late. "Showers" of uric acid occur, large quantities of sand or gravel being passed. The small quantity of sugar often found sometimes increases into a true 592 PRACTICE OF MEDICINE diabetic condition. Calcium-oxalate crystals are sometimes found in the urine. Urethritis is readily induced in gouty subjects; some writers believe that it may develop spontaneously after an attack. (_/) Eye Affectiofis. — Iritis, glaucoma, and gouty lesions in the retina or its vessels and the optic nerve, keratitis and panophthalmitis, have all been attributed to the gouty condition. Diagnosis. — Acute gout is recognized by its usually attacking the smaller articulations in the first instance. The swelling does not wander, but continues while other joints become affected. There are also less fever and sweating than in acute rheumatism. The habits of the individual and the condition of his mucous membranes are of value. The chronic form is usually made obvious by the presence of tophi in the region of the joints or in the ears, the history of the diathesis, previous attacks, and other evidences of the disease. Treatment. — Hygienic. — Gouty persons and those predisposed to the disease should abstain from fermented liquors; they should also avoid overeating, and take regular outdoor exercise. They should favor the elimination of urea through the skin by frequent bathing. Robust in- dividuals should take a cold bath every morning, followed by vigorous rubbing, and an occasional Turkish bath ; those in feeble health, a warm bath before retiring. They should wear warm clothing and guard against sudden changes of temperature. Removal from a humid atmos- phere to a higher, dryer climate is often beneficial. Dietetic. — Some writers recommend an exclusively vegetable diet, oth- ers a mixed one ; some advise the use of fruit, others forbid it. In the acute stages the food should be largely liquid ; milk, buttermilk or kou- miss, broths, junket, and gruels. Large quantities of water should be drunk, and pure water is doubtless better than water containing lithia or other solids which must be eliminated by the kidneys. Alkaline wa- ters afford relief from the hyperacidity of the stomach, and have the advantage of appealing to the fancy of the patient. Much benefit may be derived from a prolonged visit to mineral springs. Farinaceous food and fresh vegetables are generally allowed, with the exception of straw- berries, cherries, and bananas ; but sweets are to be avoided. Hot bread and articles made of Indian corn are not to be eaten. Table salt should be eaten sparingly. Fats are allowed by Ebstein. Medicinal. — The acute inflammation of the joints is greatly relieved by bathing them in hot water, then applying an ointment containing men- thol, or chloroform liniment. A mixture containing one part each of guaiacol and oil of wintergreen and two parts of olive oil is soothing to the pain. The joints should be thickly wrapped in flannel. The hot-air treatment affords at least temporary relief. The internal treatment should be begun with the administration of a mercurial purge; even when diarrhea is present, small doses of. calomel should be given. The wine or tincture of colchicum should then be ad- ministered in doses of i^xv to xxx (1.2 — 1.8), usually in combination with potassium, sodium, or lithium citrate, bicarbonate, or salicylate, gr. XV (i.o), every four hours until the pain has been relieved. The doses of colchicum should then be reduced to Tl|,x (0.6). The action of this drug is cumulative and should, therefore, be watched. Personal idiosyn- crasy often prevents its use. If used too freely it is apt to produce RICKETS 593 vomiting, epigastric pain, diarrhea, or renal irritation. Morphin is sometimes necessary for the rehef of suffering, but it should not be given until colchicum has failed, since its use should be avoided in all chronic diseases. A few doses of phenacetin or lactophenin in the beginning will often afford relief until the colchicum has had time to act. RICKETS. RACHITIS. Definition. — A disease of infancy characterized by defective nutrition, with its most pronounced manifestations in the growing bones. Etiology. — The disease is more common in Europe than in America, but it is by no means infrequent among the children of the poor in our large cities. Congenital cases have been recorded, but the disease seldom becomes apparent before the second year, or until the child has begun to crawl and stand. Male and female children are equally affected. Tardy rickets has been described, developing as late as the ninth to the twelfth year, but it is at least quite rare. Improper food, as the milk of a pregnant mother ; bad hygiene, including lack of light and ventilation, are important factors in its production. But it is occasionally met with among the children of the wealthy, especially in those fed upon con- densed milk and other artificial foods deficient in animal fats and pro- teid. Defective assimilation of lime-salts doubtless plays a part in its production. The disease is probably independent of syphilis, but may be modified by it. Morbid Anatomy. — The lesions are found especially in the bones. On account of a deficient deposit of lime, sometimes as a result of the ab- sorption of already formed bony tissue, the bones remain or become soft and unnaturally flexible. The changes are best studied in the long bones. The periosteum, cartilage, and often the bone itself, in the early stages of the disease, are hyperemic. This condition is in itself regarded as sufficient to explain the other changes, since it has been shown by Kas- sowitz, that hyperemia prevents the deposit of lime-salts and at the same time disturbs the nutrition of the bone previously formed. The periosteum may strip off readily, but it frequently brings spiculae of bone with it, and the underlying shaft is usually soft and porous. In- stead of the two narrow parallel lines which normally represent the zone of proliferation between the shaft and the epiphyses, there are two rather thick bands with bulging, serrated edges. There is a superabun- dant proliferation of cartilage-cells, and the remaining matrix often be- comes fibrillar. Unnatural areas of defective ossification are also seen. In the flat bones of the cranium, these centers are often large and promi- nent, producing the condition known as craniotabes. In the atrophied parts the bone becomes so flexible that it can be depressed with the fingers, to which it gives the sensation of bending parchment (parchment- crackling). The liver and spleen are usually larger than normal, and the systemic arteries and lymph-glands are often enlarged. After recovery has occurred, the bones have their normal firmness, but a part of the deformity generally persists throughout life. Symptoms. — The development of the disease is generally insidious, and 38 594 PRACTICE OF MEDICINE it is too often overlooked until distinct deformities have taken place. The rachitic child generally suffers early from indigestion or distinct gastro- intestinal catarrh. It is especially susceptible to bronchitis and other affections of the respiratory organs. It is usually pale, often emaciated and weak. It is fretful, peevish, and restless at night; it often rolls its head until the back of it becomes denuded of hair. It sweats profusely. It has trouble with the irruption of its teeth, which may be delayed, irregular, or slow. The child often cries with pain when it is lifted from its bed. There is often slight fever, and the enlargement of the spleen can be recognized early in most cases. The head generally appears large and has a comparatively square shape (caput quadratum), owing to the prominence of the thickened frontal and parietal eminences. The fontanels remain open until the second or third year, and their edges are extremely thin and flexible. The lower jaw often appears angular. The jaws are, in fact, poorly developed. The skin is thin, and the veins stand out like blue cords. A systolic murmur can often be heard by auscultation over the anterior fontanel or parietal region, but it is not peculiar to rickets. The Thorax. — The changes in the thorax develop early and are quite characteristic. Along either side there is a row of beadlike prominences (the rosary of rickets), due to the swelling at the junction of the carti- lages and the ribs. The sides of the chest, along the line of attachment of the diaphragm, is often drawn in, and there is an evident sinking of the chest-wall during inspiration, particularly when the child is suffering from bronchitis. In most cases the upper portion of the thorax also appears depressed laterally, as though by the hands of the mother in lifting the child. The sternum becomes prominent, especially in its lower portion, sometimes to the extreme degree known as pigeon or chicken breast. A posterior curvature of the spine is often seen also, and the vertebral processes are prominent. The clavicles are often deformed, and there may be partial fractures, especially at the insertion of the steno- mastoid muscle. The abdomen is prominent, partly as a result of the enlargement of the liver and spleen, but chiefly on account of intestinal distention. Deformity of the pelvis is usually present, and later in the life of a woman it may interfere with parturition. The extremities show a distinct enlargement of the epiphyses and the lower limbs; the tibiae especially often show characteristic curvatures, either anteriorly, posteriorly, or laterally. The femur may also become bent in extreme cases of bow-leg or knock-knee, producing a waddhng gait. The upper extremities are less commonly affected, but the humerus may become bent as a result of crawling. Sharp bends (green-stick fractures) are often produced by injuries. The deformities in nearly all cases correspond to the manner in which the weight of the body has been supported (carpopedal spasms). Rachitic children are particularly liable to nervous disturbances, espe- cially to laryngismus stridulus and convulsions. Tetany sometimes de- velops, especially in the arms and hands, occasionally also in the lower extremities. The disease almost invariably runs a chronic course unless treatment is instituted at an early stage. Improvement may be recognized by the DIABETES 595 gradual closure of the fontanels, increase in the length of the bones, and improvement in the strength of the patient. Many of the deformities, especially those of the thorax and pelvis, usually persist, and dwarfism is a not unusual result. Acute rickets (infantile scurvy) is described on page 308. Diagnosis. — Early recognition of the disease is important. Persistent restlessness, peevishness, and tossing of the head, abdominal distention, irregular or delayed dentition, should arouse suspicion of a rachitic con- dition before osseous deformity becomes apparent. The student should disabuse his mind of the idea, too often expressed, that the disease is a rare one or that it is found only among the poor. After deformities have developed, the diagnosis is apparent. Prognosis. — The disease is not of itself fatal, but by favoring the development of respirator}^ disorders and lessening the power of resist- ance to the acute infections it contributes largely to the mortality of early childhood. Treatment. — The treatment in many instances should begin before the birth of the infant. If conception occur during lactation, the child should be taken from the breast, both for its own sake and for that of the fetus. The general health of the mother should be looked after. If the child must be taken from the breast, and a wet-nurse cannot be obtained, the safest diet is properly diluted cow's milk, to which beef-juice, egg albu- men, barley-water, or oatmeal gruel may be added as its age increases. The child must be bathed daily, and the brine bath is especially recom- mended. It should also be kept in the open air and sunshine as much as possible. It should not be allowed to attempt to walk so long as the bones are in an abnormal condition. Extreme cases should be kept in bed and handled as little as possible. Medicinal Treattnent. — In mild cases, before the disease has become ad- vanced, improvement often begins promptly after the addition of salt to the food, as much as is consistent with palatability. Lime-water, cal- cium phosphate, and other remedies supposed to furnish lime to the tis- sues have been recommended, but they are probably not assimilated. Phosphorus is the most highly esteemed remedy. It should be adminis- tered in the dose of 1-120 grain (0.0005) three times daily, in codliver oil. Rubbing the skin with the oil is thought to act beneficially, particu- larly when there is marked soreness. The sirup of the iodid of iron is also useful in many cases. Orthopedic treatment often becomes necessary for the relief Qi the deformities. DIABETES. Definition. — A condition in which, owing to an inability of the system to consume it, sugar accumulates in the blood and is excreted in the urine. Etiology. — The blood normally contains a small quantity of sugar, but under ordinary circumstances it is not excreted in appreciable quan- tity by the kidneys. There is attributed to the blood also the power of destroying a considerable quantity of sugar through, as some writers believe, a glycolytic ferment contained in the leucocytes. When, however, the quantity in the blood exceeds a certain limit— a condition known as 596 PRACTICE OF MEDICINE hyperglycemia — the excess is carried off in the urine. In order to be re- garded as diabetes the glycosuria must be continuous for a period of several weeks or longer. This feature alone serves to distinguish diabetes from a transitory glycosuria arising from a great variety of causes. The exact nature and specific cause of diabetes are alike unknown. It seems probable, however, that recent investigations have approached very near to the revelation of them. It has been long known that a transitory glycosuria may result from : (<2) Profound narcosis of ether, alcohol, opium, or other drugs ; (^5) from coma of whatever origin ; (r) from poisoning with carbon dioxid, amyl nitrite, mercury, strychnin; (^) from hysteria, neurasthenia, epilepsy, the traumatic neuroses; and (^) from chlorosis, exophthalmic goiter, or the acute infectious diseases. The administration of phloridzin, a glucosid found in the bark and roots of apple and cherry trees, also produces marked glycosuria, but probably of a different kind, since its action is known to be exerted upon the renal epithelium. There is a marked difference also in the capacity of different individuals to consume sugar. In some persons the ingestion of seven ounces (200.0) or less of grape-sugar into an empty stomach produces glycosuria, a condition known as an alimentary glycosuria. Diabetes proper may probably depend upon any one of several patho- logical conditions, the most important of which are believed to be lo- cated in the liver, nervous system, or pancreas; possibly the suprarenal bodies are implicated in some cases. The theory that the disease may arise from a perversion of the glycogenic function of the liver-cells is an old one, supported by the common discovery of pathological conditions in the organ as well as by the fact that the liver is the chief factory and storehouse of sugar. Some writers believe also that the condition may be a result of disturbed metabolism in the tissues generally, or of trophic disturbances. The conditions of the nervous system most frequently associated with the disease are the results of injury, tumors, or the so- called neuroses. Conditions causing irritation of the floor of the fourth ventricle have been longer and probably oftener recorded than others, but they are not essential, sincetumors in other regions and inflamma- tion of the meninges may produce glycosuria. In the further study of pathogenesis, two facts stand out prominently, namely, (i) that there is in the body-fluids of the diabetic a ferment which is capable of inducing glycosuria, and (2) that in 50 per cent of all cases lesions can be found in the pancreas. The first of these propo- sitions has been established by repeated experiments in wiiich the injec- tion of diabetic urine into dogs produced glycosuria, even after the sugar had been removed from it by fermentation. The same result has been obtained also by injection of the contents of the intestine of a diabetic person under the skin of a rabbit or into the intestine of a dog. The Pancreas and Adrenals. — Complete removal of the pancreas, or com- plete destruction of it through disease, is immediately followed by per- manent glycosuria, with the production also of aceton, ox3^butyric acid, and other substances peculiar to diabetes. It has been found, however, that if as little as one-fifth of the gland remains, glycosuria is not pro- duced, even though the communication with the intestine be cut off. Or, if a small portion of the pancreas be previously transplanted to another part of the body, the remainder of the organ can be removed DIABETES 597 without causing glycosuria. Recent investigations by several European experimenters, and by Opie and Steele in this country, have further shown that in all cases of pancreatic diabetes lesions can be found in the islands of Langerhans, groups of cells abundantly supplied with blood, but not in any way connected with the pancreatic duct. This secretion is there- fore an internal one, and it is entirely different from the pancreatic juice. These cells are found in a state of hyalin or granular degenera- tion in many cases of diabetes. More recently Herter and Richards have shown that, after the injection, into the small animals, of dried suprarenal extract, glucose invariably appears in the urine. They found that the effect was especially pronounced when the adrenalin was injected into the peritoneal cavity or applied directly to the pancreas. In the latter in- stance, the solution produced, not the usual blanching, but intense hyper- emia and engorgement. In this respect the effect is similar to that pro- duced by the application of solutions of potassium cyanid or other sub- stances capable of reducing the power of oxidation. After fatal doses of adrenalin, the cells composing the islands of Langerhans were found to be in a state of granular degeneration. Herter concludes from these facts that it is probably an interference with the internal oxidizing power of the cells in the islands of Langerhans that is responsible in large part for the production of diabetes. Although all the experiments referred to have not been confirmed, they strongly indicate the proba- bility that the action of adrenalin upon the islands of Langerhans is at least one of the causes of their degeneration and consequently of dia- betes. Flexner's experiments seem to confirm the suspicion that the regurgitation of acid fluid from the intestine into the pancreatic duct may cause a destructive inflammation of the gland. There is some evidence that the disease may be communicated, and consequently its infectious nature has been suggested. In a little more than I per cent of a large number of cases the disease was observed in both husband and wife, and it has been affirmed that a systematic investigation would show glycosuria in 6 to 8 per cent of the apparently healthy marital partners. The discovery of the disease in several mem- bers of the same household, not related, has a bearing on this question, although it is argued also that these individuals become affected because they are subjected to the same diet and other influences, and not to a specific infection. Predisposing Infiicences. — (i) The disease may occur at any time of life, but it is more frequent after 30. A large proportion of adult cases occur after 50. Men are a little oftener affected than women. (2) Heredity is an important factor. The disease has repeatedly been ob- served in successive generations and among brothers and sisters. In many instances, also, it has been met with in families of nervous tempera- ment. It is much more frequent among the affluent than among the poor. (3) The Hebrews are particularly susceptible, and in some of the large cities the Irish rank next. (4) Obesity favors its development (lipogenic diabetes). Striimpell calls attention to its frequency among obese beer-drinkers. (5) The disease is more common in cities than in the country, and in Europe than in America. (6) It has occasionally followed the infectious diseases, as influenza, scarlatina, typhoid fever, cholera, or syphilis. Tuberculosis is often associated with it, but it usu- 598 PRACTICE OF MEDICINE ally plays the part of a terminal affection. Trousseau believed that an inherited tuberculous tendency increases the susceptibility to diabetes. The nervous influences which are believed to lead to the affection are many; among them close application to business, or other nervous strain, shock, worry, fright, and injury or disease of the brain or cord. Conditions which lower the blood pressure as well as those which increase the rapidity of the capillary circulation, particularly vasomotor paral- ysis, have been regarded as the cause of permanent glycosuria. Morbid Anatomy. — Aside from the lesions of tuberculosis and nephritis which are commonly found after death, the pathological changes are few. The body is extremely emaciated; abnormal areas of pigmentation are occasionally found in the skin. The blood contains an excess of glucose, the quantity often amounting to 0.4 or 0.45 per cent instead of the normal 0.15 per cent. Numerous fat-granules are usually seen in the plasma. The polynuclear leucocytes are especially rich in glucose. The heart is sometimes hypertrophied; endocarditis is unusual, but arterio- sclerosis is common. The lungs are tuberculous in many cases; broncho- pneumonia or chronic interstitial pneumonia is found in others. The liver is often fatty or cirrhotic and pigmented ; it is sometimes enlarged, notwithstanding the sclerosis. The stomach is frequently dilated. The kidneys are generally hyperemic and often sclerotic. The lesions found in the nervous system are not uniform. In many cases there have been tumors or cysts, once a cysticercus, pressing on the floor of the fourth ventricle, but often in other localities. Perivascular changes and inflam- mations of the meninges have been described. The important changes found in the pancreas have been referred to under Etiology. The condi- tions leading to the degeneration of the islands of Langerhans have probably not all been recognized. The changes may be inflammatory, degenerative, atrophic, or neoplastic. Symptoms. — The invasion of the disease is usually so insidious as to render the precise time of its beginning indefinite. The patient becomes languid and weak, and he rapidly loses flesh. Headache, nervous depres- sion, insomnia, and neuralgia are often complained of. The appetite becomes voracious (bulimia) and the thirst almost unquenchable. Dis- turbances of digestion are not uncommon, as nausea, eructations, and constipation, but in many cases the digestion is remarkably good. The mouth becomes dry from deficiency of saliva; the tongue becomes red and glazed ; aphthous stomatitis often develops late in the disease. In many instances the thirst and polyuria are the first symptoms to attract the attention of the patient. Three to four quarts (liters) are voided in 24 hours in the beginning, but in severe cases it may rapidly increase to 1 2 or 15 quarts. The skin is dry and harsh, and sweating seldom occurs except when tuberculosis is also present. The temperature may be sub- normal except under the same condition. The pulse is rapid and its tension is high. The emaciation and loss of strength keep pace with the progress of the disease, but cases are occasionally met with in which a comparatively large quantity of urine rich in sugar is voided for years without loss of weight or recognizable impairment of health. In most cases the emaciation corresponds to the quantity of urine that is voided. As a rule, the disease progresses with a rapidity that is inversely propor- tionate to the age of the patient. It is particularly rapid and fatal in DIABETES 599 young children, but it often lasts for many years in the aged. Nearly all young patients die in a profound coma; but older persons usually succumb to one of the complications. To this rule, also, there are excep- tions. In some of the more rapid cases, polyuria is not marked, but there has been an evident defect in the assimilation of albuminoids and fats as revealed by examination of the feces and urine. Special Symptoms. — (i) The Urine.— The quantity, as already stated, varies from 6 or 8 to 30 or 40 pints in 24 hours. It has usually a pale straw color and a high specific gravity, ranging from 1.025 ^^ 1.050 or even higher. It has a sweetish odor and acid reaction. The quantity of sugar varies from i or 2 to 10 per cent. Ten to twenty ounces may be excreted in a day, and, exceptionally, as much as two pounds. (For sugar tests see page 731.) The diagnosis should not be based upon a single examination of the urine, but only upon repeated analyses during a period of several weeks. The urea, and more particu- larly the phosphates, are often greatly increased. Glycogen and aceton are often present and /3-oxybutyric acid may be found after coma develops. Albumin is not uncommonly present, and finely emulsified fats may be found. Pneumaturia, or gaseous urine, sometimes results from fermenta- tion within the bladder. (2) T/ie Sh'u.—Owing, no doubt, to the presence of sugar in the per- spiration, the pus-formers find the skin a good medium for their growth ; consequently wounds rarely heal without suppuration, furunculosis is common, and carbuncles are liable to develop; gangrene and sloughs readily form. Eczema is often observed, and it is particularly significant of the disease when it involves the genitalia. (3) Respiratory System. — Acute tuberculosis, gangrene of the lung, lobar and bronchopneumonia are frequently terminal complications. Fat-emboli have been found in a few instances. The breath has often the sweetish odor of aceton, not unlike that of chloroform. (4) Ciradatoiy System. — The chief affection is arteriosclerosis, which may be manifested in many ways, often in the form of an interstitial nephritis, sometimes as a myocarditis, or by the production of cerebral hemorrhage, edema and, later in some cases, gangrene of the extrem- ities. (5) Nervous System. — Coma is especially frequent in young patients. Occasionally it is the first symptom to arouse suspicion of the disease. In other cases it is preceded by indigestion, nausea, vomiting, or one of the respiratory lesions accompanied with great dyspnea; or it may develop suddenly and with little or no premonition. It may last four or five days, or it may terminate fatally within a few hours. It is at- tributed to the presence of some toxic substance in the blood, possibly /J-oxybutyric acid. Neuritis is comparatively common, appearing as a sciatic, trigeminal, intercostal, or other form of neuralgia, as muscular pain or cramp, facial paralysis, hemiplegia, hyperesthesia, or paresthesia of small areas, the latter being occasionally the seat of pain. Herpes zoster sometimes occurs. The knee-jerk is occasionally lost late in the disease, and there may be steppage gait, but the posterior columns of the cord are rarely or never affected unless locomotor ataxia develop in the patient. Atrophy of the optic nerve has been observed. Perforating ulcer of the foot is occasionally encountered. Lesions of the central 6oo PRACTICE OF MEDICIXE nervous system are less frequent, although severe headache is not un- usual, and the patient often becomes morose or hypochondriacal, and general paralysis may occur. The sexual power is often lost; conception rarely occurs, and abortion is apt to follow. (6) Organs of Special Sense. — Cataract is not uncommon, and it is especially rapid in its development among young persons. Retinitis, atrophy of the optic nerve, paralysis of accommodation, or sudden amau- rosis is liable to occur. Diagnosis. — Diabetes is to be distinguished from transient glycosuria and simple polyuria; and the diabetic coma is to be differentiated from that of uremia and alcohol. The distinction from transient glycosuria is practically one of time ; but in most cases of the latter condition there is less rapid emaciation, the urine has a lower specific gravity and con- tains less sugar. In polyuf'ia the specific gra\dty is usually below i.oio, and sugar is not present. In alcoholic cojna there is usually other e\'idence of alcohohsm; the patient can be aroused to attempt the answer of questions; the condi- tion passes off in a few hours. The urine has a dark color and lower specific gravity, and it contains no sugar, or at most a mere trace. In uremic cojtia, dropsy is generally present, the urine is highly albu- minous and contains casts, but no sugar; the bladder may be almost empty. Deception has been practiced, as recorded by Osier, through the intro- duction of cane-sugar or glucose into the urine. Bremer and Williamson have each proposed a blood-test, which may be of value in the diagnosis of obscure cases. (See p. 718.) Prognosis. — Recovery from true diabetes is extremely rare. Inter- mittent glycosuria, which is probably often mistaken for diabetes, is, on the other hand, very amenable to treatment. In patients under middle age, the prognosis is exceedingly grave, while in older persons the disease usually runs a slow and milder course, more amenable to treatment. The severity of a case may be estimated from the response to the re- removal of all carbohydrates from the food, as by putting the patient upon a milk diet for a few days. If the elimination of sugar continues without marked reduction, the case may be regarded as a grave one. Treatment. — Dietetic. — Theoretically the patient should abstain en- tirely from carbohydrates, since the glycosuria depends to a great extent upon the quantity of these ingredients in the food, but practically this is next to impossible in most cases, and, if too rigidly insisted upon, it is apt to destroy the appetite, and lead to an occasional refraction of the rules with highly injurious consequences. It is probably better, as Thompson advises, to allow a small portion of bread, from two to four ounces daily, preferably toasted, for the craving for bread generally proves stronger than for any other article of food. Potatoes may occa- sionally be substituted for the bread, since they contain a smaller pro- portion of starch. In other respects the carbohydrates should be ex- cluded, bearing in mind, however, the apothegm of Von Noorden, " Under all circumstances, the diet in diabetes must be so ordered that the strength of the patient may be thereby maintained and as far as possi- ble increased." \\Taen it is found that the patient is not holding his own DIABETES 60 I on a restricted diet, some change should be made, and the effect of any particular diet should be carefully estimated through repeated analyses of the urine. A number of diabetic flours are offered in the market, but few of them are reliable, and some of them are largely adulterated with wheat-starch. On account of the ravenous appetite of the patient it is often less difficult to institute the diabetic diet by degrees, causing a daily reduc- tion of the quantity of carbohydrates, and at the same time giving a substitute, unless the urgency of the case demands a prompt change. Sugar should be the first article enjoined, and in its place the patient may use saccharin tablets. There is no better diet, perhaps, than one consisting largely of fats. The patient should consume two ounces or more of butter daily, and as much cream as his digestion will tolerate. Other sources of fat are, beef, bacon, smoked sausage, and ox tongue, cream cheese, mackerel, salmon, eels, and the free use of mayonnaise or other dressings prepared with olive oil. Bone-marrow is tasteful to many persons. One or more of these articles should be included in the dietary of each meal. The patient may eat also beef, veal, pork, venison, and the meat of domestic or wild fowl and birds, also the heart, sweet- breads, brain, and kidneys, nearly all parts, in fact, except the liver; but the meats must not be breaded. Oysters, lobsters, crabs, and shrimps may be taken. Among vegetables, those which grow above the ground are generally allowable, as lettuce, celery, cauliflower, asparagus, toma- toes, onions, cabbage, cucumbers, and watercress. Sour fruits may gener- ally be eaten, especially sour oranges, apples, lemons, cherries, currants, pears, plums, strawberries, raspberries. Among liquids the patient may take clear soups, especially bouillon, turtle, and oxtail ; coffee, tea, choco- late, cocoa, with cream, but sweetened with saccharin ; whole milk, butter- milk, plain and carbonated alkaline mineral waters. The list of articles to be avoided usually includes bread and all farina- ceous preparations, potatoes and other vegetables that grow below the surface, and such beverages as beer, sweet and sparkling wines, and all that contain sirup. Confections are of course to be avoided. Hygieiiic Treatment. — The patient should guard against overwork, ner- vous strain and worry, and he should take more than ordinary care to avoid exposure to cold. He should take moderate exercise daily. At the same time the skin should be kept in good condition by frequent bathing, either warm or cold, according to the reaction after the bath. A cold bath in the morning is the best if well borne; the warm bath is better at night. Medicmal Treatment. — Opium has long held first place among remedies, and fortunately it is usually well borne and less liable to develop the habit than in a normal individual. It is better, however, not to inform the patient that he is taking it. It should be given in the form of pills containing gr. ss (0.032), two or three times a day, or codein may be given in the same dose, since it is less constipating. The dose should be gradually increased until 8 or i o grains are taken daily, or amelioration of the symptoms has been obtained. It should be gradually withdrawn, after the elimination of sugar has nearly or entirely ceased. Good re- sults have been obtained from the use of the arsenite of bromin in doses of Ti^iij to V (0.18 — 0.30), and more recently from a solution of the 6o2 PRACTICE OF MEDICINE bromid of arsenic and gold in gradually increasing doses from gtt. iij to XV. Many other drugs have been employed with alleged benefit, es- pecially the salicylates, creosot, iodoform, arsenic, nitroglycerin, jambul, and lactic acid. A glycerin extract of the fresh or dried pancreas, and trypsin, have been employed on the erroneous assumption that they supplied the internal secretion that is wanting, but little benefit has been claimed. Strychnin is an excellent tonic, and ergot may be combined with it as a vasomotor stimulant when needed. Constipation should be guarded against, since it increases the liability to coma. Should the digestion fail, the bitter tonics and a dilute mineral acid should be ad- ministered. Codliver oil may be given to supply the needed fat. A two or three grain pill of asafetida (0.15 — 0.20) has been recommended for the relief of the feeling of insatiety and epigastric gnawing. The pruritus and eczema are treated by bathing the skin with a boric-acid or sodium- hyposulphite solution, and applying an ichthyol or other ointment. The coma is usually fatal, and little can be done to delay the result. Inhalation of oxygen has been thought of benefit, and large doses of sodium-bicarbonate, have been recommended to reduce the acid intoxica- tion. Subcutaneous or intravenous injection of physiological salt-solu- tion should be tried, since it has proved beneficial, to the extent of temporarily restoring consciousness in a few instances. DIABETES INSIPIDUS. Definition. — A chronic condition in which anexcessive quantity of nor- mal urine is voided daily by a person who in other respects is in good health. Eiiology. — The cause is unknown. From analogy the disease is gener- ally regarded as of nervous origin. It sometimes follows emotional ex- citement, concussion, or other injury of the brain, as well as trauma of the trunk and extremities, or such acute infectious diseases as typhoid fever, malaria, or cerebrospinal meningitis. Again, it has been attributed to congenital syphilis and malnutrition. In some instances the condi- tion has followed sunstroke or the drinking of a large quantity of water on a hot day. It is to be distinguished, however, from the excessive flow of urine which is due to excessive drinking in polydipsia, a condi- tion characterized by excessive thirst and often a hysterical manifesta- tion. ., The disease is a rare one. It occurs most frequently in young boys, sometimes in girls ; it may develop in middle life, seldom later. It some- times appears to be inherited, and congenital cases have been observed. Morbid Jinafomy. —There are no essential lesions. Various lesions of the nervous system have been found. The kidneys are sometimes en- larged and congested. Dilatation of the renal pelvis and ureters and hypertrophy of the bladder are sometimes present. Death has usually been the result of an independent affection, as tuberculosis. Symptoms. — The condition develops gradually in the absence of a definite cause, otherwise abruptly. The essential symptom is the marked increase in the volume of urine. As much as 8 or 10 quarts (liters) are often excreted in 24 hours, and cases have been observed in which the quantity reached three or four times this limit. The specific gravity OBESITY 603 usually ranges from i.ooi to 1.004, and the color is extremely pale. The total solid constituents may remain normal. Sometimes there is slight excess of urea, and inosite, phosphoric acid, sulphuric acid, creat- inin, and very rarely a mere trace of albumin or sugar have been noted. The thirst is extreme, and the dryness of the tongue and skin resembles that of diabetes mellitus, but furunculosis is rare. Salivation has been noted. The appetite is generally good, and the general health may be undisturbed for many years. In cases due to a definite cause, however, there may be decline with emaciation, languor, feebleness, and sometimes insomnia. Diminution of the urinary secretion sometimes follows the development of an intercurrent malady. Recovery is extremely rare, but death is usually a result of another disease, as tuberculosis, pneumonia, or cancer. Diagnosis. — The condition is to be distinguished from the polyuria of diabetes mellitus, hysteria, and interstitial nephritis. From the first of these it is readily distinguished by the low specific gravity of the urine and the absence of sugar; from hysterical polyuria, by its permanent character and the absence of hysterical manifestations; from that of interstitial nephritis, by the absence of albumin and casts or other evi- dence of ill health. Treatment — It is useless to restrict the diet or to limit the quantity of fluid consumed, except so far as the thirst can be relieved by chipped ice instead of water. Opium has been employed, but it is not curative. Valerian, in doses of 5 grains (0.30) of the powdered root, gradually increased to 20 grains (1.30), three times a day, has proved of benefit. Ergot, the salicylates, arsenic, strychnin, bromids, carbolic acid, atropin, and galvanization of the cervical spine have all been recommended. If a cause for the condition can be discovered, it should be treated. Con- genital syphilis may thus call for specific treatment. OBESITY. Definition. — A condition of disordered nutrition characterized by a greatly increased development of adipose tissue. Etiology. — The proximate cause is generally regarded as deficient oxidation. The condition may be to a great extent inherited, but it is seldom transmitted to all members of a family. By some writers it is thought to be related to the uric-acid diathesis, diabetes, and other forms of perverted nutrition. It is more apt to develop after middle life, but it is not infrequent in children. The principal causes that lead to it are excess of food and drink, especially of starches, sugar, and malt liquors, with deficient exercise, yet many fleshy persons are remarkably abstemious, and some are overcome with fat in the midst of an active life. Morbid Anatomy. — The heart is usually large and infiltrated with fat, the right side dilated and the left hypertrophied; or there may be at- rophy of the muscular structure of the entire organ. The lungs are usu- ally, small the liver large and fatty ; the stomach is large and the mus- cular coat well developed; the intestines are often dilated; the spleen, kidneys, and lymph-glands are usually small, and the pancreas hyper- trophied. The blood often contains a greatly increased quantity of fat. 6o4 PRACTICE OF MEDICINE Symptoms. — The appearance is too well known to require description, except for the fact that the individual may be either ruddy or pale and anemic. All the functions of the body may be carried on normally, but there are usually interruptions, particularly of digestion. The bodily activity is impaired; the mind may be sluggish and dull, or bright and active. Obesity is generally progressive, except when it begins in early life ; it may then subside at puberty. More important is the tendency to disease, and the diminished power of resistance which it entails. Death may occur by syncope from extreme fatty degeneration of the heart, from apoplexy due to the rupture of an atheromatous artery in the brain, from acute pulmonary congestion, rupture of the heart, angina pectoris, or uremia. Treatment — The general indications are to reduce the quantity of carbohydrates ingested and the allowance of fluid; alcohol should be forbidden. The change should not be too suddenly made, or carried to the extent of reducing the patient's strength. There are several methods of regulating the diet, chiefly by limiting the quantity of fluid and ex- cluding certain articles of food. Banting's method consists in reducing the quantity of all kinds of food to an extent that can seldom be en- forced. It permits only from 21 to 27 ounces of solids in a day, of which 13 to 16 ounces consist of animal food and only 2 ounces of bread. Sugar and other starches are strictly excluded. Ebstein restricts the same articles, but allows fats, because they produce satiety and diminish thirst, a fact observed by Hippocrates. Oertel strongly objects to the free allowance of fat and adopts a diet consisting of lean beef, veal, or mutton, and eggs, with green vegetables, and a limited quantity of fats and carbohydrates, including 4 to 6 ounces of bread daily. The quantity of fluid he limits to 6 oz. of tea, coffee, or milk, morning and evening, 12 oz. of wine, and 8 to 16 ounces of water in 24 hours. A most important part of his treatment, however, consists in systematic forced exercise, particularly mountain-climbing. The Weir Mitchell treat- ment confines the patient to bed for a month or six weeks on a regu- lated milk diet, with massage and the Swedish movement. Hot baths, massage, and active exercise, including much walking, may be employed as adjuncts to any of the other methods which do not in- clude them. Among drugs, the most satisfactory, perhaps, is the thyroid extract in doses of gr. v (0.32) t. i. d., but it fails in many cases. Adiposis Dolorosa. — An affection of middle age, characterized by an irregular, symmetrical deposit of fatty masses in various regions of the body, preceded or attended with pain. The disease was first described by Dercum. Large, often pendulous, nodular, encapsulated masses of reddish fat are formed. Nerve fibers run over the nodules. Paresthesias sometimes develop. The nature of the disease is not definitely known, but atrophic changes in the thyroid gland, and interstitial neuritis, have been observed in cases, and improvement has followed the administration of thyroid extract. SECTION IX. Intoxications and Miscellaneous Diseases. ALCOHOLISM. INEBRIETY, DRUNKENNESS. Definiiion. — An acute or chronic intoxication due to excessive indul- gence in alcoholic beverages. Eiiology. — i. While the immediate cause of acute alcoholism is over- indulgence, there are many influences which predispose or lead to it. Among these are the example or invitation of companions, the desire to meet the demands of society, to cope with a rival, to relieve fatigue, anxiety, melancholy, grief, or pain. In most instances the intoxication is accidental, for the individual seldom starts with the intention to be- come drunken. 2. Chronic alcoholism is doubtless largely due to an inherited neurotic taint or instability of the nervous system. Not in- frequently a more or less continuous line of inebriety is associated through several successive generations with occasional cases of hysteria, epilepsy, or insanity. The influence of example is also strong; but it often happens that the remembrance of a drunken parent stimulates the children to abstinence. The inherited tendency may crop out, how- ever, in the third generation. The use of alcohol as a medicine in acute diseases has seldom begotten a fondness for it, but the physician should be guarded in advising its use as a tonic. Other predisposing causes are occupations requiring the handling of liquors, overwork, idleness, and other forms of debauchery. Symptoms.— (^1^ Acute Alcoholism.— The first effect of the ingestion of a large quantity of alcohol is usually shown in an increased rapidity and force of the circulation. The face becomes flushed, later, perhaps, cyanotic ; the pulse full and bounding, and the respiration deep and some- times irregular. Nervous phenomena soon follow. There is at first stimulation of the centers of the cortex and cerebellum. The ideas flow rapidly, but later they become confused, and finally there is a com- plete demoralization both of common and of special sense. Natural peculiarities of disposition are exaggerated, and the individual becomes obtrusive in his friendship or quarrelsome to a degree. Muscular inco- ordination soon supervenes, then relaxation, and finally narcosis. While in this state, the drunken person is unconscious and to a, great extent anesthetic ; but he can almost always be aroused to the point of mut- tering answers to questions. The pupils may be either dilated or con- tracted, they are seldom unequal. The temperature is reduced, some- times to several degrees below normal, even to 90°, 85° F. (29.5° C), or 6o6 PRACTICE OF MEDICINE less ; the respiration may become stertorous. The breath has the strong odor of alcohol. Muscular twitchings are not uncommon, but convul- sions seldom occur, except in the chronic drunkard or after the ingestion of an enormous quantity of alcohol. Under such circumstances the con- vulsions may be fatal. A homicidal mania is sometimes induced. The term dipsomania is applied to the habit of indulging in an occasional spree, especially by one strongly predisposed to inebriety. Diagnosis. — The diagnosis is seldom difficult, but serious errors are the more frequent on that account. The alcoholic coma is to be differen- tiated from that due to apoplexy, uremia, diabetes, epilepsy, opium, and other poisons. In most cases the diagnosis is best established by ex- amination of the stomach-contents. The odor of the breath and con- dition of the pupils are alike untrustworthy, since these forms of coma frequently occur in alcoholic subjects. Apoplectic coma is more profound, the pupils are more constantly unequal, and the hemiplegic relaxation of the muscles of one side and deviation of the tongue may be recognizable. Uremic coma. — An edema- tous face, contracted pupils, muscular twitchings, and convulsions are common, the coma is profound, and, unless the individual has indulged in alcohol, the odor of the breath is ammoniacal. The urine is albu- minous, and contains casts. Diabetic coma is deep; the breath may be sweetish, the urine contains sugar. Epileptic coma follows a seizure the character of which can usually be recognized. Opium narcosis is char- acterized by extremely slow, interrupted respiration, close contraction of the pupils, feeble pulse and great muscular relaxation. Other drugs — absinth, chloral, ether, chloroform — and poisonous gases are generally recognizable by their odor upon the breath of the patient; the drug may be discovered in the stomach-contents or in the urine. (2) Chronic Alcoholism. — This condition follows either constant or periodic excess, but more rapidly the former. The effects are seen for the most part in the gastrointestinal and nervous systems. The patho- logical changes are chiefly of a sclerotic character, and affect especially the liver and the peripheral nerves (alcoholis neuritis). To what extent the central nervous system may be involved has not been fully deter- mined. Digestive System. — Chronic gastritis is one of the most common re- sults of excessive alcoholic indulgence. This is manifested by indigestion, nausea, gastric distress, vomiting, especially in the morning, anorexia, perverted appetite, furred tongue, and foul breath. Constipation usually accompanies it. Hepatic cirrhosis is induced in a variable proportion of cases, but especially in those who habitually take undiluted whisky mto an empty stomach. Symptoms. — Nervous System. — The manifestations may be either func- tional or organic in character; but the transition from functional dis- turbance to structural change is an insidious one. Among the func- tional symptoms are tremors of the hands and tongue, dullness of in- tellect, apathy, forgetfulness, disregard of duty, irritability of temper, often slovenliness, and sometimes general immorality and degradation. Periodical hallucinations may occur. Epilepsy and various forms of in- sanity, especially paralytic dementia, are generally regarded as possible results of chronic alcoholism. ALCOHOLISM 607 The facies of the toper is generally characteristic. His eyes are watery, the conjunctivge congested, the nose and cheeks are reddened by the dilatation of superficial veins, producing acne rosacea, the countenance becomes dull, and the speech slow and indistinct. Circulatory System. — The heart of the chronic drunkard is not in- frequently dilated, and a more or less general arteriosclerosis is almost uniformly present at a late stage of the disease. The extent to which the kidneys are affected by alcohol is variously estimated. It is not unusual, however, to find them normal. Formad has described an en- largement, especially in the transverse diameter, peculiar to excessive drinkers of beer. Delirium Tremens (^Mania a Potii).—T\\\'s> affection is generally only an acute disturbance occurring during the course of chronic alcoholism, but it may supervene upon a debauch or occur shortly after the cessa- tion of a long-continued excess. Rarely it develops from a single spree, and then, as a rule, in one given to excess. Again, it is sometimes in- duced in an alcoholic subject after weeks of abstinence, by the receipt of an injury, a surgical operation, or an attack of illness ; abstinence from food and mental distress are often operative factors. Symptoms. — The attack usually begins with restlessness, insomnia, fear, and suspicion. Hallucinations of sight and hearing soon super- vene. Rats, mice, and snakes, often of brilliant colors, appear upon the wall or crawl over the bed. The patient is often busily engaged in some imaginary employment; angels or demons are often his advisers or tor- mentors. In an unguarded moment he often tries to escape from his persecutors. Muscular tremors, especially of the hands and tongue, are constant features. 'The patient often sinks into a typhoid state, with elevation of temperature, seldom above 102° or 103° F. (39.5° C). The pulse is rapid and soft, and the tongue becomes heavily coated. The symptoms subside after a few days, or the strength gradually de- clines and death ensues from failure of the circulation. Diagnosis. — The condition is usually readily recognized when the his- tory of indulgence is known. It is important, however, to make a thor- ough examination, particularly of the lungs, in order to exclude the pres- ence of pneumonia, especially in the apex. Meningitis is not infrequently suggested by the condition. Erysipelas is often accompanied with de- lirium like that of alcoholism. Treatment. — Sleep is generally a specific in acute cases. After a de- bauch, sleep generally comes spontaneously. In delirium tremens, how- ever, it must be induced by the administration of drugs. Chloroform may be cautiously administered in a violent case. Chloral is safer, and should be combined with the bromids, gr. xv. (i.o) of the former and gr. xxx (2.0) of the latter, every two hours. Small doses of apo- morphin (gr. 1-40; 0.0016) every hour often quiet the patient. Hyos- cin hydrobromate, gr. i-i 00 (0.0006) hypodermically, is perhaps better. Morphin is much employed, but it is often useless and never free from danger. Two or three doses of ^ grain (0.016) should be the limit. When the case is seen early, lavage of the stomach is indicated, unless vomiting has occurred. Milk and broths, given at short intervals, should constitute the diet. It is sometimes necessary to administer al- cohol to support the heart for a few days, and strychnin should gener- 6o8 PRACTICE OF MEDICINE ally be given. When the temperature is low, the hot pack and hot bottles should be applied. For the relief of the gastric irritability and headache, usually following a debauch, the aromatic spirit of ammonia should be given in half-dram (2.0) doses. Blood-letting is recommended in sthenic cases following the ingestion of a large quantity of alcohol. The treatment of chronic alcoholism is exceedingly unsatisfactory. As a rule, relapse occurs sooner or later. In a few cases, when there is a strong desire on the part of the patient to reform, prolonged resi- dence in a sanitarium is effectual; but in the absence of determination and more than ordinary will-power, treatment is useless. The " drug- ging" of the patient's liquor with apomorphin or tartar emetic is occa- sionally successful in producing a temporary disgust for drink. The hypo- dermic administration of small doses of atropin, apomorphin, and strych- nin, but more particularly of hyoscin hydrobromate, is said to have a similar effect. When circumstances will permit, a permanent removal to new scenes, and a careful selection of new associates, or continued travel in the companionship of persons capable of giving moral support to the patient's feeble determination, are sometimes productive of good results. MORPHINISM. MORPHIA HABIT, MORPHINOxMANIA, OPIUM HABIT. Definition. — A chronic intoxication with morphin or one of the other derivatives of opium. Eiiology. — In a majority of cases, in this country at least, the habit is acquired through the prolonged use of the drug for the relief of pain or insomnia, or to quiet alcoholic nervousness. It is most readily ac- quired from hypodermic administration. The habit is prevalent to a sur- prising degree among physicians and druggists, and a majority of the other habitues are women. It is very rarely deliberately developed for the supposed pleasure of it, but in the nether-world it is often adopted simply as an additional mode of dissipation. Morphin is taken hypo- dermically, laudanum and paregoric are drunk, and occasionally opium is smoked in the same manner as in the Orient. The same difference of susceptibility is observed as in alcoholism. Some persons give up the drug without difficulty after using it constantly as a medicine for many months, while others develop a craving for it almost frorn the beginning. Those who inherit an alcoholic tendency are the surest victims. Symptoms. — For a short time the drug produces a feeling of exhilara- tion, a pleasant freedom from worry and care; but this is soon lost, and an increased indulgence is essential to even moderate comfort. As the effect of a dose begins to wear off, a feeling of weakness and mental depression, often accompanied with gastric distress and nausea, comes over the victim, and unless another dose is taken, he' becomes nervous, irritable, cold, and tremulous. The continued use of it develops an ap- pearance which is characteristic. There is progressive emaciation ; the face becomes sallow, often -wTinkled and prematurely aged. The pupils are contracted to the size of a pin-point when under the influence, or widely dilated, irregular, and changeable when deprived, of the drug. Itching, especially of the nose, is commonly a symptom. The tongue is COCAIN HABIT 609 dry, and the lips must be frequently moistened; the speech becomes slow and drawling, and old habitue's are not infrequently overcome with drowsiness, even in the midst of conversation. Sleep is often dis- turbed. The muscles twitch, and the limbs sometimes assume positions suggestive of catalepsy. Profound hysteria or neurasthenia is, in fact, often developed in women. Chills sometimes occur, and the tremor and •excitement occasioned by deprivation of the drug may amount almost to mania. The quantity required by different habitues is not the same. Some never exceed 5 or 6 grains a day, while others rapidly increase the dose to 20, even 40, or more grains. In some instances, as in al- coholism, a moderate quantity is taken continuously, and a large dose is indulged in occasionally. The patient's statements can seldom be relied upon in regard to the quantity taken, for in most cases they be- come utterly untruthful. The duration of the habit is also variable. In Oriental countries the drug has apparently little effect upon the health, and it is often tolerated for many years. In other instances a fatal decline of strength is early induced by it. Treatment. — The physician in general practice is seldom justified in attempting to cure the habit. What can be accomplished with safety and almost certainty in a sanitarium is extremely difficult and often dangerous elsewhere. The patient must be removed from the possibility of securing a supply of the drug. The method usually employed is the gradual withdrawal of the morphin. The doses must be given at exact intervals, about four a day, and each day less. The greatest difficulty is experienced in the final withdrawal. Atropin in sufficient doses, to produce extreme dryness of the mouth and throat and other physio- logical effects, is an aid at this time. During the treatment the patient should receive the most nourishing food at regular intervals, and of a character depending upon the condition of the digestion. The aching pains, sleeplessness, and general nervousness that usually occur toward the end of treatment are best relieved by hot baths and massage. Trional may be required at night in doses of 20 or 30 grains (1.30 — 2.0). A new treatment has been advocated by Lott of Texas, and supported by Hare and others. It consists in the administration of large doses of hyoscin hydrobromate, even gr. ^/( (0.015) in each twenty-four hours, and the immediate withdrawal of the morphin. The patient often de- velops alarming symptoms, but recovers without a craving for the drug. Pettey has shown that the treatment is extremely dangerous in some cases, and that in another group it is efficient in much smaller dosage than recommended by Lott, providing the intestine be thor- oughly evacuated by free purgation before its administration is begun. The treatment has not yet been extensively employed. After recovery the patient should remain for several months away from home. A change of residence is often advantageous in removing old suggestions of the habit. COCAIN HABIT. The cocain habit is becoming prevalent, especially among the negroes and lowest class of whites. It is most frequently taken in the form of snuff, sometimes hypodermically. Before its dangers had been recognized, 39 6io PRACTICE OF MEDICINE many individuals acquired the habit from the use of sprays, ointments^ and solutions for the nose, throat, or eye. The effect of a large dose is often maddening, but prostration ensues, and the individual lies for several hours in an unconscious state. Hallucinations of sight and hear- ing are commonly induced. The pupils are dilated, nystagmus is com- mon. The pulse is rapid and feeble. The continued use of the drug produces the utmost depravity. The appearance is not always distinc- tive. The inflamed and often ulcerated condition of the nose, the black- ness of the tongue and teeth, the anemic appearance, and restlessness of the eyes will generally suggest the use of the drug. Treatment. — The management of the case is practically the same as that of the morphin habitue. CHLORAL HABIT. This habit is acquired in much the same manner as that of morphin. It is less common than either morphinism or cocainism. The effect of the drug is less exhilarating, and the ultimate effect is profound depression, anemia, and tremor of the hands. The patient is nervous, irritable, morose, and may finally become demented. Indiges- tion and diarrhea are common, the breath is fetid, and the tongue heavily coated. Erythema and other cutaneous eruptions are common, the general integument is dry and blanched. As in other habits, the moral sense is obtunded. The treatment consists in the withdrawal of the drug either gradually or at once, and the administration of bromids in large doses, hyoscin, and tonics, particularly strychnin and iron. The treatment is more easily accomplished in an institution for the treatment of inebriety. LEAD-POISONING. PLUMBISM, SATURNISM. Etiology. — The disease may be produced by the slow intoxication of the system with lead. The disease occurs most frequently among artisans — those handling lead in any form, from the smelter to the painter and glazier. Miners are seldom affected. The lead may be absorbed through the respiratory passages, the digestive tract, or the skin. In the smelting of the ore, the grinding of white lead, and the mixing of paint, the poisoning arises probably both from the inhalation and swallowing of the dust or fumes. Among painters, glaziers, plumb- ers, and the like, it is largely a matter of carelessness in eating with unwashed hands. Poisoning sometimes results from drinking water, wine, or cider which has passed through new lead pipes or that has been stored in lead-lined tanks. Women are often very susceptible to the poison, and have been affected through the use of cosmetics, hair-dyes, false teeth, or by biting lead-dyed silk thread. Morbid Anatomy. — The lead becomes deposited more or less generally in the soft tissues of the body, but especially in the muscles, nerves, and mucous membranes. Slow elimination takes place through the skin, kidneys, liver, and salivary glands. The muscles become pale, atrophied, LEAD-POISONING 6ii and sometimes indurated with fibrous tissue. Parenchymatous neuritis is also found most markedly in the peripheral ends of the nerves, and the nerve-endings in the muscles are degenerated. Sclerosis of the arteries, liver, and kidneys is found in advanced cases. Symptoms. — The manifestations of lead-intoxication usually follow long exposure, but in some instances they have developed after exposure of only a few weeks, or even of only a few days' duration. Rapid poi- soning is more common as a result of the inhalation of the fumes of smelting-furnaces, the dust from the grinders and mixers, or that from sand-papering in paint-shops. The symptoms may be either acute or chronic in character. Acute Symptoms. — Cases are occasionally encountered in which the vio- lence of the poisoning resembles that caused by the taking of a large dose of one of the soluble salts of lead, intense pain in the abdomen, vomiting, and diarrhea. As a rule, however, the more rapid intoxica- tion is shown by a rapidly developing anemia, peripheral neuritis, some^ times accompanied with convulsions and delirium. Severe gastrointes- tinal symptoms are equally common. Obstinate constipation develops, and the patient is suddenly seized with a violent cramp in the abdo- men (painters' colic). The wall of the abdomen is usually retracted, and there is a feeling as though the intestine was being twisted into a knot beneath the umbilicus. The paroxysm may continue almost con- stant for several hours, or it may be intermittent. In the intervals there are moderate pain and tenderness. Vomiting sometimes occurs. The temperature may be subnormal. The urine is usually scant and albuminous. Such attacks may recur at intervals for months and years, especially when the patient continues to work in lead. Death may, however, occur within the first two weeks, rarely even in the first attack, especially in an individual who has been overwhelmed by a short ex- posure to lead. Acute lesions of the central nervous system are not common, but hemiplegia has been attributed to an exposure of only three days. Chronic Symptoms. — The most typical symptoms are those of a chronic character, the most distinctive of which are anemia, paralyses, the de- posit of lead in the gums, and encephalopathies. (i) Afiemia^ or the saturnine cachexia, is characterized by emacia- tion, deep pallor, sometimes a yellowish hue, and dryness of the skin. The blood-count shows a decrease of the red corpuscles seldom reaching 50 per cent, with corresponding reduction of the hemoglobin and a granular degeneration of the erythrocytes. (2) A blue line in the gums, which, when present, is one of the most valuable diagnostic signs. It is due to the formation of lead sulphid, and is best seen along the margin of the lower gum as an indigo-blue line, which cannot be removed by cleansing. It usually forms early, and may persist indefinitely or it may shortly disappear. (3) Lead-Palsy. — Several forms of lead-paralysis occur as a result of a peripheral neuritis. The most common is : («) That known as wrist- drop, or the antibrachial type. When the arms are extended, the hands and fingers droop and cannot be raised through the action of the ex- tensor muscles. It is due to aff"ection of the musculospiral nerve. Less frequent forms are : (/;) The brachial, in which the scapulohumeral 6i2 PRACTICE OF MEDICINE is involved, producing paralysis of the deltoid, biceps, brachialis anticus, and rarely of the pectorals. It may follow wrist-drop, but is occasion- ally a primary affection ; (.f) The Aran-Duchenne form, which may closely resemble poliomyelitis anterior chronica, affecting the small muscles of the hands, and producing marked atrophy, especially of the thenar and hypothenar eminences. In some instances the muscular atrophy is the primary change ; (^/) the peroneal form, affecting the muscles of the lower extremities, especially the lateral peroneals and extensors of the big toe. The steppage gait is produced. (^) A rare form in which the ad- ductors of the larynx are involved. Cramps sometimes occur in the affected muscles or in the flexed joints (lead-arthralgia), and tremors, increased by muscular effort, are not unusual. Sensation may not be altered. Rarely there is a general paralysis which slowly or rapidly extends to all the muscles of the ex- tremities, resembling an ascending spinal paralysis. The diaphragm may be involved, with fatal result. A febrile form also has been recog- nized. The electrical reaction of degeneration is usually present, (4) Cerebral Symptoms (Lead-Encephalopathy). — These may be purely functional or they may depend upon structural lesions, particularly end- arteritis of the cerebral vessels. Manifestations of a hysterical nature are common in women ; convulsions may occur, or epilepsy may develop. Acute delirium with hallucinations may occur independently or alternat- ing with convulsions. (5) Arteriosclerosis is frequently produced, especially in the kidneys, and hypertrophy of the heart may follow it. (6) Saturnine gout is occasionally observed, especially in England. It is believed that the presence of lead favors the deposit of urates in the tissue of the joints. Diagnosis.— The history of the case seldom leaves doubt in the diag- nosis. Lead-colic is to be distinguished from that of volvulus or ap- pendicitis, and from renal and hepatic colic. This is usually not diffi- cult, on account of the retraction of the abdomen and the peculiar sense of constriction at the umbilicus, the absence of tumor or fecal vomiting and the subnormal temperature. The pain is not of the sharp, cutting character of hepatic and renal colic, and it is confined to the umbilical region, as a rule. Alcoholic neuritis is distinguished from that due to lead by the presence of sensory disturbances and the more usual affec- tion of the lower extremities. Prognosis. — This is favorable in a majority of cases. When the symp- toms develop with violence after short exposure, it is often less favor- able than in the more chronic cases. Atrophy of the muscles and the reaction of degeneration are unfavorable indications. The cerebral dis- turbances sometimes become permanent. Persistent treatment of the paralysis is often followed by surprisingly good results. Treatment. — Prpphy lactic measures should be adopted by all workers in lead. Respirators are in a measure beneficial to those working in the smelting-works and where lead is grovmd or mixed. The greatest care should be taken in the cleansing of the hands, including the nails. The colic requires the hypodermic injection of morphin and the application of hot stupes. The constipation should be overcome by repeated dram doses of magnesium sulphate, which serves also to render the lead in- ARSENICAL POISONING 613 soluble. The elimination of the lead from the tissues is favored by po- tassium iodid in doses of gr. v to x (0.30 — 0.60). It should not be given in the more violent cases, or until it is probable that all of the metal has been removed from the intestine. The action of the kidneys should be maintained by the drinking of a large quantity of water. For the paralysis, galvanic and faradic electricity may be employed, with massage of the muscles. Iron and strychnin are also indicated for the anemia and to restore muscular tone. The effect of the strychnin is more pronounced and more rapid when the drug is injected into the paralyzed muscles. ARSENICAL POISONING. Etiology. — The poison may enter the system either through ingestion or through inhalation. Poisoning is not infrequently developed among artisans in the manufacture of glazes and colors for paper and other fabrics. The red and green colors of wallpaper, artificial flowers, car- pets, and draperies are the most likely to contain arsenic. Through the action of moisture or certain molds the poison may be liberated in the air. Poisoning has been contracted also through the sorting of playing- cards and other glazed paper, curing skins by the taxidermist, and in the manufacture of stained glass. Paris green is a frequent source of poisoning to farmers, who use it as an insect-poison. A case is occasion- ally met with in which the prolonged use of arsenic as a medicine has produced toxic effects. There is a great difference in individual sus- ceptibility. The arsenic habit is sometimes contracted, especially by the Austrian peasants, who take as much as eight grains daily without seri- ous effects. Morbid Anatomy. — A degenerative peripheral neuritis is commonly found, associated with a similar change in the anterior horns of the spinal cord. A granular degeneration of the viscera is often produced, especially in the liver and kidneys. Symptoms. — Edema of the eyelids, and conjunctivitis with headache, vertigo, attacks of nausea, mental depression or hysteria, are the symp- toms which usually first attract attention. Anemia, with more or less emaciation, is a constant symptom. The mucous membranes of the nose and throat are generally dry or inflamed, especially if the poison has entered with the respired air. The skin is dry, the hair falls out, and there may be pigmentation or bronzing, eczema, herpes, or urticaria. The arsenic may be found in the secretions, especially in the urine. Albumin and casts are also present, and sometimes blood-corpuscles. Arsenical paralysis is sometimes developed ; it is a progressive and pain^ ful neuritis affecting in the beginning the extensors and peronei muscles of the legs and foot, and sometimes involving later the arms. Tremors and contractures of the muscles and the steppage gait are usually pro- duced. Diagnosis. — Lead-neuritis is distinguished by the history, the blue line in the gums, and generally by the primary affection of the arms. Alcoholic neuritis can generally be recognized by the history and appear- ance of the patient; the face is flushed, not pale, and generally an acne rosacea appears. 6i4 PRACTICE OF MEDICINE Treatment. — The source of the poisoning must be removed; the occu- pation of the patient changed, perhaps. In early cases this is soon fol- lowed by recovery. The patient should drink freely of water in order to favor the elimination of the poison. Further than that the treat- ment is symptomatic. Galvanism and massage are beneficial for the neu- ritis. FOOD-POISONING. BROMATOTOXISMUS. 1. Ptomain-Poisoning. — This is, perhaps, the most common form of food-poisoning encountered in our country. The nature of these poi- sonous alkaloids has been described on page 35. They may be formed in the food before it has entered the body, or afterward in the intestine. Some ptomains are extremely toxic, others are harmless. The poison is to some extent destroyed by cooking. 2. Meat-poisoning (kreotoxismus) is produced by eating pork, sau- sage of various kinds (botulismus or allantiasis), and occasionally from beef, veal, or mutton. Although the poisonous ingredient is in most in- stances due to a form of decomposition, it is not known to be identical with any of the ptomains. Its nature is, in fact, not known. Such intoxication has repeatedly followed the eating of canned meat, but in some such cases the poisoning has been attributed to a metallic poison. The meat of wild animals and birds is sometimes rendered poisonous by their food. Symptoms. — The symptoms usually develop within six hours after the poison has been ingested. WTien due to a ptomain formed within the body, they may be delayed as long as forty-eight hours or more. The first indication is often a chilliness or pronounced rigor, followed by nausea, vomiting, griping pains in the abdomen, with vertigo, ex- treme prostration, cold perspiration, and great thirst. Diarrhea is gen- erally present and may be severe. Fever, 101° toio3°F. (38°— 39.5° C), is common and may last for several days. The pulse becomes rapid and feeble, dyspnea may be urgent. An intense pain is sometimes felt in the chest or between the shoulders. The tongue is heavily coated, often brown, with red tip and edges. The stools are offensive. Cramps in the extremities, twitching of the face-muscles, prickling and tingling of the fingers, and psychical disturbances or stupor characterize some cases. Fatal cases are usually attended with collapse, like that of cholera, with extreme coldness of the surface and rapid shrinking of the tissues. 3. Milk-Poisoning (Galactotoxismus). — This is due to the develop- ment of poisons by bacteria in milk, and it is most frequently encoun- tered in infants. Cream, ice-cream, and cheese are often poisonous from the presence of the t3^rotoxicon of Vaughan, or even more fre- quently from the presence of other poisons not }'et identified. The symptoms are those of acute gastroenteritis, and do not materially differ from those of ptomain and meat-poisoning. 4. Poisoning by Fish (Ichthyotoxismus) and Shellfish— (^r) Two forms of fish-poisoning are recognized. One is due to a poison secreted by glands of the fish, especially the sturgeon of Russia, the barb of Europe, and the tetrodon of Japan. The other is produced by the bac- FOOD-POISONING 615 teria of putrefaction. The symptoms are those of intense disturbance of the gastrointestinal tract, nausea, vomiting and diarrhea, some- times accompanied with profound nervous prostration and weakness. Death sometimes occurs within a few hours. ((^) Mussel-Poisoning (Mytilotoxismus).— This form of intoxication is attributed by Brieger to a ptomain found chiefly in the liver of the mussel; cooking does not destroy it. The symptoms are acute and often fatal. They are almost solely due to the effect of the poison on the nervous system, and consist of numbness, extreme weakness, with rapid, feeble pulse, dilated pupils, subnormal temperature, and finally collapse. Vomiting and diarrhea occur in some cases. Owing to idiosyncrasy, some persons are poisoned by eating oysters or clams. In such cases there is usually gastrointestinal disturbance, and often an eruption of erythema or urticaria. The treatment of all these conditions is alike. Vomiting and diar- rhea are to be encouraged, until it becomes evident that they no longer serve a beneficial purpose in removing the poison. In case they do not occur, the stomach should be washed out or an emetic administered, followed by a purge. The further treatment is symptomatic. Stimu- lants are generally required for the prostration and feebleness, morphin to arrest the diarrhea and quiet the nervous manifestations. 5. Grain- Poisoning (Sitotoxismus). — This was formerly of frequent occurrence in some parts of Europe, but it is almost unknown in the United States. It may occur under several forms : (eaf/we/7f.— Prophylaxis requires care in the passage from a high to low pressure. A series of chambers having graded pressures is provided in properly constructed caissons. The immediate return of the patient to the higher pressure relieves all symptoms, and he may then, in a short time, be gradually removed to the surface. When this cannot be done, the patient must be confined to bed. Morphin may be required for the pain ; hot fomentations and massage ameliorate the suffering. Strychnin should be administered in the treatment of the paralyses. MYELITIS. ACUTE, GENERAL OR TRANSVERSE MYELITIS, WHITE SOFTENING OF THE CORD, INFLAMMATION OF THE SPINAL CORD. Definif/on.—A localized transverse or diff'use inflammation of the spinal cord, followed by softening or sclerosis. Eiiology. — The disease usually occurs in males between the ages of 10 and 30 years. It most frequently follows exposure to cold and wet, but may result from severe trauma, as fracture of the spine, strong muscular strain, or from emotional disturbance. It occasionally develops upon one of the acute infectious diseases, as the exanthemata, rheumatism, septicemia, or smallpox. It is sometimes associated with syphilis or nephritis, and it may be induced by one of the metallic poisons or chronic alcoholism. Peripheral neuritis and meningitis are thought to be possible causes. A syphilitic history is frequently obtained. Morbid Anatomy. — In transverse myelitis the disease is limited to a small vertical area extending entirely across the cord; when a larger portion is affected, it is termed diffuse myelitis. When several areas are involved in different parts of the cord, it is a disseminated myelitis; and when only the gray matter is aff'ected, it is a central myelitis. The disease is most frequently situated in the upper dorsal region, next in the cervical, and then in the lower dorsal; it rarely affects the lumbar cord, except in the disseminated form. In some cases the cord shows little or no change upon ocular inspection, while in other, advanced cases it is extremely soft, almost diffluent, or greatly hardened, sclerotic, owing to the proliferation of interstitial connective tissue. The cord may appear swollen, the membranes congested, the fibers in a state of yellow atrophy (the color being due to pigmentation), or there may be fatty degeneration in cases of long standing. In central myelitis there is often red softening, occasionally also small cavities. Such new elements as the so-called Deiter's "spider" cells and granular fatty masses may be found. Amylaceous bodies are not uncommon. The nerve fibers and cells may 640 PRACTICE OF MEDICINE "be swollen and disintegrated in the lesions and for some distance above and below them. Blood-corpuscles are sometimes present. Obliterative arteritis is observed in some cases. Symptoms. — The onset may be acute with fever, subacute, or chronic. Convulsions may occur in children. The manifestations vary with the portion of the cord affected. Such premonitory symptoms as numbness, tingling, formication, and weight or girdle pains may be present, but, as a rule, the motor disturbances precede the sensory. The first symptoms are irritative ; they may be motor, sensory, vesical, or rectal. A girdle sensation corresponding to the location of the lesion soon develops, and a partial or complete paraplegia follows. Hyperesthesia may be present, especially in the zone above the girdle, but in a short time all sensation is lost in the parts affected. The application of heat to the hyperesthetic area occasions a sensation of pain. WTien the myelitis extends to the cervical spine, the power of motion is lost in the upper extremities. The reflexes, both of the tendons and of the skin, are diminished or obliter- ated in the beginning, but later become exaggerated, except in central myelitis, when they are lost unless the disease be confined to the cervical and upper dorsal region. The electrical reactions generally remain nor- mal, but the reaction of degeneration is sometimes obtained. When the centers of the sphincters are involved, there is involuntary fecal evacua- tion and incontinence of urine from overdistention of the bladder. Atro- phic changes are unusual. The muscles become soft and relaxed, but there is little atrophy except when the gray matter is involved. Rigidity often occurs. Bedsores frequently develop early ; they are superficial and not regarded as trophic. In chronic cases, however, deep sloughs of this character may occur. Optic neuritis is sometimes observed in these cases. The duration of the disease varies from a few days to several years. Apparent improvement may occur, but, as a rule, the disease becomes chronic and the patient is left a hopeless paralytic, greatly tormented at times by muscular twitching, spasm, or flexures, involuntary evacua- tions of urine and feces, and bedsores. Recurrent cases are occasionally encountered. In another group spontaneous recovery occurs after a year or more of complete rest. Acute central myelitis is distinguished by a more violent onset, with hyperpyrexia, sometimes with convulsions and complete paralysis. The course is rapid and usually fatal. In transverse myelitis of the cervical cord as high as the sixth or seventh vertebra, the upper extremities are more or less completely par- alyzed, and sensation is gradually lost. In some instances, however, only the arms are involved, and the shoulder muscles sometimes escape. Vomiting, hiccough, slow pulse, contracted pupils (miosis), dysphagia, dyspnea, and syncope are sometimes met with. Diagnosis. — Acute ascending paralysis is excluded in the diagnosis of central myelitis, which it most resembles, by the less marked sensory and trophic disturbances and the absence of fever. In multiple netiritis there is not usually so marked anesthesia, and the control of the sphincters is not usually lost. Tumors and hemorrhages of the cord are sometimes difficult or impossible of diagnosis, from the fact that they produce a form of pressure myelitis. MYELITIS 641 Prognosis. — An acute case may terminate fatally within a week ; chronic cases are often protracted for one or two years. Treatment. — In the more acute cases the spinal cord must be given complete rest, and the patient must, therefore, be confined to bed. This necessitates the greatest care and the exercise of scrupulous cleanliness in order to avoid the development of bedsores. In chronic cases the patient may take such exercise as he can, short of fatigue. He may be able to propel himself in a rolling-chair, but should always sit upon an air or water cushion. Catheterization is usually necessary, and should be done with due regard to cleanliness and the avoidance of cystitis. If incontinence persist, the patient should wear a urinal. Little or nothing can be done to modify the condition in the spinal cord. Ice-bags, coun- ter-irritation, blisters, and cupping are recommended, but they are of doubtful benefit. Mercury and potassium iodid are of doubtful utility, even in syphilitic cases, for they cannot restore the destroyed tissues. It is quite probable that the cases which recover do so independently of treatment. Strychnin should be administered, however, in full doses, gr. 1-40 to 1-20 (0.0016 — 0.0032), in order to stimulate the nerve-cen- ters to action; and after voluntary motion has been restored, the fa- radic current and massage of the muscles are of great value. Quinin and arsenic are also esteemed for their tonic effects. COMPRESSION OF THE SPINAL CORD. COMPRESSION MYELITIS. Definition. — Arrest of the functions of the cord, with or without in- flammation, as a result of compression. Etiology. — The cord may be compressed in any part in individuals of any age. The principal causes are fracture of the spine and tubercular caries (Pott's disease). It may be due to gummata, malignant neo- plasms, abscess, hemorrhage, thickening or purulent exudates of the me- ninges, thoracic or abdominal aneurism, echinococcus and other cysts, retropharyngeal abscess, extreme lateral curvature (scoliosis) or spina bifida. IVIorbid Anatomy. — The cord may be compressed or bent so as to lose its normal appearance without necessarily showing inflammatory changes. In some cases, however, there are punctiform hemorrhages, degeneration of nerve fibers, and proliferation of neuroglear cells. In old cases de- generative changes can be traced upward and along the cord from the primary lesion. Symptoms. — i. Vertebral Syniptoins. — Various deformities follow frac- ture, vertebral caries, growth of tumors, or other causal conditions. The disease sometimes develops rapidly, and terminates fa,tally through ero- sion of the vertebral artery. Pain is present in all cases, and it is espe- cially severe in those due to aneurism or other tumor. Local tenderness is usually present, and the slightest jar causes pain. 2. Nerve-Root Symptoms. — These differ as different nerve-roots are in- volved in their outward passage between the vertebrae. They consist for the most part of radiating peripheral neuralgic pains. Exquisitely painful areas (anesthesia dolorosa) are sometimes developed, especially in secondary cancer of the spine. Atrophy of the muscles supplied 41 642 PRACTICE OF MEDICINE through the affected roots often follows, but in a large group of cases attended with extensive vertebral disease the nerve-roots escape. 3. Cord Symptoms. — These vary with the region affected. There may be paraplegia or paralysis of all the extremities (quadruplegia), dyspnea from involvement of the phrenic nerve, dilatation of the pupils, trophic and vasomotor disturbances, as muscular atrophy, cutaneous eruptions and desquamations, bedsores, sweating, and alterations of local tempera- ture. The sphincters may be paralyzed, a girdle sensation may be pres- ent, and other symptoms like those of subacute or chronic myelitis are commonly observed. The diagnosis rests upon a careful study of the symptoms and the discovery of the underlying condition. The pain is most severe in cases due to aneurism, and the nerve-roots are more constantly affected in malignant cases. The symptoms are often obscure in tuberculous cases, but in these, as in those due to syphilis, there are usually other lesions and a definite history of infection. Persistent lumbago, Janeway states, is a significant sign of vertebral caries in some cases. Prognosis. — Cases due to tubercular caries sometimes become quiescent and those due to syphilis may subside under treatment, but in all other conditions the prognosis is exceedingly unfavorable. Treatment. — Tubercular cases should be treated according to the gen- eral methods for tuberculosis, with the addition of orthopedic appliances for the removal of pressure and the prevention or correction of deformity. Confinement to bed, with extension, is often necessary for a time. Cases due to gummata are generally relieved by potassium iodid. Excision of the vertebral laminae (laminectomy) has proved beneficial. In hopeless cases, as those due to tumors, morphin should not be withheld, and every effort should be made for the prevention of bedsores and excoriations. ACUTE ANTERIOR POLIOMYELITIS. I. ACUTE ANTERIOR POLIOMYELITIS OF CHILDREN. Infantile Spinal Paralysis, Essential or Atrophic Paralysis of Children, Definition. — An acute, febrile disease affecting the gray matter of the anterior horns of the spinal cord of young children, and producing pa- ralysis of certain muscles, followed by rapid atrophy of them. Etiology. — The disease usually appears before the fourth year of life and in previously healthy children of either sex. It rarely occurs in adults, mostly males. It is often erroneously attributed to injury, as by a fall. It is sometimes attributed to cold, dentition, muscular exer- tion, or mental strain. Most cases occur in summer, and for this reason, in part, but more particularly because the disease has appeared in epidemic form, it has been regarded by some writers as an infection. It may follow acute disease, menstrual suppression, sexual excess, dissipa- tion, or syphilitic infection. Morbid Anatomy.— The essential lesion is an acute hemorrhagic mye- litis in the cervical or lumbar enlargement. Degeneration follows, with rapid destruction of the ganglion cells, the growth of sclerotic tissue, vascular dilatation, and endarteritis. The disease is believed to originate probably as an embolism or thrombosis, in the ventral spinal artery. ACUTE ANTERIOR POLIOMYELITIS 643 usually of one side, rarely of both ; since the lesions correspond to the dis- tribution of its terminal or cornual branches. The cord is more or less deformed as a result of atrophy and sclerosis. The affected muscles also undergo degenerative changes, and the interstitial tissue becomes sclerotic. Symptoms. — The invasion is abrupt, or preceded by slight fever and malaise for a day or two. The course of the disease may be acute, sub- acute, or chronic. The first recognizable symptom, as a rule, is paralysis of one or more hmbs. Convulsions very rarely occur. The paralysis becomes complete within 24 hours, and the affected member is generally hyperesthetic and painful. In some instances, however, the disease pro- gresses more slowly. When more than one part is affected, the lesions are not symmetrical, except occasionally in adults. Monoplegia is the rule, with many exceptions, in children; paraplegia in adults. All the muscles of a limb are not usually affected to the same degree, and only a certain group may be involved, especially in the upper extremity. Crossed paralyses are peculiarly common to this disease. The paralyzed muscles undergo atrophy within a few days. Sensation is not affected, but the reflexes are obliterated in the affected limb, and the electrical reaction of degeneration is early established. The essential feature of this reaction is a sluggish contraction of the muscle in a state of degen- eration or supplied by a degenerated nerve to the galvanic current. The contraction is not instantaneous, as in health, but it may be induced by a weaker current, and the anode-closure contraction may be greater than the cathode-closure contraction. The less important features are an absence of response on the part of the muscles to the faradic current and a failure of the nerve to react to either the galvanic or faradic current. After a week or two, less frequently after three or four days, recession of the paralysis occurs in some or all of the muscles, but complete res- toration of voluntary motion is seldom, if ever, obtained. Later the affected limb falls behind the sound one in its growth, and muscular contractures increase the apparent shortening and deformity. All the forms of talipes are produced in different cases. The head of the humerus sometimes slips from its place, owing to weakness of the deltoid. Prognosis. — Error is rarely possible. Multiple neuritis seldom occurs in young children. It affects the peripheral muscles of the limbs sym- metrically and is accompanied with sensory disturbances. In the pseudo- paralysis of rickets the legs are usually affected, but the motion is restricted on account of pain, the power is not lost, and the muscles do not atrophy. The rachitic prominences lipon the head and joints, and along the sternum, the hyperesthesia and sweating, assist in the diagnosis. Prognosis. — The general health is not impaired, except by the loss of exercise. Complete recovery cannot be promised, but a great deal can be accomplished by persistent efforts for the improvement of the par- alyzed members. Treatment. — The patient should be made comfortable in the beginning by bandaging the affected limb loosely in a thick la)^er of cotton. A purgative dose of magnesium citrate should be administered. Excessive fever should be reduced by cool sponging. Morphin is rarely required for the pain. Sodium bromid may be given for the restlessness. The fluid extract of ergot should be administered in doses of Tl|x to xx (0.60 — 1.20) t. i. d for the first week. Counter-irritation over the spine only adds 644 PRACTICE OF MEDICINE to the suffering and accomplishes nothing. As soon as the acute symp- toms have subsided, a regular course of treatment by massage and electricity should be begun. A mild galvanic current should be applied at least twice a week to the spine and the affected muscles. The case should not be abandoned as hopeless for several years. Orthopedic treatment is often necessary for relief of the deformity. The nutrition of the child must be maintained with proper food, codliver oil, and malt preparations. 2. ACUTE POLIOMYELITIS IN ADULTS. When the disease occurs in adults, it does not differ materially from that of children, except in the more frequent occurrence of sym- metrical paralyses, as paraplegia or quadruplegia. Multiple neuritis is probably mistaken for this disease in some instances, although its onset is usually less sudden, the atrophy is less rapid and less profound, and the reaction of degeneration is very exceptionally present. When complete recovery follows a doubtful case, the diagnosis of multiple neuritis is established. ACUTE ASCENDING PARALYSIS. LANDRY'S PARALYSIS. Definition. — An acute paralysis beginning in the legs and extending rapidly upward to the trunk, arms, neck, and face, ultimately involving the muscles of respiration, and generally terminating fatally. Eiiology. — Men between 20 and 30 years of age are generally affected. Little is known of the cause, and pathological lesions have seldom been found. The disease sometimes follows an acute infection, and it has been regarded as a peripheral neuritis. A plausible theory is that it is pro- duced by a toxic agent affecting the lower motor neurons. Some authors look upon it as purely functional in character. Symptoms. — The first manifestation of the disease is usually a weak- ness of the legs, which develops into complete paralysis, often within a few hours. The muscles of the trunk, arms, neck, and, finally, those of respiration, deglutition, and articulation are affected in rapid succession. The entire course of the disease in fatal cases may occupy only two or three days, and it rarely extends over more than two weeks. The muscles do not atrophy, and the electrical reactions may remain normal; the reflexes are lost. The sensation may be normal or slightly impaired. The sphincters are not involved, profound dyspnea is induced when the respiratory muscles become implicated, respiration being carried on solely by the diaphragm. The mind and organs of special sense escape. The spleen and lymph-glands are sometimes moderately enlarged, and albu- minuria has been noted. Diagnosis. — The diseases to be excluded are myelitis, especiall}^ the acute central form, anterior poliomyelitis, neuritis, and possibly the par- alytic form of hydrophobia. From all these the distinction is based upon the rapid ascent of the paralysis, the great predominance of motor symptoms, if not entire absence of sensory manifestations, the presence of fever, and absence of electrical changes or sphincter involvement. Prognosis. — The disease usually terminates fatally within a few days, sometimes not for several weeks, from involvement of the bulbar centers PROGRESSIVE MUSCULAR ATROPHY 645 controlling the action of the heart. Recovery is possible only when the disease stops before it reaches the medulla. Treatment. — The patient should be given complete rest and freedom from noise or other disturbance. Ergot should be given in conjunction with potassium iodid. Quinin proves beneficial in some cases. It may be given in doses of gr. ij to iij (o.io — 0.20) three or four times a day along with the other remedies. If the case does not terminate fatally, the after-treatment is the same as that of poliomyelitis or multiple neuritis. PROGRESSIVE MUSCULAR ATROPHY. CHRONIC POLIOMYELITIS, WASTING PALSY, ARAN-DUCHENNE TYPE OF MUSCULAR ATROPHY. Definition. — A progressive' atrophy of the muscles, generally combined with paralysis and spastic rigidity, due to degeneration of the motor tract of the cord. Etiology. — The disease usually affects men between 20 and 60, develop- ing after exposure or during convalescence from an acute infection, as typhus or typhoid fever or diphtheria. A hereditary tendency can some- times be traced. Syphilis, lead-poisoning, or occupational strain of partic- ular muscles may lead to its development. IVIorbid Anatomy. — The essential lesion is a degeneration of the motor neurons of the lower segments of the cord, subsequently extending also to those of the upper segments. The muscles at the same time undergo degeneration and atrophy, with hyperplasia of their connective tissue (sclerosis). A distinct atrophic degeneration of the anterior columns of the cord is often visible, and the microscope reveals atrophy or destruc- tion of the multipolar ganglion cells. A similar change extends to the gray matter of the medulla. The neuroglia undergoes hyperplasia, which extends to the lateral columns in the so-called amyotrophic lateral sclerosis. In rare instances the degeneration can be traced to various levels in the motor areas of the brain, and the cortical centers may show degeneration. Symptoms. — The disease advances slowly and is for a time confined to groups of muscles in the upper extremities, much more frequently on the right side than the left. It occasionally begins in the legs, and rarely affects all the muscles except those of the eyeball and jaw. The onset may be preceded by pains like those of chronic rheumatism. The hands are generally first affected; the ball of the thumb becomes soft and wasted, then the interossei and lumbricales, and the characterist'ic claw hand is finally produced. In the forearm the flexors precede the ex- tensors; in the shoulder the deltoid is first affected, and sometimes it is the first to be involved in the upper extremity. The disease generally skips some of the muscles, and these falsely appear hypertrophied. Even the bones seem abnormally large in an advanced stage of the disease. Sensory disturbances are not usually observed. The atrophied muscles show a fibrillary twitching, which is intensified by percussion or a draught of air. The reflexes are greatly increased, and it is in this disease that a jaw-clonus can oftenest be obtained. The excitability of the nerves may remain after the muscles have become completely paralytic, and a partial reaction of degeneration is generally obtained. There is often a feeling 646 PRACTICE OF MEDICINE of numbness and coolness in the affected limbs. Sweating is often in- creased, the skin becomes harsh and pigmented, the nails curved and brittle, from trophic change. In the tonic form of the disease, the amyotrophic lateral sclerosis of Charcot, an interesting form of spastic paraplegia is sometimes observed. When the patient starts to walk, he is unable to step. After a moment's hesitation he takes several rapid short steps with the body inclined for- ward, then walks at a rapid gait until he attempts to turn, when the process must generally be repeated. The wasting of the muscles in this form is less than in the atrophic. As the disease extends upward in the spine, the symptoms of bulbar paralysis are produced, and the patient may still later become demented. Three other types of the disease, described also as muscular dystro- phies, are occasionally encountered. These are : (<;?) Erb's juvenile type, usually hereditary, occurring in young patients and similar to the atro- phic, except that muscular tremors and the reaction of degeneration are absent ; (Ji) the facial type of infants, beginning as an atrophy of the muscles of expression. The eyes show animation and seem to protrude, but the muscles respond but slightly in an attempt to smile. The dis- ease usually extends to the shoulders; (t-) the peroneal type (Charcot, Marie, Tooth). This begins in the legs, and several years later attacks the hands and forearms. Clubfoot is often produced. The duration of the disease is from 5 to 25 years or longer. Diagnosis. — In chronic myelitis the paralysis precedes the atrophy, and contiguous muscles are affected. The same is true of simple neuritis. There are also in some cases pain and hyperesthesia. The pain and sen- sory disturbances of multiple neuritis suffice for its exclusion, and the atrophy is never primary. Muscular pseudohypertrophy may cause con- fusion in the early stages, but the hypertrophy always affects the lower extremities, and the defective movements are not seen in the apparently atrophic muscles. Syringomyelia cannot always be differentiated, but, as a rule, the sensory disturbances enable one to recognize it. The prognosis is always unfavorable. A few cases of recovery have been reported. Treatment. — Strychnin should be given in full doses, and the vitality of the muscles should be further stimulated as long as possible by faradization, with an occasional application of the galvanic current, and massage. The patient should live in the open air and take light and regular, exercise. The needle bath and other methods of hydrotherapy should be tried, and nutrition must be maintained. Gowers favors the use of arsenic. Potassium iodid and mercury must be employed in cases having a syphilitic taint. GLOSSOLABIOLARYNGEAL PARALYSIS. PROGRESSIVE BULBAR PARALYSIS. Definition. — A progressive paralysis and atrophy of the muscles of the tongue, lips, and larynx. Etiology. — The disease rarely occurs in those under 40. It is most common in men of neurotic type. Syphilis, alcoholism, and mental strain are predisposing causes. POSTERIOR SPINAL SCLEROSIS 647 Morbid >l/7afo/n/.— Degenerative changes are found in the nuclei of the hypoglossal, facial, spinal accessory, and vagus, and in the anterior pyramids. The lesions are identical with those of progressive muscular atrophy, and the symptoms of the latter disease are often present. 5/myofo/ws.— Prodromal numbness in the back of the neck or slight pain has been noted, but it is unusual. The first symptom is generally a difficulty in the pronunciation of the labials, dentals, and linguals : /, b; /, d; /, m, etc. As the lower lip becomes affected, it droops and the saliva escapes. The food collects between the lip or the cheek and the gums. Mastication and deglutition soon become difficult, for the tongue is unable to propel the bolus into the fauces, and the food is often regurgitated into the nares. Then the voice becomes feeble and nasal. The patient becomes emotionate and neurasthenic. The affection of the facial muscles causes partial loss of expression, and the nasolabial folds are deepened. The involvement of the pneumogastric causes alteration of the heart's action and dyspnea. Diagnosis. —The conditions most Hkely to be confounded with the dis- ease are cerebral hemorrhage, especially bulbar hemorrhage, multiple scle- rosis, and possibly facial trophoneurosis. From all these, however, it is readily distinguished by its slow development and progress, the sym- metry of the lesions, and the reaction of degeneration. Prognosis.— Recovery probably never occurs, but the course of the disease is often slow, and interrupted by intervals of more or less com- plete remission. Death is seldom delayed beyond five years, however, and may occur at any time as a result of aspiration pneumonia from the entrance of food into the trachea, or from asphyxiation due to its lodg- ment in the larynx. Treatment— K medication be employed, it should be the same as for progressive muscular atrophy. It is more important, however, to main- tain the nutrition and strength by a concentrated liquid diet. After the patient becomes unable to swallow, gavage must be resorted to. THE SPINAL SCLEROSES. POSTERIOR SPINAL SCLEROSIS. LOCOMOTOR ATAXIA, TABES DORSALIS. Definition.— A chronic disease characterized by degeneration and scle- rosis of the posterior columns of the spinal cord, producing inco-ordina- tion, sensory and trophic disturbances, and sometimes associated with degeneration of the spinal ganglia and peripheral nerves. Etiology. — The disease occurs, as a rule, in men between 30 and 40, and particularly in those who have at some time been the subjects of syphilis. Exposure to cold and wet, fatigue, dissipation, sexual excess, and in- jury are often contributing influences, any one of which may induce the disease in a syphilitic subject, even though that disease may have been dormant for many years. Morbid Anatomy.— The disease begins as a degeneration of the pos- terior root-zones. From the several sets of fibers the degeneration ad- vances into the tract of Lissauer and the columns of Burdach, Clark, 648 PRACTICE OF MEDICINE and GoU, and the fibers are ultimately replaced to a great extent hy connective tissue the contraction of which causes compression of the cord. Several investigators trace the beginning of the disease a step further to a chronic inflammation of the pia mater. The nerve-fibers are very unequally affected in some cases, one set showing an early stage of degeneration, while another is far advanced in the sclerotic process. Finally, the entire posterior columns become converted into a mass of. connective tissue containing few remnants of nerve-fibers. In some ad- vanced cases the anterolateral ascending tract is involved and a periph- eral neuritis is developed, particularly in the sciatic nerve, sometimes in the optic, fifth, sixth, eighth pneumogastric, and glossopharyngeal. The articular affections are attributed to asymmetrical lesions sometimes found in the anterior columns. Lesions are occasionally found within the cranium. Symptoms. — ^The course of the disease is exceedingly chronic and by no means uniform ; it may last for many years, or it may terminate at any stage through various accidental complications. The symptoms are conveniently considered under three heads, corresponding to different stages of the disease. These stages are not separated by distinct lines, and there is great diversity in their sequence. (i) Initial or Preataxic Stage.— Sensory symptoms are often first to be recognized, and one of the most common is pain. This is manifested in the form of sudden, spontaneous, often atrocious, darting, or " light- ning" pains, shooting down the arms or thighs, or visceral and affecting the stomach and bowels. The latter form is usually accompanied with violent retching and vomiting independent of the ingestion of food, and constitutes the gastric crises. In the same manner crises may affect the heart, larynx, kidneys, bladder, urethra, clitoris, or rectum. These crises may precede other symptoms for several years. Paresthesia is often an early symptom, alone or associated with the pain and other manifestations. It usually begins as a numbness, tinghng, itching, creeping (formication), or burning in the feet and legs. A highly char- acteristic complaint is an absence of normal sensation in the soles. The patient feels in walking as if he were treading upon a soft carpet or upon the air. The hands may be involved early or late, and he experi- ences difficulty in executing delicate movements, as in tying a cravat or buttoning his clothing, and his handwriting is altered. The tactile sense is affected so that the sense of pain, as that of a pin-prick, travels slowly and may be referred to the wrong extremity or to both. The tempera- ture sense may be impaired or completely lost. A feeling of constriction, or girdle pain, is sometimes experienced at the wrist, knee, or ankle. Loss of the patellar reflex, or knee-jerk, is a valuable and early symp- tom in many cases and may precede all others (Westphal's symptom). This feature is rarely absent. The patient should sit for the test upon the edge of a table, or the leg may be supported by the hand of the examiner placed under the knee, and his attention should be diverted by having him grasp the sides of the table or chair, while a sharp blow is struck upon the lower border of the patella. The other reflexes are usually lost during the progress of the disease. Ocular symptoms appear early in some cases and late in others. The most common of them are a gradual loss of vision, sometimes terminating in blindness, due to atro- POSTERIOR SPINAL SCLEROSIS 649 phy of the optic nerve; single or double ptosis (drooping- lids), paralysis of one or more of the external muscles of the eye, and the Argyll Rob- ertson pupil, in which the iris contracts during accommodation, but not to light. The pupils are often closely contracted (spinal miosis). Trophic and vasomotor symptoms are occasionally observed early, but not, as a rule, until the ataxic stage. Difficulty in the evacuation of the bladder and decrease of sexual power and desire are sometimes early manifestations ; incontinence of urine and cystitis may appear later. (2) Ataxic Stage. — The typical symptom of this stage is the loss of the muscle sense. This is usually gradual, and, as stated, may appear early or it may be well advanced before it is recognized. In it the patient loses the normal sensation in the feet, as already described, and he cannot recognize the position of his hmbs in bed. He is unable to walk steadily in the dark, to stand upon one foot, or with his feet to- gether, when his eyes are closed (Romberg's symptom). A toppling forward while in the act of washing the face is highly typical. Inco-ordi- nation of movements soon develops, and the characteristic ataxic gait is produced. The patient can guide the movements of his feet only through the sense of sight. He walks with his body inclined forward, his feet wide apart, and usually with the aid of a cane. The feet are swung outward and forward and brought down flat or on the heel. Inco-ordination of the arms develops later in most cases, occasionally before that of the legs. The patient experiences difficulty in all delicate movements. If asked ta extend the arm and to immediately touch the tip of his nose with the forefinger, he misses the mark and may fail to touch his face. The muscles become relaxed and the joints can be abnormally extended; the knees sometimes bow backward, yet the muscular strength is retained. Sensory Symptoms. — Li addition to the sensory symptoms referred to under the Initial Stage, areas of hyperesthesia or of anesthesia may be present, particularly in the lower extremities, but sometimes in the form, of bands about the thorax. The affections of the eye sometimes develop in this stage, but it is a peculiar fact that atrophy of the optic nerve is rarely associated with ataxia. Deafness may develop, but the sense of smell is seldom affected. There may be incontinence of urine and cystitis in this stage, as stated, and the inflammation may extend to the kidneys. Obstinate constipa- tion is the rule; the anal sphincter becomes relaxed. Trophic disturbances are common. The fulgurant pains may be ac- companied with an eruption of herpes, edema or local sweating. The nails become atrophic and the hair falls. A perforating ulcer sometimes forms in the foot, back of the big toe or in the heel, occasionally in the cheek, and a round ulcer may be found in the rectum. The joint lesions most frequently affect the knees. In the so-called Charcot joint, the con- ditions are very similar to those of arthritis deformans, but suppuration sometimes develops, and dislocation or spontaneous fracture may occur. Extensive effusion sometimes collects about the joint (hydrarthrosis) and may rupture spontaneously. Late in the disease the muscles un- dergo atrophy, probably as a result of degeneration in the ventral horns or of peripheral neuritis. Frankel has called attention to the ability of the patient to extend his legs completely when they are at a right angle to the body, lying upon the side (hypotonia). Cerebral symptoms are 650 PRACTICE OF MEDICINE frequent : hemiplegia at any time ; melancholia, paralj^tic dementia, or paranoia, at a late period. 3. Paralytic Stage. — This stage begins when the patient finally be- comes unable to walk. Absolute helplessness often characterizes the condition, and the sphincters are often paral_vzed. The patient may linger for months in this state, often blind and deaf, until death super- venes from exhaustion or some intercurrent disease. Diagnosis. — There is seldom difficulty in the diagnostication of a well- marked case. The loss of patellar reflex, the inco-ordination, the loss of muscular sense, the crises, and the Arg}dl Robertson pupil are all pathog- nomonic. Several conditions may, however, enter into consideration. Disease of the ce7-e'benii7n is accompanied with inco-ordination, nausea, and vomiting, but there are also headache and vertigo, and the pain and pupillary reaction are absent. Ataxic paraplegia \% c\v3.x3s:ttx\ztA.\iY an increase of the patellar reflex. Multiple neuritis produces hyperesthesia along the course of the affected nerves, without inco-ordination, crises, or ■ocular symptoms. Poly7ieuritis is attended with a steppage gait, without the more characteristic symptoms of tabes. Its onset and course are much more acute. There is often ataxia in cerebral disease, but only one limb is aff"ected, as a rule. General paresis is sometimes accompanied by the symptoms of locomotor ataxia or it may develop late in the history of the latter disease; under such circumstances a diagnosis may be difficult. Recurrent attacks of visceral neuralgia are often an initial manifestation of this disease, and its absence can be determined only when, after careful study of the case, all other s3^mptoms are found to be absent. In a syphilitic subject a conclusion should not be too hastily arrived at. Prognosis. — Recovery is impossible after the disease has become fully established and the cord sclerotic. Long periods of quiescence may occur, however, and a slow progress of fifteen or twenty years is possible. Treatment. — The first essential is a removal of all causal influences, as alcoholism, sexual or other excesses, and the patient must avoid fatigue. Since the mind remains unaffected until a very late stage, he may con- tinue his occupation if a professional or business man. It is well in all cases to administer mercury and potassium iodid for a period of several months, as the disease is often arrested in this manner, for a time at least. Gold and sodium chlorid and silver nitrate are occasionally em- ployed, but they are of doubtful utility, and the danger of argyria ex- ceeds any possible gain to be obtained from the silver salt. Ergot, calabar bean, arsenic, strychnin, and other drugs are recommended by some writers. Local applications, ice-bags, cold douches, blisters, and the cautery, are recommended, but they are to be thought of only in cases presenting an unusually acute onset, and they, as a rule, unnecessarily confine the patient to bed. Galvanism of the spine is extolled by Gray and others, but it is not always well borne. The suspension treatment is now seldom resorted to. It consists in suspending the patient by the arms and head by means of a suspension apparatus for from 30 seconds to three minutes twice a week. The ob- ject is to make traction upon the cord. Many patients are much relieved for a time, but the method can exert no influence upon the sclerotic tissue. PRIMARY LATERAL SCLEROSIS 651 The crises can be overcome in some cases only by the administration •of an opiate, which is to be avoided as long as possible. Sodium sali- cylate, phenacetin, acetanilid, or canabis indica should be employed ; and when they fail, codein may be given in doses of gr. % (0.0 1). Regula- tion of the diet and relief of constipation often diminish the frequency of the gastric crises. The application of the faradic brush is sometimes of benefit. When the crises are accompanied with high arterial tension, they ^re sometimes relieved by continued administration of glonoin. Fran- kel's method of re-educating the patient in co-ordinated movements yields good results in some cases in the hands of a skillful instructor. In the paralytic stage the utmost care is necessary for the avoidance of bedsores and excoriations. Catheterization, vesical irrigation, and liigh rectal injections are often beneficial. PRIMARY LATERAL SCLEROSIS. SPASTIC PARALYSIS OF ADULTS, SPASTIC SPINAL PARALYSIS. Definition.— K gradually increasing paresis with spasm of the muscles, without atrophy or sensory disturbance, usually beginning in the lower extremities and probably due to degeneration of the pyramidal tracts. Eiiology. — The disease is most frequent in middle-aged men with syphi- litic taint. Symptoms.— The patient complains of fatigue and stiffness of the legs, sometimes of pain, and later his legs become rigid when he stands. He walks stiffly upon the balls of the feet without touching the heels and without bending the knees, taking short, quick steps and, in an advanced stage, crossing one leg in front of the other. The legs can be passively ilexed slowly to any angle, and remain there, but an attempt at sudden flexion is resisted. In the worst cases the legs are drawn closely together "by the adductors. x\ll the reflexes of the lower extremity are usually much increased. The strength of the muscles is retained until late, as a rule. In an advanced stage, the arms often become similarly affected, rarely simultaneously with the legs. Ocular symptoms are rare. The sphincters are involved late in some cases. The plantar reflex is so altered, in some cases, that slight irritation of the sole causes exten- sion of only the great toe (Babinski sign of organic disease of the pyramidal tract). The course of the disease is exceedingly chronic, but it may not interfere materially with the general health for many years. Diagnosis. — In the absence of a definite pathology, the diagnosis is necessarily difficult. Tumors, hemorrhage, vertebral caries, transverse myelitis, and hysteria can sometimes be excluded with great difficulty. General paresis sometimes begins with the symptoms of this affection. Prognosis. — Recovery is not to be hoped for. Treatment. — Potassium iodid and mercury should be administered. Ergot may also be employed. Hot baths and massage may be of benefit. Hereditary Spastic Paraplegia (Hereditary Spastic Spinal Paralysis). — (See also Cerebral Paralyses of Childhood.) Two groups of cases are recognized. One develops in infants or young children and is accom- panied with cerebral disturbances, as epileptic seizures or mental dullness. 652 PRACTICE OF MEDICINE Erb referred the symptoms to degeneration of the lower part of the pyramidal tract. In the other group the disease develops between the 2oth and 30th years as a spastic condition of the legs, short of paralysis, progresses slowly for years, and finally affects the arms. At the end the paralysis becomes complete and may slightly involve the bladder. Amaurotic Family Idiocy. — This is another form of infantile paraly- sis occurring in families and characterized by mental disturbances which deepen into idiocy; paresis ending in paralysis, partial and later total blindness, with normal, increased, or decreased tendon reflexes. Secondary Spastic Paralysis. — This term is applied to spastic paralysis developing in the course of any disease affecting the pyramidal tract, as in transverse, compression, or chronic myelitis, or in multiple sclerosis. The condition is recognized by the rigidity and the exaggeration of the reflexes. Erb's Syphilitic Spastic Spinal Paralysis (Toxic Spastic Spinal Pa- ralysis — Osier). — This is regarded by Erb as a form of transverse myelitis. It is characterized by muscular rigidity, exaggeration of the deep re- flexes, sometimes with paresthesia and the girdle sensation, disturbance of the sphincters, and impotence. Hysterical Spastic Paraplegia. — This is characterized by partial loss of power, moderate rigidity, atrophy, increased reflexes, and in some cases a spurious ankle clonus (Gowers). ATAXIC PARAPLEGIA (GOWERS). Definition. — Sclerosis of the posterior and lateral columns, sometimes annular or diffuse and not confined to the pyramidal tracts. Etiology. — The disease usually occurs in men of middle age without syphilitic history, sometimes after injury or exposure to cold. Morbid Anatomy. — The sclerosis in many cases is confined to the ter- minal branches of the dorsal spinal artery (Marie). Symptoms. — The legs feel tired and the gait is unsteady and stamping. There is no pain or sensory disturbance. The inco-ordination and rigid- ity increase, and the arms finally become involved. The reflexes become exaggerated. The sphincters are affected late. Eye symptoms are rare. The diagnosis is based upon the inco-ordination without loss of reflexes, ocular or sensory changes. HEREDITARY ATAXIA. FRIEDREICH'S ATAXIA, HEREDITARY TOXIC PARAPLEGIA, POSTEROLAT- ERAL SCLEROSIS. Definition. — A combined degeneration and sclerosis of the posterior and lateral columns of the cord and posterior nerve-roots, producing ataxia and paraplegia. Etiology. — The disease occurs in families, affecting, as a rule, several brothers and sisters, but it is not always hereditary. It generally de- velops in childhood or early life and more commonly in males. Syphilis is not a constant factor in its production. SYRINGOMELIA 653 Morbid Anaiomy. — The lesions are a combination of those belonging- to locomotor ataxia and those of the ataxic paraplegia of Gowers. The sclerosis is thought by some writers to be neuroglear and different from other spinal scleroses. The lesions are generally found in the cer- vical and lumbar regions. Symptoms. — The inco-ordination begins in the legs, and the gait is more irregular and swaying than that of locomotor ataxia. The arms are more pronouncedly affected than in the latter disease. There is often a swaying movement of the arms and head (static ataxia) when the body is at rest; sometimes the movements are more like those of chorea. The patient is generally unable to walk. The paraplegia is rather a paresis than a paralysis. Late in the disease, contractures, scoliosis, and talipes equinus,with dorsal flexion of the great toe, develop. Hyperesthesia and retardation of sensation are occasionally present, but, as a rule, there is no sensory disturbance. The deep reflexes are early lost, but the cutaneous and pupillary remain normal. Nystagmus is a constant and characteristic symptom. The speech is slow and scan- ning. The mind remains normal until late. Diagnosis. — Ataxic paraplegia is excluded by the absence of the knee- jerk, ankle clonus, and muscle spasm. Locomotor ataxia is distinguished by its ocular symptoms, and it is a disease of later life. Disseminated sclerosis is characterized by greater inco-ordination of the arms and less of the legs. He^-iditary chorea is not accompanied with nystagmus, loss of the deep reflexes, scoliosis, talipes, or flexion of the toe. Prognosis. — There is no possibility of recovery, but the disease is not incompatible with many years of life. Treatment. — This is the same as that of locomotor ataxia, but fewer cases are benefited by the potassium iodid. Massage and other methods for the prevention of contractures should be employed. Cerebellar Type. — Marie and others have described a type of the dis- ease occurring in adults and due to atrophy of the cerebellum. The legs become rigid, but the tendon reflexes are retained. Scoliosis and talipes are absent. Toxic Combined Sclerosis. — A combined sclerosis affecting several col- umns of the cord is sometimes observed after poisoning with ergot and in pernicious anemia, pellagra, and some of the chronic wasting diseases, probably as a result of poisons produced in the body. Progressive Interstitial Hypertrophic Neuritis of Infants.— This is a rare family disease occurring in early life, described by Dejarine and Sottas. It is characterized by the symptoms of locomotor ataxia com- bined with those of progressive muscular atrophy, including the face, and hypertrophy and sclerosis of the peripheral nerves. SYRINGOMYELIA. Definition.— k disease of the spinal cord due to the growth of glioma- tous tissue about the central canal, and resulting in the formation of small cavities. Efiofogy.— The disease is an infrequent one, usually affecting males 654 PRACTICE OF MEDICINE from the fifteenth to the thirtieth year. Nothing is known of the excit- ing cause. Morbid Anatomy. — Small cavities of various shapes are formed around the central canal resembling, but distinct from, hydromyelus. The cavity is usually situated in the dorsal region, sometimes in the cervical, and may extend the entire length of the cord. It may involve only one dorsal cornu. The morbid process is a gliosis, a growth of embryonic neuroglear tissue, with subsequent degeneration or hemorrhage and cav- ity formation. Symptoms. — The disease begins with pains in the arms and pares- thesia of the hands, followed by anesthesia. Its progress is slow, ex- tending to the trunk and then to the lower extremities. A spastic con- dition develops, with exaggeration of the reflexes and sometimes the peculiar symptoms of amyotrophic lateral sclerosis. The tactile and muscular senses and the special senses are retained, but the perception of pain and differences of temperature is lost. Injury often results from the latter condition. Trophic and vasomotor changes are common, par- ticularly in the hands. The sphincters are not involved until late, when the medulla becomes involved. Scoliosis may be produced. Very irregu- lar symptoms are sometimes observed which have been described bv Schlesinger as belonging to different types of the disease, as the (a;) motor, (i^) sensory, (r) trophic, or (^) tabetic manifestations predom- inate. Diagnosis.— The differentiation is to be made from progressive muscu- lar atrophy, Morvan's disease, and the anesthesia of leprosy. In a typical case the muscular atrophy, with the gait of amyotrophic lateral sclerosis, loss of pain and temperature perception, and retention of the tactile sense, is pathognomonic. Morvan's disease is further distinguished by its unilateral invasion and the loss of tactile sense ; and in leprosy the anesthesia is complete, perineuritis and tubercles are present, and the bacillus is found. Prognosis. — The course of the disease is slow and interrupted by re- missions. It may thus persist for fifteen or twenty years, but is ulti- mately fatal. The treatment is purely symptomatic. Morvan's Disease. — This is the trophic type of syringomyelia in the classification of Schlesinger. It occurs in neurotic subjects, usually young- adult males, sometimes after injury or exposure, with pains and atrophy of the hands and arms, followed by anesthesia, analgesia, and whitlows, sometimes with necrosis of the phalanges. The course of the disease is protracted. TUMORS OF THE SPINAL CORD. Tumors of almost every variety may be found in the cord or its membranes. With the exception of congenital lipomata, they usually occur between the ages of 30 and 50, more frequently in men. Tuber- cular, syphilitic, and gliomatous growths are the most common within the cord, while fibromata, sarcomata, syphilitic, and tubercular growths generally attack the dura. Parasitic cysts are occasionally found in the MALFORMATIONS OF THE SPINAL CORD 655 extradural space. The probable exciting causes are trauma and expos- ure. The tumor generally begins in the meninges; tumors of the ver- tebra sometimes extend to the cord. The tumor is small, and is usually situated in the lower cervical or in the dorsal region. The symptoms are a result of hemorrhage or softening and degeneration due to pres- sure; myelitis is occasionally set up. Symptoms. — There are often no local symptoms, in the absence of vertebral disease. Pain, referred to the distribution of the nerves that are involved in the pressure, is the most constant symptom, which is generally accompanied with disturbed sensation, at first unilateral, but becoming bilateral with the increasing growth of the tumor. Muscle rigidity and contractures develop, the reflexes are increased, and paraly- sis follows, with such trophic affections as bedsores. Sometimes a dif- ferent picture is presented, with loss of reflexes, girdle sensation, pares- thesia, hyperesthesia, or anesthesia in different areas, spasm of the mus- cles, and finally paralysis. The anesthetic areas are sometimes painful. The diagnosis is generally based upon the character of the disturbances in the nerve-roots from the affected region and the gradual paralysis, but in many cases the manifestations are so slight or so vague as not to be diagnosticated during life. In caries of the vertebrae, the pain is not usually so severe, and there are local tenderness and swelling or angular curvature (kyphosis). Cervical meningitis yields symptoms identical with tumor, but its progress is more rapid, as a rule. Trans- verse myelitis has also a more rapid course, and is further distinguish- able by the different order and location of the pain and other symptoms. The prognosis is unfavorable, except in early recognized syphilitic cases. The duration seldom exceeds three years. Treatment. — Potassium iodid should be given in large doses when there is a probability of syphilis. In other cases the treatment is symp- tomatic, unless surgical measures can be resorted to. MALFORMATIONS OF THE SPINAL CORD. Spina Bifida (Meningocele, Myelocele, Hydrorrhachis). — This is a con- genital affection, chiefly of surgical interest, due to imperfect closure of the spinal canal. A fluctuating tumor is formed beneath the skin, which contains a portion of the dura and arachnoid and cerebrospinal fluid. The tumor, usually situated over the lumbar or sacral region, varies in diameter from one to five inches. The cord may be normal or atrophic, and the dilated central canal sometimes communicates with the cyst cavity. Various pressure symptoms are occasionally produced, as talipes and perforating ulcer of the foot. Suppuration may de- velop in the sac, or rupture may occur, with immediately fatal result. Pressure upon the sac sometimes distends the fontanels and may pro- duce dyspnea and coma. The condition usually goes from bad to worse, but the patient occasionally recovers spontaneously or through oper- ative measures. Lesions of the Conus Medullaris and Cauda Equina.— Injury, disease, or tumor situated below the second lumbar vertebra may produce paraly- sis in groups of muscles or areas of anesthesia, loss of sphincter control,. 656 PRACTICE OF MEDICINE and disturbance of sexual function through pressure upon the lumbar nerve-roots. When the cauda equina alone is affected, the loss of sphinc- ter power may be the only symptom. DISEASES OF THE BRAIN AND ITS MENINGES. DISEASES OF THE MENINGES. EXTERNAL PACHYMENINGITIS. Definition. — An inflammation of the external layer of the dura mater of the brain. Etiology. — The most common cause is injury, especially fracture of the skull, caries, or inflammation extending from without, chiefly from the middle ear, frontal, or ethmoid sinus. Erysipelas is occasionally re- sponsible for an acute attack; syphilis is a common factor in the more chronic cases. Morbid Anatomy. — The dura is thickened, hyperemic, edematous, and opaque ; it may be detached and separated by an accumulation of blood or exceptionally by pus, but it is more commonly bound down by firm connective tissue. Laminge of bone are sometimes formed in it in chronic cases. Symptoms. — There are no typical manifestations. Headache and lo- calized tenderness are common to this and many other affections. Con- vulsions or local paralyses, usually of a mild type, are sometimes ob- served as a result of pressure. In a large group of cases, especially in the insane, the disease is discovered only upon autopsy. Treatment. — Medicinal treatment is limited to syphilitic cases, in which the usual remedies should be employed. An early resort to the trephine is indicated in most nonsyphilitic cases, especially when there is evi- dence of suppuration. Counter-irritation with the cautery has been rec- ommended. INTERNAL PACHYMENINGITIS. This is an infrequent aff'ection occurring as a pseudomembranous, puru- lent, or hemorrhagic inflammation, of which the hemorrhagic is the most common. Etiology. — The aff'ection is met with chiefly in advanced life, occasion- ally in children. It may occur, however, in chronic tuberculosis, syphilis, pernicious anemia, leukemia, valvular disease of the heart, or other con- ditions leading to degeneration of the blood-vessels. Morbid Anatomy. — One or more punctate, rarely profuse hemorrhages occur, as a result of which an accumulation of blood of variable quan- tity is formed between the dura and arachnoid. The clot becomes or- ganized to some extent. It is usually situated beneath the parietal bone, and the condition is sometimes bilateral. A hematoma is formed in the more extensive cases. Symptoms. — In many cases these are absent. Pressure symptoms are sometimes produced, however, and, from the situation of the aff'ection over the cortical centers, monoplegia or hemiplegia may result. Apha- sia may be produced. \^Taen the hemorrhage is extensive, convulsions DISEASES OF THE MENINGES 657 or fatal coma may be induced. In another group of cases, recurrent symptoms, not unlike those of brain tumor, may exist for many years. Spontaneous recovery has been noted in a few instances. The treat- ment is the same as that for external pachymeningitis. LEPTOMENINGITIS. Definition. — An inflammation of the pia and arachnoid membranes of the brain. Etiology. — Inflammation of the meninges in acute cerebrospinal men- ingitis, and that due to tuberculosis or syphilis, are not included under this heading, but are considered elsewhere. The disease under consideration occurs, as a rule, in the third and fourth decade of life, occasionally in childhood, and somewhat more frequently in males. («) It may arise from secondary infection through the bacilli or toxins of such diseases as typhoid fever, influenza, the acute exanthemata, rheumatism, septic pneumonia, or chronic nephritis. The pneumococcus or micrococcus lanceolatus is found in most of these cases, independently of pneumonia. The typhoid bacillus and the bacillus coli communis have been found. (^) Another group of cases owes its origin to extension of the inflammation from the middle ear, wounds, fractures, or caries of the skull, in which staphylococci or streptococci are usually present. Or the disease may arise from abscess of the brain, thrombosis of the sinuses, suppurative inflammation of the nose, frontal or ethmoid sinuses, or to erysipelas. Morbid Anatomy. — The lesions may be limited to a small, circum- scribed area, or they may extend over the entire brain and cord. They may be limited to the ventricles, particularly in children. When due to otitis, the disease is usually unilateral; due to pneumonia or ulcerative endocarditis, it is bilateral and generally confined to the cortex. In nephritis and cachectic conditions it is ordinarily confined to the base. The inflammation becomes suppurative almost from the beginning. (Consult also the paragraphs on the Morbid Anatomy of Cerebrospinal Meningitis, p. in, and Tubercular Meningitis, p. 179.) Symptoms. — Although a more or less typical train of symptoms is common to nearly all cases, there are often no peculiar manifesta- tions by which the exact character or location of the lesions can be diagnosticated. In a majority of cases the features are the same as those described under Cerebrospinal or Tubercular Meningitis. It should be borne in mind also that the supervention of headache, photophobia, retraction of the head, possibly with vomiting, constipation, and in- crease of temperature in the course of typhoid fever or other acute infection, may be due to hyperemia of the meninges, without actual in- flammation. W^en, however, these symptoms persist, and especially if convulsions occur, the pulse becomes slow, the vision obscure, the hearing impaired, and, when hyperesthesia develops, the face assumes a pained expression, and opisthotonos becomes pronounced, there is no longer doubt of the presence of meningitis. These symptoms often de- velop gradually, and the diagnosis may be in doubt for several days. In the early suppurative cases there are often chills, irregular fever, sweating, with projectile vomiting, and the pulse may be accelerated 42 658 PRACTICE OF MEDICINE instead of slow. The slow pulse, with fever, is more significant of this disease. Rigidity and twitching or spasm of the muscles, sometimes unilateral, are frequently observed. Incontinence of urine and feces often develops toward the close. Basilar meningitis is characterized more especially by pressure symp- toms due to involvement of the nerve-trunks within the cranium. Stra- bismus, ptosis, slight facial paralysis, anesthesia, and throphic disturb- ances due to involvement of the fifth nerve are common symptoms. The pupils, at first small, become dilated and often unequal. Optic neu- ritis, with deepening blindness, is not uncommon, and the respiration often becomes irregular. The reflexes may be exaggerated in the begin- ning, and lost at a later stage. Diagnosis. — The differentiation from acute cerebrospinal meningitis may be difficult, but this can generally be excluded by the absence of an epidemic, and the primary development of symptoms on the part of the spinal cord, as pain and tenderness, with retraction of the neck and rigidity or contractures of the extremities. The differential diagnosis between meningitis and other affections is considered under Cerebro- spinal Meningitis and Tubercular Meningitis. Prognosis. — Acute suppurative cases usually terminate fatally, but sur- prising exceptions are occasionally observed. In cases due to secondary infection, especially when they develop near the natural termination of the disease, the outlook is more hopeful, but the disease is always a grave one, and death is often preferable to the blind, paralytic, and frequently imbecile condition in which the patient is left after recovery. Treatment. — All the measures employed in the treatment of acute cerebrospinal meningitis are applicable in acute cases. The patient must be given complete rest in a quiet room. Ice-bags should be applied to the head, and to the spine when the cord is involved. Thorough ex- amination should be made in cases of obscure origin in order to deter- mine the cause, and, this done, the propriety of attempting relief through surgical measures should be considered. The assistance of a specialist is generally advisable. Counter-irritation by means of the cautery lightly applied to the back of the neck is often of benefit, and the barbarous seton of fifty years ago was often followed by prompt remission of symptoms. Lumbar puncture has yielded good results in some cases. The bromids should be administered freely ; morphin is sometimes neces- sary for the relief of pain. Potassium or ferric iodid is of benefit during convalescence. The diet should be nutritious and for the most part liquid. The action of the bowels must generally be regulated with laxatives. AFFECTIONS OF THE BLOOD-VESSELS AND CIRCULA- TION OF THE BRAIN. Endarteritis and Arteriosclerosis.— Degenerative changes are exceed- ingly common in the blood-vessels of the brain. The process is the same as that described under the heading Arteriosclerosis in the chapter on Diseases of the Circulatory System. It may be localized or general, and may result in moderate thickening of the intima or a complete obliteration of thelumen of the vessel (endarteritis obliterans). Atherom- atous patches are frequently produced, and a further result in many AFFECTIONS OF THE BLOOD-VESSELS 659 cases is the formation of miliary aneurisms. Syphilis is an important etiological factor, and a great majority of the cases not so produced occur in advanced life. Nodular periarteritis is peculiar to syphilitic cases. Aneurism of the Cerebral Arteries.— Aneurisms, other than miliary, which are considered under the head of Cerebral Hemorrhage, are occa- sionally met with, chiefly upon the outer surface of the brain, and, as a rule, in middle-aged men. They result from endarteritis or embolism and they are sometimes associated with endocarditis, since it is the most frequent cause of embolism. The left middle cerebral artery is most frequently affected, then the basilar or internal carotid and the commu- nicating arteries. The aneurism is generally saccular, occasionally ses- sile, seldom fusiform, and rarely exceeds a half-inch in diameter. Its structure is the same as that of aneurisms in other locations. They erode the overlying bone, produce moderate compression of the brain substance, and not infrequently rupture. Symptoms. — A constant headache is the most important feature. This is aggravated by anything which increases the blood-pressure, as exertion, straining, or stooping. There is usually a throbbing sen- sation, and the patient may hear a bruit with each pulsation. Vertigo, nausea, and vomiting are frequent symptoms. Manifestations distinctive of the location of the aneurism are seldom present. Rupture, with the production of apoplexy, is the usual termination. Diagnosis. — Aneurism is differentiated from other tumors of the brain chiefly by the intensification of the symptoms upon slight increase of the circulation. Optic neuritis favors tumor, endocarditis aneurism. Pressure symptoms involving the nerve-roots at the base generally point to aneurism, since it is more commonly situated in that region. Prognosis. — The disease terminates fatally by rupture in most cases within a few weeks after the development of pronounced symptoms. THROMBOSIS OF THE SINUSES AND VEINS. Thrombosis may arise primarily or secondarily through extension of inflammation from contiguous parts. Primary thrombosis is occasionally encountered in infants under six months of age, and generally in connection with diarrhea. Cowers re- gards thrombosis of the veins as a frequent cause of infantile hemiplegia. The so-called autochthonous sinus-thrombosis is met with in cases of anemia and chlorosis, usually in connection with thrombosis of the veins in other parts of the body. It occurs also in the late stages of cancer, tuberculosis, and other chronic wasting disease (marantic throm- bosis). Secondary thrombosis is a more frequent affection. It usually arises from disease of the internal ear, rhinitis, meningitis, tubercular caries, or fracture of the skull, compression by tumors, erysipelas, or suppura- tive disease in the tissues outside of the skull. Morbid Anatomy.— (Sae Thrombosis, p. 15.) Symptoms. — These are by no means uniform. Many cases begin with fever, and chills follow, often preceded by a constant headache, dizziness, and vomiting. The patient becomes listless, stupid, and finally delir- 66o PRACTICE OF MEDICINE ious, or he may have convulsions. Hemiplegia is not unusual, and other manifestations arise which more definitely point to the situation of the thrombus. Longitudinal Sinus. — Thrombosis of the longitudinal sinus is occa- sionally discovered at autopsy in cases presenting no symptoms. Head- ache, epistaxis, convulsions, vomiting, and other disturbances may, however, occur, and the veins of the face and head may be distended and the side of the head edematous. The fontanels are .distended in an infant, and meningitis may develop or convulsions and coma may be pro- duced. Lateral Sinus. — \Mien the cause is suppuration of the internal ear, this affection becomes aggravated and the tissues about the ear become edematous. The external jugular vein of the affected side, receiving less blood than its fellow, is more rapidly emptied during a full inspiration (Gerhard). The clot may extend into or through the internal jugular vein, causing it to become indurated and sensitive to pressure. Optic neuritis and nystagmus may develop, and in rare cases there is hoarse- ness or aphonia, dysphagia, and spasm of the muscles of the neck. Cavernous Sinus. — The important feature of this location is obstruc- tion of the flow of blood from the ophthalmic vein, causing edema of the conjunctiva and eyelids of the affected side, with protrusion of the globe. The retina becomes edematous, its veins distended and pulsat- ing. The orbital muscles may become paretic, with the production of strabismus. The ophthalmic branch of the fifth nerve becomes painful. Suppurative panophthalmitis may develop. In secondary thrombosis the onset is often sudden and the symptoms of septicemia may be pres- ent from the beginning, along with others to some extent of a localiz- ing order. The diagnosis is based upon the peculiar symptoms of localization, for the general features are common to tumors, abscess, and other affec- tions. The development of the symptoms described, in connection with chlorosis or anemia, is highly diagnostic of thrombosis. The prognosis is grave and usually extremely unfavorable. The treatment is surgical, especially in cases due to ear disease; or it is only palliative. ANEMIA OF THE BRAIN. The brain becomes anemic in those conditions in which there is gen- eral anemia, as after profuse hemorrhages, pernicious anemia, leukemia, or inanition. Anemia of the brain may result also from the accumula- tion of a large quantity of blood in certain regions, as in the peritoneal cavity after tapping for ascites. A more permanent condition results from aortic stenosis. Sometimes it is due to such local conditions as obliterative endarteritis, the pressure of tumors, or an obliteration of a portion of the circle of Willis, accumulation of fluid in the ventricles, the anemia involving the entire brain or only a part of it. The appearance of the brain after death is typical. The smaller ves- sels are empt}-, and the entire brain substance is moist and extremely pale. Anemia of the pia mater is usually associated with that of the brain. CEREBRAL HEMORRHAGE 66 1 Symptoms. — When the anemia develops acutely, vertigo or syncope is produced. WTien a little less acute there is roaring in the ears, flashes of light before the eyes, the sight becomes dim, respiration is rapid, sometimes nausea and vomiting occur, and the patient may become delirious. HYPEREMIA OF THE BRAIN. Hyperemia of the brain may be active or passive. Active hyperemia probably accompanies any marked increase of the general circulation ; but hyperemia of the brain is a condition of high intravascular ten- sion rather than an increased quantity of blood. A more or less general active hyperemia occurs in all inflammatory conditions, and perhaps in some of the acute iijfectious diseases, especially those accompanied with restlessness, insomnia, delirium or other cerebral manifestations. Passive hyperemia is induced by any influence which fetards the re- turn of blood from the cerebrum, as in general venous engorgement of valvular disease, emphysema, asthma, and sometimes from the pres- sure of tumors. The symptoms of hyperemia are not uniform. In- somnia, restlessness, convulsions, are generally attributed to active hy- peremia, while mental dullness and coma are regarded as belonging to passive hyperemia. Treatment. — That of anemia is general, consisting in the administra- tion of remedies for the improvement of the condition of the blood, re- lief of inanition, and tonics to strengthen the circulation. In hyperemia an effort should be made to reach the cause. Some relief is aff'orded by the application of ice-bags to the head, and the administration of full doses of the bromids, or 1 5-drop doses of hydrobromic acid. EDEMA OF THE BRAIN. This occurs, for the most part, in atrophy of the cerebral convolu- tions, thrombosis of the sinuses, passive hyperemia, chronic nephritis, occasionally in acute alcoholism, and locally in the vicinity of tumors and abscesses of the brain. The appearance of the brain is similar to that of anemia. The quantity of fluid in the ventricles and tissues is increased and there is general pallor. The symptoms are not clearly defined. If the view of Leube is correct, they embrace many of the cerebral manifestations of uremia. Treatment. — An effort should be made to hasten the absorption of fluid by catharsis, diuresis, and diaphoresis. The treatment must be modified to a great extent, however, to conform to the causal indica- tions. Digitalis and strychnin should be employed when the circulation is feeble. CEREBRAL HEMORRHAGE. APOPLEXY, INTRACRANIAL HEMORRHAGE, "PARALYTIC STROKE." Definition. — Hemorrhage due to the rupture of a cerebral blood- vessel. Etiology. — Cerebral hemorrhage occurs most frequently in individuals 662 PRACTICE OF MEDICINE over 50 years of age. It is occasionally met with, however, in infants or in young adult or middle life. In the latter group of cases it is gen- erally a result of syphilitic disease of the arteries. It is more common in men than in women, and the transmission of a hereditary tendency is often apparent, particularly in gouty families. Individuals with habitu- ally high arterial tension, whether natural or the result of alcoholic or other poisoning of the blood, are doubtless more liable to apoplexy than others, but there is no type of stature or physique by which such tendency can be invariably prognosticated. Predisposing Causes. — Conditions which favor a degeneration of the blood, with the production of endarteritis or arteriosclerosis, and par- ticularly the production of miliary aneurisms, strongly tend to the de- velopment of cerebral hemorrhage. Among these are syphilis, chronic alcoholism, chronic nephritis, gout, lead and other metallic poisons, anemia, leukemia, and purpura hemorrhagica. Excitijig Causes. — Violent muscular effort, nervous excitement, anger, fright, and intoxication are frequent exciting causes, but many cases occur independently of any such influences, at night and during sleep. Engorgement of the stomach by overeating and drinking, perhaps asso- ciated with constipation, often precedes an attack. Morbid Anatomy. — The essential lesion in a majority of cases is a rup- ture of a miliary aneurism. Next most frequent is the rupture of a ves- sel at a point weakened by atheromatous degeneration. Either of these conditions results from a primary hyalin or other degeneration of the intima, with softening, degeneration, and finally distention or destruc- tion of the media ; or beginning in the media and involving the intima. The aneurism which has ruptured is often found with great difficulty. It is most frequently situated upon a branch of the middle cerebral artery, especially in the anterior perforated space, but any of the cere- bral vessels may be involved. Secondary changes are found in the clots, and the nerve-fibers that have been subjected to pressure become sclero- tic or otherwise degenerated. Symptoms. — The onset is usually sudden, often in the midst of appar- ently good health and without premonitory symptoms. Such prodromes as headache, vertigo, thickness of speech, or numbness and tingling of the hand are observed in some cases for a few hours, possibly for several days before the seizure. Following the hemorrhage the symptoms may be divided into two groups, those of the attack (chiefly reflex), and later or localizing symptoms. The Seizure. — The first symptoms are in great measure due to shock. The patient becomes unconscious; rarely he is seized with a convulsion. Occasionally the seizure is less violent, intense headache is complained of, there are vertigo and nausea, vomiting, and psychical disturbance; the loss of consciousness is less sudden, and the paralysis may be recog- nized before coma has supervened. The coma is generally profound. The face is intensely cyanotic, or it may have an ashen hue. The respi- ration is rapid, full, snoring, and often stertorous. Expiration is ac- companied with dilatation of the cheeks and puffing of the lips. The pulse is at first slow and full, the arterial tension may be relatively normal or greatly increased. When the tension is high, the pulse often becomes rapid. The pupils are usually dilated, often unequal, and do CEREBRAL HEMORRHAGE 663 not respond to light. Conjugate deviation of the eyes and rotation of the head toward the side on which the hemorrhage has occurred are often observed; rarely the opposite or an alternating deviation. The tempera- ture is subnormal during the first twenty-four hours, but generally rises to 100° or 101° F. (37.8° — 39.3° C.) when the attack is not imme- diately fatal. The skin is cool and moist. This reactionary fever, as it is called, probably due to changes in the blood-clot and its absorp- tion, may last a week or two. All the muscles, even the sphincters, are at first relaxed — those which are paralyzed to a more profound degree than those of the opposite side. The face, particularly the mouth, is drawn toward the sound side. All the reflexes are abolished for a time. The paralyzed limbs may be warmer than those of the un- affected side. The localizing symptoms vary with the situation of the lesion. Since this is, in a majority of cases, in the anterior portion of the internal capsule, compression of the motor fibers from the cortex is produced, and hemiplegia results. The hemiplegia is said to be complete when the face, arm, and leg are affected, and incomplete when either of these parts escapes. The paralysis affects the side opposite the lesion within the brain, owing to the decussation of the fibers. In those instances in which the fibers do not decussate, and when the pressure is exerted below the point of decussation, the paralysis involves the muscles of the same side. In such cases the lower part of the face only is affected, the frontalis and orbicularis palpebrarum escape. The hypoglossal nerve is involved in hemiplegia, the tongue deviates to the affected side. Aphasia is some- times present. The completeness of the paralysis varies in different cases and in dif- ferent parts. That of the arm is usually deeper than that of the leg. •There is often absolute paralysis of the arm and leg, with only partial loss of power in the face muscles, and occasionally the leg is most deeply affected. A paralysis that is absolute in the beginning may rapidly subside into a partial one. Certain muscles frequently escape. Such trophic changes as the formation of vesicles or sloughing are sometimes developed in the paralyzed member. Monoplegias are sometimes observed, particularly when the hemorrhage is in the motor area of the convo- lutions. This is, however, an infrequent form of paralysis, except in chil- dren, when it is generally accompanied with convulsions. When con- fined to the frontal or right parietal lobe, focal symptoms may be absent. In other cases localizing symptoms are observed in the following rela- tions : (' O^ rj ^ ^■'^ ^ / \ '^^^'-^ \ r Fig. 25.— Normal and pathological red and white blood-corpuscles, a, Normal red corpuscles; b. nucleated red corpuscles; c. lymphocytes; d, large mononuclear; c', transitional forms between c and d; e, transitional forms; c-', transitional neutrophiles; f, polymorphous forms; g, eosinophiles; /?, myeloc}"tes. be perfectly clean and dry, and the manipulation rapid in order to pre- vent coagulation of the blood within the tube. If too much blood is drawm in, the tube must be cleansed and dried before the procedure is repeated. After the desired quantity has been secured, the tip is quickly cleansed and immersed in the diluting fluid. Suction is again applied and the fluid drawn exactly to the mark loi. The blood is thus diluted in a definite ratio. If the tube ha.s been filled to the mark i, the ratio EXAMIKATIOX OF THE BLOOD 713 is I to 100, and if to only the mark .05, it is i to 200. The latter ratio is g-enerally the better, hence it is better to draw the blood only to the .05. The rubber tube is now removed, and the tube is closed by placing" the thumb and finger over its ends, and shaken in order to mix the blood and diluting fluid in the chamber E. After this the tube may be Fig. 26. — Thoma-Zeiss hemacytometer, laid aside or transported, providing the ends be closed by placing a rubber band around it longitudinally. Another valuable diluting fluid is that of Hayem : Mercuric chlorid » „ 0.5 Sodium sulphate , 5.0 Sodium chlorid „ „ „ 2.0 Distilled water , „ .,^00.0 The dilution may be made also with either a 3 per cent solution of sodium chlorid, or a 15 to 20 per cent solution of magnesium sulphate. In making the count, the slide and ruled cover-glass belonging to the hemacytometer must be used, and the utmost care is necessary to have all parts perfectly clean, and to secure exact coaptation of the surfaces. Fig. 27. — Thoma-Zeiss pipette for diluting red blood-corpuscles. A low objective with a high ocular generally gives the best results, the adjustment being" so arrang-ed that the ruled squares will occupy a little less than the entire field. The illumination should be moderate. The corpuscles should then be counted in a definite number of squares, or until about 1,200 have been counted. A regiilar order must be followed 714 PRACTICE OF MEDICINE to avoid error, and it is well to check off the squares as they are counted on an extemporaneous diagram. Cells lying on the lines should be counted with the square below or to the right, to avoid counting them twice. After the count has been completed, the number of corpuscles in the cubic millimeter is computed by multiplying the average number in each square by 4,000, and this by the dilution. The percentage may then be calculated on the basis of 5,000,000 to the cubic millimeter in normal blood. In women, however, the normal is usually a little lower, from 4,000,000 to 4,500,000. Enumeration of Leucocytes. — In counting the leucocytes, a lower dilu- tion is necessary, as a rule, i to lo or less. When the leucocytes ar6 greatly in excess, however, as in leukemia, the count is more readily made in a dilution of i to 20 or even i to 50. The diluting fluid is a 0.33 to 0.50 per cent solution of acetic acid, which dissolves the red corpuscles. The addition of a few drops of a gentian-violet solution facilitates the count by stain- ing the leucocytes. The tube must be held in a horizontal position or closed with the rubber band, for its large cali- ber permits the escape of the fluid. The manipulation is the same in all respects as in the dilution of the red corpuscles. The blood is drawn into the tube exactly to one of the di- visions, quickly freed from superficial blood, and the di- luting fluid is drawn in to the niark 11. The computation is made by multiplying the aver- age number of leucocytes in each square by 4,000, and the product by the dilution. In ex- treme leucocy tosis, the erythro- cyte tube should be employed. Estimation of Hemoglobin. — The most accurate method is that by means of the Fleischl hemoglobinometer (Fig. 28). The end of the capil- lary pipette accompanying the instrument is touched to the drop of blood. As soon as the tube is filled, its contents are washed into the compartment a with water from a medicine-dropper or pipette. This compartment is then completely filled with water and mixed by stirring. The upper surface of the mixture of blood and water should be slightly convex, care being taken that there is no overflow into the other com- partment. Compartment d^ is filled with pure water. An artificial light of moderate strength, as that of a candle, is reflected through the com- partments from the mirror S. The color of the blood-mixture is com- pared with that of the red glass slide KK, which is thinner cit one end than the other, and therefore lighter in color. It is moved by the thumb- screw T. The percentage is read from the scale PP at the line M. The •estimate is usually a trifle low. The accuracy of the observation is not Fig. 28. — The Fleischl hemoglobinometer. EXAMINATION OF THE BLOOD 715 ■entirely, complete, and the result obtained by two observers is seldom exactly the same, since the eye is not capable of discriminating the deli- cate shades of color. The ratio of hemoglobin to the individual cor- puscles may be determined by dividing the percentage of hemoglobin by the percentage of the red corpuscles to the normal as determined by the blood-count. Staining the Blood-Specimen.— Staining is resorted to chiefly for the purpose of facilitating the differential count of the corpuscles, bringing out nuclei, granules, and other peculiarities. Permanent specimens may be mounted in this manner. A small drop of blood is spread between two covers in the usual manner; the covers separated and the smear allowed to dry. It is then fixed by passing it rapidly through the Bunsen flame ten to twenty times, or by immersion in (phoul fever 1, Kegc^tne i5, partial reaction; c, positive reaction (Nichols ) dilution of i rjo is, therefore, a positive demonstration of typhoid fever in nearly all cases, unless the patient has previously passed through the disease, for the blood often continues to agglutinate the bacilli for many years after recovery. About half the cases do not give a positive re- action before the beginning of the second week, and about a third of the cases do not give a reaction before the early part of the third week. It may appear, on the other hand, as early as the fourth or fifth day. Rarely it is first obtained in a relapse. SPECIFIC GRAVITY OF THE BLOOD. Hammerschlag's Method.— A mixture of chloroform (sp. gr. 1.526) and benzin (sp. gr. 0.889) is prepared in such proportions that the specific gravity of the mixture is nearly that of the blood (1.050 to 1.060). A drop of the blood, which must be free from air, is dropped upon the surface of this mixture. If the drop sink, it is heavier than the mixture, and chloroform must be added; if it rest on the surface, it is lighter, and benzin must be added. The fluids must be thoroughly mixed after each addition. When the blood-drop remains stationary, neither sinking nor rising, the specific gravity of the blood is the same as that 7i8 PRACTICE OF MEDICINE of the mixture, which can be determined with the urinometer. This mixture can be kept indefinitely after being used, the blood-drop having" been removed with a pipette. BACTERIOLOGICAL EXAMINATION OF THE BLOOD. Bacteria are found in the blood in such small numbers, as a rule, that they can be detected only after cultivation on suitable media. This can seldom be accomplished without laboratory facilities. The method con- sists in flowing the blood removed from a vein with a hypodermic syringe over the surface of a blood-serum and agar culture-medium. The culture must be kept at a temperature of 3 7 ° C. Plate cultures are the most satisfactory. Any growth that occurs may be examined by the usual methods of bacteriological examination. Other Tests. — Hemoglobinemia. — The hematocrit tube is filled with blood and revolved rapidly for three minutes upon the centrifuge. Nor- mally the blood separates into three portions, the erythrocytes occupying about half the space, leucocytes a narrow band, and clear plasma the other portion of the tube. If free hemoglobin be present, the plasma is tinged with red. Diabetes. — There are two fairly reliable tests of diabetic blood. Brem- er's test consists in the application of the acid stains. \^Tiile in normal blood these are promptly taken up by the erythrocytes, they have no eff"ect upon these cells in diabetic blood. Winiamso7i's test consists in adding the blood to a methylene-blue solution. Diabetic blood changes the color to yellow, while normal blood produces no change. TESTS FOR BLOOD. Hemin Test. — Crush a small crystal of sodium chlorid, or, better, evaporate a drop of a 0.5 per cent salt solution on a slide, and add to it a small particle of the substance to be tested in a dry state. Fluids should be previously evaporated to dryness without scorching. Over these particles place a cover-glass, and allow to flow under this a drop of glacial acetic acid. Heat the specimen gently for about a minute, adding more acetic acid as Fig ^o —Hemin crvstals. i^ evaporates. As soon as a brownish stain is produced, allow the specimen to evaporate to dr3'ness and mount in glycerin. Small rhomboidal crystals of hemin (hematin chlorid) are seen (Fig. 30) if blood be present in the speci- men. Guaiaoum Test. — To a few cubic centimeters of a freshly prepared tinc- ture of guaiacum add half as much hydrogen peroxid in a test-tube. Under the mixture flow, through a tube or down the side of the test- tube, the fluid to be tested. Immediately or perhaps after ten or fifteen minutes, a blue ring appears at the junction of the two fluids. Stains mav be tested by this method by first impregnating a piece of pure filter-paper with the stain or a solution obtained from it with distilled EXAMINATION OF STOMACH-CONTENTS 719 water, then moistening an adjoining portion of the paper with the guaiacum-hydrogen-peroxid mixture. If blood be present the blue line is formed at the junction of the moistened areas. It must be remem- bered, however, that iodin, iodids, and many other substances produce this reaction. Blood-Plates. — These are irregularly shaped bodies seldom recognized in the ordinary blood examination. They can sometimes be recognized, however, in a strictly fresh specimen. To obtain this, a cover-glass should be placed upon the slide, and a drop of blood deposited immedi- ately from the ear at one edge of the cover. The plates are highly cohesive bodies about half the diameter of a red corpuscle and are usually found clinging together in irregular masses. They are colorless and have no ameboid movement. They may be stained, however, with eosin. MuUer's Blood-Dust. — These are small, highly refractile, colorless gran- ules from J^ to I, a in diameter, or equal to the finest fat-droplets, and exhibiting rapid molecular motion, but no independent motility. They are insoluble in alcohol or ether, and stain with eosin or the triacid stain, but not with osmic acid. They are best seen with the Welsbach light. Similar granules are sometimes seen in hydrocele fluid and pus. EXAMINATION OF STOMACH-CONTENTS. The stomach-contents should be obtained for examination one hour after a test-meal, which should be ingested in the morning without other food. The contents are obtained by means of the stomach-tube. In conditions in which the digestion is slow, and when the food is re- tained in the stomach longer than is normal, the stomach should be washed out the evening before. Several test-meals have been proposed, but those of Ewald and Boas are most employed. Test-Meals. — Ewald's test-breakfast consists of a wheat-roll to be eaten without butter, and 300 to 400 c.c. of water or weak tea without sugar. Boas's test-breakfast consists of a tablespoonful of oatmeal added to a quart (liter) of water with a little salt, and boiled down to a pint (500 c.c). The only advantage claimed for this meal over that of Ewald is that it is free from lactic acid. Passing the Stomach-Tube.— The tube should be moistened with clear water before it is introduced. The patient should sit erect with the head thrown a little backward and the mouth wide open. He should be instructed to breathe regularly during the passage of the tube. At- tempts to swallow as advised by many writers do not always facilitate its passage and often confuse the patient. The tip of the tube is placed against the posterior wall of the pharynx, and then steadily pushed onward until the white ring is about on a level with the incisor teeth. The first passage of the tube is disagreeable to most patients, and it may be rendered difficult, if not impossible, by the gagging that is ex- cited. Usually, however, with a little persuasion and by quick manipu- lation it can be made to reach the stomach before the patient becomes greatly alarmed. The gagging and nervous excitement can be dimin- ished in many cases by holding the end of the tube in chopped ice until it becomes thoroughly cold before it is introduced. The contents of 720 PRACTICE OF MEDICINE tke stomach can generally be made to flow by having the patient con- tract the abdominal muscles with the glottis closed, as in straining in the act of defecation. In some cases, however, it must be started by means of suction with the Politzer bag, Or by "stripping" the tube. The tube is held firmly between the thumb and finger of the left hand, while the right thumb and finger are pressed firmly, and drawn down the tube in such a manner as to produce suction within it. After the flow has been started, the tube is converted into a siphon by holding the external end below the level of the stomach. From 50 to 75 c.c. of contents are usually obtained. The stomach-contents should be filtered through dry filter-paper, a process requiring considerable time unless a filter-pump is used. After this the contents may be examined for free and combined acids, the di- gestive ferments, the products of digestion, and other ingredients, if desired. QUALITATIVE TESTS. Test for Free Acids. — A few drops of a i per cent aqueous solution of Congo-red are added to a few drops of the filtered stomach-con- tents. If free or combined hydrochloric acid or the organic acids be present, a dark-blue or blackish-brown color is produced, while in a neu- tral or alkaline solution the red color is imparted. Test for Kydrochloric kci&.—Topfers Test.—Om^ or two drops of a 0.5 per cent alcoholic solution of dimethylamidoazobenzol are added to about double the quantity of stomach-contents. If hydrochloric acid be present, a bright red color is produced; if it be absent, a bright yellow is produced. The test is sensitive to about o.oi per cent of the acid, more minute traces yielding a brownish color. Boas's Test.—T\\^ test-solution consists of Resublimed resorciia„, ...~ - -...- ..^..,. 5-o White sugar 30 95 percent alcohol 100. o To a few drops of the gastric contents in a porcelain evaporating- dish a nearly equal quantity of the test-solution is added. The mixture is then gently evaporated over a Bunsen burner. In the presence of hydrochloric acid a rose-red color appears around the edge of the mix- ture as it evaporates; if it be absent, a yellow or brownish color is produced. Gilnzhur^s Test.—TMi^ test is now less frequently employed than for- merly, owing to the instability of the test-solution and the cost of the ingredients. The formula is: Phloroglucin 2.0, vanillin i.o, absolute alcohol 30.0. Its application and the results are the same as those of the Boas test. Test for Organic Acids.— A small portion of the gastric contents is shaken with eight or ten times its quantity of ether having a neutral reaction. The reaction of the ethereal extract is then tested with litmus- paper. An acid reaction indicates the presence of organic acids. If, however, the Congo-red test fails, organic acids are not present. Test for Lactic Acid.— The acid reaction obtained in the foregoing test is usually due to the presence of lactic acid. Its presence may be EXAMINATION OF STOMACH-CONTENTS 721 more positively determined, however, by Uffelmann's test. The test-solu- tion is made fresh as it is required by adding a few drops of a dilute aqueous solution of ferric chlorid to a 2 per cent phenol solution, and diluted with water until an amethyst color is obtained. Two or three cubic centimeters of the filtered stomach-contents is added to a like quantity of this solution. In the presence of lactic acid a bright lemon or canary color is produced. In its absence the amethyst color is re- tained or changed to a gray. Reacting to lactic acid alone, the test is sensitive to about 0.0 1 per cent, but its accuracy is impaired by the presence of hydrochloric and other acids. This difficulty may be avoided by applying the test to the ethereal extract of the contents. Test for Fatty Acids.— The simplest test for the volatile fatty acids, acetic, butyric, etc., is made by holding a piece of moistened litmus- paper in the vapor arising from boiling gastric contents in a test-tube. Test for Pepsin. — The test for pepsin is made by submitting small fragments of egg-albumen, coagulated by boiling, to the action of the stomach-contents. If the stomach-contents contain hydrochloric acid, the fragments of albumen are dropped into 5 or 10 c.c. of it in a test- tube and kept at a temperature of 37° C. If the pepsin be normal in quantity, the albumen is completely digested and dissolved in six or seven hours ; if it be deficient, the digestion is delayed, and if it be ab- sent, no digestion occurs. In case the hydrochloric acid is absent from the gastric contents, it must be added in the ratio of o.i to 0.2 per cent. Test for Rennet. — A few drops of the stomach-contents are added to 10 or 15 c.c. of milk, and kept at a temperature of 37° C. If the ren- net-ferment be normal, the milk will coagulate in 10 or 15 minutes. Delayed coagulation indicates deficiency of rennet. When hydrochloric acid is absent, however, a few drops of calcium chlorid must be added in order to convert the rennet-zymogen into active rennet. Test for Proteids. — Acid albumin, or syntonin, is precipitated by ex- actly neutralizing the filtered stomach-contents. An excess of either acid or alkali causes it to be again dissolved. Albumin. — The acid albumin is first removed by filtration after pre- cipitation in the foregoing test. The filtrate is then boiled or other- wise tested for albumin. A cloudiness or precipitate indicates its pres- ence. Albumose (Propepton). — The syntonin and albumin are first removed by boiling and filtering a small quantity of the gastric contents (both are thus thrown down without neutralization) ; the filtrate is then al- lowed to cool, and it is mixed with an equal volume of a saturated solution of sodium chlorid, and a drop or two of acetic acid is added. If albumose be present, the fluid becomes turbid ; the turbidity disappears upon heating and reappears upon cooling. Pepton. — Albumin, syntonin, and albumose are first removed by the above methods. The filtrate is then tested with the biuret test. A purple or a violet red color indicates the presence of pepton. For ac- curacy, the absence of albumin should first be determined by means of the ferrocyanid test. Blood. — Wlien the presence of blood cannot be determined by inspec- tion or by means of the microscope, the hcmin or guaiacum test may be employed (p. 718). 46 722 PRACTICE OF MEDICINE Bile. — The presence of bile can generally be determined by the green color of the gastric contents, but a more reliable method is the Gmelin nitric-acid-contact test, in which a play of colors is produced, of which green is characteristic. Carbohydrates. — A few cubic centimeters of Lugol's solution of iodin and potassium iodid are diluted until only a faint color remains. A few drops of the filtered contents are then added. A blue color indicates the presence of unchanged starch; a deep mahogany brown indicates erythrodextrin. The presence of sugar can be determined by the usual copper or fermentation tests. QUANTITATIVE TESTS. Volumetric analysis is employed in testing the gastric contents chiefly with a view to determining the total acidity, the acidity due to free or combined hydrochloric acid, and that due to the organic acids. These tests are usually made by titration with a decinormal solution of so- dium hydroxid and a suitable indicator — a solution by means of which the exact neutralization of the acidity can be recognized. The sodium solution must be made with the greatest accuracy, and owing to the hygroscopic nature of the salt it cannot be made by weight. About 4 grams of sodium hydroxid must be dissolved in 8 or g c.c. of dis- tilled water, and the solution tested with a decinormal solution of hy- drochloric acid which can be more readily prepared by the specific-gravity method, or purchased ready for use. After the exact alkalinity of the solution has been thus determined, sufificient distilled water is added to reduce it to the decinormal standard, i.e., representing o.i gram of the hydroxid to the liter, or 0.3996 per cent. Determination of Total Acidity.— A definite quantity of stomach-con- tents, as 5 or 10 c.c, is placed in a beaker (a porcelain dish or capsule is even better on account of its white color). To this are added a few drops of I per cent solution of phenolphthalein in 50 per cent alcohol as an indicator. This is then titrated with the decinormal sodium-hydroxid solution, drop by drop, from the burette, and followed by agitation or stirring of the mixture until a permanent pale-pink color is produced. The degree of acidity is then determined by multiplying the quantity of sodium-hydroxid solution employed, expressed in cubic centimeters, by its acidity, which is 100, and dividing the product by the number of cubic centimeters of the gastric contents tested. The normal acidity is gen- erally from 40 to 65. Determination of Free Hydrochloric Acid.— To a definite quantity of the gastric fluid add a, few drops of a 0.5 per cent alcoholic solution of dimethylamidoazobenzol. When HCl is present, a cherry or brownish color is produced ; if it is absent, the color is a pure yellow, and titra- tion is unnecessary. To determine the acidity, the mixture is titrated with the decinormal sodium-solution until a permanent, pure yellow color is obtained, and the calculation is made as in the preceding test. Normally the acidity due to free HCl is between 40 and 60. To deter- mine the percentage of the acidity, the degree should be multiplied by .003637. Determination of Combined Hydrochloric Acid.— 77/*? AHzarifi Method. EXAMINATION OF STOMACH-CONTENTS 723 — The gastric fluid is titrated as before, using a i per cent aqueous solu- tion of alizarin-sodium-solfonat as an indicator. When the acidity has been neutrahzed, a permanent, pale violet color is produced. The per- centage of acidity may then be calculated as in the preceding test. The method lacks accuracy, however, owing to the wide range of almost imperceptible color that can be produced. The more accurate tests are not applicable to clinical work. Determination of Organic Acids.— After the total acidity of the speci- men has been determined, the organic acids should be removed from another portion of the gastric filtrate by extraction with ether. To accomplish this, a portion of the filtrate is shaken with a quantity of neutral ether, and the fluids allowed to separate. The gastric portion is then shaken with another quantity of ether, and the process is re- peated until the gastric fluid has been extracted with eight or ten times its volume of ether. Its total acidity is then determined as before, and the difference in the result represents the loss occasioned by the removal of the organic acids. Determination of the Fatty Acids.— Since the fatty acids are volatile, they can be removed by heat. After the total acidity has been deter- mined, another definite quantity is thoroughly boiled, and the fluid lost by evaporation is replaced by the addition of water. The total acidity is again determined by titration, and the loss represents the degree of acidity due to the fatty acids. Determination of Lactic Acid.— The degree of acidity due to lactic acid is represented by the difference between the total acidity due to organic acids and that due to fatty acids. If fatty acids be absent, the acidity due to lactic acid represents the total organic acidity. To de- termine the percentage of lactic acidity, multiply the degree by .008979. MICROSCOPIC EXAMINATION. This examination is generally of minor importance, owing to the almost constant presence of a great variety of unimportant substances. For the examination, a small mass of the solid matter left in the filter should be picked up on the platinum loop, spread on a slide, and ex- amined with low and medium power. After the Ewald breakfast the field is largely made up of starch-granules. These can be more distinctl}^ brought out by passing a drop of dilute iodin solution under the cover- glass. Other substances commonly seen are fragments of other undi- gested food, fat-globules, crystals of fatty acids, erythrocytes, leucocytes, various micro-organisms, and sometimes leucin, tyrosin, or cholesterin crystals from the intestine. The bacteria may be stained in the usual way, or cultures may be made in order to differentiate the varieties. Fragments of solid tissues may be hardened and cut for histological examination. EXAMINATION OF THE STOMACH-CONTENTS AFTER FASTING. This examination is sometimes desirable in order to determine the presence of superacidity and its character. The stomach must be washed out and emptied the evening before. No food or drink is then taken until the stomach-contents have been obtained with the stomach-tube 724 PRACTICE OF MEDICINE in the morning. If the quantity obtained exceed 60 c.c, there is super- secretion. The percentage of acidity, pepsin, and rennet may then be determined by the methods that have been given. EXAMINATION OF STOMACH-WASHINGS. The chief importance of this is in cases of suspected poisoning. It is best in such cases, if possible, to secure some of the stomach-con- tents before lavage ; otherwise, the water must be examined for the vari- ous poisons. If the examination is to be made by a chemist with a view to criminal prosecution, the specimen should be placed in a clean bottle, securely sealed, and marked in some manner, as by pasting a strip of paper over the stopper and neck of the bottle with the legend of the case and the signature of the physician. It is well, also, to give the date and hour of the examination. EXAMINATION OF VOMITUS. This examination is seldom of importance except for the purpose of determining whether, in a case of suspected stricture of the esophagus, the food ingested reaches the stomach. The presence of HCl, pepsin, and rennet is generally sufficient evidence that the vomitus has come from the stomach, and that it has not simply been regurgitated from the esophagus. In achylia gastrica, however, these substances may be absent. The coloring matter of bile should be tested for, and, if this be present, it is conclusive evidence that the food has come from the stomach. Test of the Motor Power of the Stomach.— If food is brought up with the water in lavage of the stomach seven hours or longer after its in- gestion, the motor power of the stomach is deficient; if food be absent when the washing is done within three or five hours after a meal of mixed food, it is evidence of increased motility. Salol Test. — A gram (gr. xv) of salol is administered in capsules im- mediately after a meal. As soon as this substance reaches the alka- line juice of the intestine it is converted into phenol and salicylic acid, and the latter substance appears almost immediately in the urine. Its presence is detected by the addition to the urine of a few drops of a dilute aqueous solution of ferric chlorid. A violet or brown color is significant of salicylic acid. The test should be repeated every half-hour until a reaction is obtained. This occurs normally in an hour to an hour and a half. Should the stomach-contents be alkaline, however, the reaction appears much earlier and the test is of no value. Test of Absorptive Power.— From 0.20 to 0.40 gram (gr. iij— vj) of potassium iodid should be administered, during fasting, in a capsule freed from the drug upon its exterior. The saliva is then tested for iodin with starch-paper at intervals of one or two minutes. Normally the re- action is obtained in five to fifteen minutes. A much longer interval indicates delayed absorption. EXAMINATION OF INTESTINAL DISCHARGES. The feces and other intestinal discharges may be submitted to macro- scopic, microscopic, chemical, and bacteriological examination. EXAMINATION OF INTESTINAL DISCHARGES 725 Macroscopic Examination.— Simple inspection of the feces reveals their color, consistence, and form, and aftords an adequate idea of the completeness of the processes of digestion as well as of the presence of parasites, foreign bodies, blood, pus, fat, shreds of tissue, and other abnormal substances. The source of blood may be inferred from its color and other conditions. WTien the fecal mass is merely streaked with it, the source of the hemorrhage is usually at or near the anal orifice ; when bright fluid blood accompanies the dejection, it is generally from the rectum and may be due to hemorrhoids or ulcer. When the blood is coagulated or black and tarry, its source is higher up in the intestine or stomach. The odor also reveals to some extent the completeness of the digestion. Segments of tapeworm should be compressed between two slips of glass in order to render them more translucent. Microscopic Examination. — A small portion should be picked up on the platinum loop, transferred to a slide, and mixed with a drop of water, after which the cover-glass is applied. The examination should be made first with a low power. The substances commonly revealed are frag- ments of incompletely digested animal or vegetable food, as muscle ^ b c d Fig. 31. — Ova of intestinal worms (X275). a, Tenia saggplnata with and without albuminous covering; 6, ascaris lumbricoides; c, trichocephalus dispar; c/, anchylos- toma duodenale. (Nichols.) fibers, connective-tissue fibers, starch-granules, chlorophyll, fat, fatty-acid crystals, cholesterin, amorphous and granular matter, ammoniomag- nesium-phosphate crystals, calcium oxalate and carbonate, spermin and hematoidin crystals, erythrocytes, leucocytes, epithelium, saccharomyces and other fungi, bacteria, small animal parasites, and crystals or other remains of drugs that have been ingested. In examining for small parasites and ova, a moderate quantity of fecal matter should be placed in a cylindrical glass, thoroughly mixed with water and allowed to stand for ten minutes. The parasites and ova settle to the bottom, and by pouring off the supernatant fluid and repeating the process several times they may be obtained free from extraneous matter. They can then be subjected to microscopic examination. The more frequent varieties of ova are illustrated in Fig. 31. Fat-globules can be more distinctly brought out by staining them red with Sudan III. To prepare this solution, first allow a saturated alco- holic solution of the Sudan III to stand a few days, then add one part 726 PRACTICE OF MEDICINE of it to one part each of alcohol and water. The solution is ready for use as soon as it has become clear. Starch-cells are rendered more visible by treatment with dilute Lugol's solution. A drop of acetic acid renders leucocytes and epithelial cells more distinct, and dissolves phosphates and carbonates, the latter bodies evolving minute bubbles of carbonic acid. Filn-in may be stained red with Ehrlich's triple stain or blue with Weigert's gentian-violet stain. Mucin is always present, and when ab- normally abundant it can generally be recognized without the micro- scope. If its identity is doubtful, it may be dried, fixed on a slide with alcohol or mercuric-chlorid solution, and stained blue with methylene blue, green with the triple stain, and reddish with toluidin blue. Solid tissue-particles should be broken up, teased, or sectioned, as their char- acter permits. Chemical examination is seldom of sufficient importance to justify the labor. The reaction is often of importance, however, and this is determined with litmus-paper. If the fecal mass be firm and dry, it must be broken open, and the moistened litmus-paper pressed between its surfaces. A quantitative test of the degree of acidity or alkalinity can be made by testing a watery extract of a definite quantity of the fe- cal matter, using the titration method employed for stomach-contents. The proteids may be recognized by digesting feces with water acidu- lated with acetic acid, and, after filtering, applying the usual tests for albumin, albumose, and pepton. For the carbohydrates boil a small quantity of the matter in water, filter, concentrate the filtrate by evaporation, and test for starch and erythrodextrin with iodin, and for sugar with the urine tests. Fat and Xk\^ fatty acids may be recognized with the microscope or by extracting with ether and applying the tests given in the examination of the gastric fluid. Bilirubin may be detected with the nitric-acid test applied to the aqueous or chloroform extract, or the acid may be applied directly to the fecal mass. The green color is distinctive. Blood is distinguished by the hemin test applied either to a dried fragment of the clot or to an evaporated aqueous extract of the fecal matter. The guaiacum test may also be applied to the aqueous ex- tract. Calculi. — For the discovery of these, the feces should be mixed with water and forced through a sieve of fine mesh. The sandlike particles, if too small for macroscopic recognition, may be examined chemically and microscopically. Bacteriological Examination.— The micro-organisms ordinarily found in the intestinal discharges are so numerous that little can generally be gained from an attempt to isolate them. Many of them can generally be recognized, however, with any of the usual stains applied to a dried and fixed specimen on the slide. A it^ are worthy of note. The Ameba Coli. — The feces must be fresh and examined before cool- ing, on a warm slide, in order to retain the ameboid movement. Tuber- cle bacilli may be stained in the usual manner after drying and fixing on a slide. Typhoid bacilli can sometimes be obtained. The cholera vibrios axe usually so numerous as to be recognized without difficulty. EXAMINATION OF THE URINE 727 Plate-cultures may be made from the dejections, but the growth is generally so luxuriant as to render the isolation of species next to im- possible in clinical work. DISINFECTION OF DEJECTA. The best disinfecting agents for this purpose are a 1 :5oo acidulated solution of mercuric chlorid, a i :2o solution of carbolic acid, a i :2o solution of formalin, and chlorinated lime. The latter substance should be used in the dry state. It is especially suited to the disinfection of trenches and privies. The carbolic-acid and formalin solutions are less corrosive to metallic drain-pipes than the corrosive sublimate. The disinfection of stools, especially in typhoid fever, should be be- gun as soon as the disease is recognized, and continued for at least ten days after the fever has subsided. The following rules should be ob- served : 1. The bedpan should contain a pint of the bichlorid solution at all times, ready to receive the dejection. The pan must be cleansed with boiling water and one of the disinfecting solutions. 2. Enough of the solution should be poured over the stool to cover it and be thoroughly mixed with it; the vessel should then stand two hours before it is emptied. 3. Lumps of fecal matter should be immediately broken up with a stick, and the stick subsequently burned. 4. The urine should be disinfected by the addition of enough carbolic acid or mercuric chlorid to convert it into a 1:20 ori:5oo solution, respectively. 5. All linen and bedclothing should be soaked in a i :2o carbolic-acid solution, and afterward boiled for two hours. 6. As a further precaution, the nurses, physicians, and other attend- ants should wash their hands, and immerse them in a i :iooo mercuric- chlorid solution after handling the patient, the bedpan, syringe, ther- mometer, or other articles coming in contact with him. EXAMINATION OF THE URINE. The Specimen. — To secure accurate results the specimen should be taken from a mixture of all the urine voided in twenty-four hours. When this cannot be done, a specimen passed three hours after a meal is most likely to reveal any abnormalities present. To preserve the speci- men, a few drops of formalin, chloroform, or alcohol, or a few grains of chloral or salicylic acid may be added. The average normal quan- tity in twenty-four hours is from 1,200 to 1,500 c.c. (40 to 50 ounces). The reaction of a mixed specimen is usually acid, but after a meal con- sisting largely of carbohydrates it may be alkaline, in health. Reaction. — This is tested with litmus-paper. Acid urine turns blue litmus red; alkaline urine turns red litmus blue. An amphoteric reaction may occur in which both papers are changed by the same specimen. Huppert attributes this to the presence of acid and neutral phosphates. When the blue color of red litmus fades upon becoming dry, the reaction is due to a volatile alkali. 728 PRACTICE OF MEDICINE Specific Gravity. — This can be determined with sufficient accuracy with the ordinary urinoraeter. An instrument of certified accuracy should be em- ployed, however, as many of those offered in the market are unrehable. If the specimen be fresh, its temperature should be measured, and one degree added to the reading of the urinometer for every seven degrees of tem- perature above the standard of the instrument, which is usually 60° F. Solid Ingredients.— The simplest method of approximately estimating the solids of the urine is to multiply the last two figures of the specific gravity by 2.33, which gives the number of grams in each 1,000 c.c. TESTS FOR N0R:^LA.L INGREDIENTS. Urea. — Test. — To a drop of the fluid (urine) on a slide add a drop of pure nitric acid and gently warm. Rhombic or hexagonal prisms or plates of urea nitrate are formed, and are visible with a low Jlilli, power. 1 § Biuret Reaction.— To the urine evaporated almost to dry- ^jlf%s, £j ness, and while warm, add a trace of potassium hydroxid and a drop of dilute cupric-sulphate solution. A rose-red or P 5 I ^ , violet color denotes urea. I i-'||fi E Quantitative Determination. — The hypobromite method is '' ' generally employed by means of the Doremus ureometer (Fig. 32). Two solutions are required: ((?) Sodium hydroxid 100, distilled water 250; and (/^ bromin. 'ij l| Immediately before the test is made, mix i c.c. bromin I' I 11 with 10 c.c. of the sodium-hydroxid solution, and add enough ' water to fill the long arm of the ureometer. The fluids may be mixed in the ureometer. The instrument is reclined so as to allow the fluids to fill the long arm, then restored to -x the upright position. One cubic centimeter of the urine is now slowly injected from a pipette into the bulb so as to come into contact with the hypobro- mite mixture only at the base of the long arm, al- lowing the liberated nitrogen to collect at the top. The result in fractions of a gram of urea to the Fig ~^— Doremus cubic centimeter of urine may be read from the apparatus for the es- Scale after about fifteen minutes. The mark 0.02 timation of urea. represents the norm.al 2 per cent. Uric Acid. — Murexid Test. — To a small quantity of the sediment or to the residue after evaporation, in a porcelain cap- sule, add a few drops of nitric acid, evaporate over a flame to almost dryness, and add a drop of ammonia. In the presence of uric acid, a beautiful purple-red color is produced. Silver Tfst. — Moisten a piece of white filter-paper with a little silver- nitrate solution. Touch the spot with a drop of urine made alkaline with sodium-carbonate solution. A brownish yellow color indicates a trace, and black o.ooi per cent or more of uric acid. Xanthin. — With a few drops of urine mix an equal quantity of nitric acid, and evaporate to dryness. The yellow residue is changed to red by potassium hydroxid, and reddish purple by heat. EXAMINATION OF THE URINE 729 Creat/'nin. — Weyl's Test. — Add to the urine, solution of sodium nitro- cyanid, followed by sodium hydroxid. A red color is produced, which turns to yellow upon standing. By the addition of zinc-chlorid solution, and evaporation, groups of characteristic crystals of creatinin-zinc chlorid are formed (Fig. Ferments. — Pepsin has been found in normal urine, particularly in that voided in the morning. It is detected by soaking small pieces of fibrin in the urine, then removing them to a o.i per cent solution of hydrochloric acid at 37° C, where they are quickly digested. Traces of a milk -curdling ferment like rennet and a diastatic ferment, probably trypsin, have been isolated from the urine. C hi rids. — Add to the urine in a large test-tube a little nitric acid to hold the phosphates in solution, then a drop of silver-nitrate solu- tion (1:8). A precipitate forms, which is soluble in ammonia, but in- soluble in nitric acid. If the precipitation be merely a flaky white cloud, the chlorids are diminished in quantity; if it be a heavy white mass, falling quickly, they are at least normal in quantity ; if there be no pre- cipitate, they are absent. Quantitative TQst.—Mohr's Method.— Th.& following solutions are used : (i) A standard silver-nitrate solution made by dissolving 29.075 gm. of pure silver nitrate in 1,000 c.c. of distilled water, each cubic centi- meter of which will precipitate 10 mgm. (0.0 10) of sodium chlorid; and (2) a saturated aqueous ,^^**f*^^ ""% solution of neutral potassium chromate. i. * Dilute 10 c.c. of urine with 100 c.c. of distilled ^>"* '' . m^^^fL^ water, and add a few drops of the potassium-chro- ^^^ mate solution. Then titrate with the silver solution. „ /- .• • . , . . . r ^^ 1 1 ■ 1 • 1 , rIG. 2)Z- — Creatinin- A white precipitate 01 silver chlorid is produced zjnc chlorid crystals. until all the chlorids have been removed; then a red precipitate of silver chromate begins to form. As soon as the pink color becomes permanent, the calculation can be made from the quan- tity of silver solution that has been used. One cubic centimeter should be deducted from the quantity of silver solution, however, to offset the other substances which unite with the silver before the potassium chro- mate. Phosphates. — Earthy Phosphates. — Render the urine strongly alkaline with sodium, potassium, or ammonia, and gently warm. The earthy phosphates are precipitated and soon settle. If in a test-tube of 2 cm. diameter they form a deposit to the depth of i cm. ; their quantity is normal. Alkaline Phosphates. — Remove the precipitate formed in the preceding test. To the filtrate add one-third its volume of a solution consisting of magnesium sulphate and ammonium chlorid each i part, distilled water 8 parts, and pure liquor ammonia i part. The alkaUne phosphates are precipitated in a white cloud. If a distinctly creamy appearance is produced, they are increased; if a very slight opacity, they are dimin- ished. Sulphates. — Acidulate 10 c.c. of urine with hydrochloric acid, and add one-third the quantity of barium-chlorid solution. A milky white pre- cipitate indicates a normal quantity of the sulphates. 73Q PRACTICE OF MEDICINE Carbonates. — The addition of an acid to urine containing carbonates liberates carbonic acid. By passing this gas through Hme-water or baryta-water, a cloudy precipitate is formed. ABNORMAL CONSTITUENTS. Albumin. — Heat the upper portion of a column of urine in a test-tube. A precipitate which is not redissolved by the addition of nitric acid is due to albumin. Excess of acid must be avoided. Alkaline urine must be rendered acid before boiling. This test reacts to globulin, mucin, pine acids from cubebs, copaiba, etc., and albumose is precipitated after the specimen becomes cold. The pine-acid precipitate is redissolved by alcohol. Nitric Acid Test (Heller). — Underflow the urine with nitric acid with- out mixing. A white ring is formed at the line of junction corresponding in depth of whiteness with the quantity of albumin. The precipitate may not appear for an hour or two. Slightly warming the urine intensi- fies the reaction and renders nucleoalbumin less apt to appear. A cloudi- ness due to mucin may appear at a little distance above the line of contact. Purdy's Heat and Acid Test. — Add to the urine enough of a filtered saturated solution of sodium chlorid to raise its specific gravity ten or fifteen degrees, to prevent reaction with mucin. To two-thirds of a test- tubeful of this mixture add one or two drops of strong acetic acid, and boil the upper inch of the column for about half a minute. Albumin will appear in the boiled portion as a milky turbidity. This is one of the most delicate tests. Potassiiim-Ferrocyanid Test. — Pour into a clean test-tube 15 to 30 drops of acetic acid, add to it three or four times as much of a 5-per- cent solution of potassium ferrocyanid, and shake. Then fill the tube two-thirds full of the urine. Albumin will appear as a more or less milky cloudiness. To recognize a slight cloudiness, the urine tested should be compared with another sample of the same urine in a tube of the same size. This is one of the most reliable tests, as it reveals all forms of albumin, and nothing else. It must be performed just as directed. Potassium Mercuric lodid Test. — The following solution is used : Po- tassium iodid, 3.32 gm. ; mercuric chlorid, 1.35 gm. ; acetic acid, 20 c.c. ; distilled water, q.s. to make 100 c.c. The salts are dissolved sepa- rately, the solutions mixed, the acetic acid added, with enough water to make up the volume. A little of the reagent is poured into a test- tube, and the urine flowed over it without mixing. The test is sensitive to albumin, but reacts also to pepton, proteoses, mucin, and the pine acids. Picric-Acid Test. — Over the surface of the urine flow a saturated solution of picric acid (6 or 7 grains dissolved in an ounce of hot water). Albumin is revealed by a cloudiness in the area in which the fluids mix. Albumin, mucin, pepton, proteoses, and vegetable alkaloids respond to the test, but all except albumin and mucin are redissolved by heat. Biuret Test. — Add to the urine a solution of potassium hydroxid, then EXAMINATION OF THE URINE 731 a weak solution of cupric sulphate, drop by drop from a pipette. If albumin be present, the greenish precipitate is redissolved and the mix- ture assumes a reddish violet color. Albumose and globulin yield the same reaction, urea a rose-red or violet, and pepton a red color. Milloii's Test. — Dissolve one part of mercury in two parts of nitric acid of 1.42 sp. gr., and dilute with two volumes of water. To one dram of urine add ten minims. A trace of albumin is recognized by a red color on heating; larger quantities produce a precipitate which be- comes red on heating. The test reveals the aromatics and some of the benzol group. Alcohol Test (Truax). — From a pipette passed down nearly to the sur- face of 98 per cent alcohol in a test-tube, drop a little urine. If al- bumin be present, it is precipitated in a whitish streak extending to the bottom of the tube; if mucin be present, a general cloudiness is pro- duced. Quantitative Determination.— CV«/n/«^rt;/ Method.— lo 10 cc. of urine in the centrifuge tube add 3.5 cc. 10 per cent potassium-ferrocyanid solution, and 1.5 cc. acetic acid, and mix thoroughly. After revolving until the fluid is left perfectly clear, each tenth cc of precipitate at the bottom of the tube denotes i per cent of albumin by bulk. It should be remembered that a precipitate amounting to 50 per cent by bulk in any of the tests rarely exceeds 2 per cent by weight. Globulin. — Exactly neutralize the urine, and filter; then add magne- sium sulphate until it no longer dissolves. If globulin be present, a white precipitate is formed. Roberts's Test. — Globulin falls out of solution when the specific gravity is reduced below 1.002. To a test-tubeful of distilled water add the urine by drops. If globulin be present, each drop is followed by a milky streak until the entire volume becomes opaque. The cloudiness is re- moved by acetic acid. Hemoglobin. —Heller's Test. — Render the urine strongly alkaline with sodium-hydroxid solution, and heat to boiHng. The precipitate of earthy phosphates is colored red by hematin. If the urine be alkaline, a few drops of magnesium solution produces an artificial precipitate, which, when heated, brings out the hematin. The guaiacum and hemin tests may also be employed. Fibrin. — The urine may become flaky, coagulae may form, or it may coagulate into a firm mass after being voided, especially in chyluria. The fibrin is not soluble in water, swells on the addition of hydro- chloric acid, and is dissolved by pepsin added to the acid fluid. Alkapton. — Test. — Add to the urine one drop of a very dilute ferric- chlorid solution; a dull green color is produced, which immediately vanishes. Repeated additions of the same solution produce a repetition of the reaction. The surface of alkapton urine becomes dark upon ex- posure to the atmosphere, and the discoloration gradually extends to the entire specimen. TESTS FOR SUGAR. Trammer's Test.— To a quantity of urine in a test-tube add half as much sodium or potassium hydroxid solution (i 13); to this add a drop or two of cupric-sulphate solution (1:10), and shake. An azure-blue 732 PRACTICE OF MEDICINE color i-s produced. Heat the mixture to boiling. If sugar be present, the color changes first to yellow, then to an orange-red. Although the azure-blue color is not sufficiently distinctive, it does not usually appear in the absence of sugar. Fehling's Test. — The following reagents are required : («) Copper solution: Dissolve of pure crystallized cupric sulphate, 34.64 gm., in enough of distilled water to make 500 c.c. (^) Rochelle salt solution: Dissolve sodium hydroxid, 125 gm., and chemically pure potassium- sodium tartrate, 173 gm., in sufficient distilled water to make 500 c.c. These solutions may be preserved in well-stoppered bottles. Fehling's solution is made by mixing them in equal parts at the time of using. The Method. — About i c.c. of the FehHng solution is diluted in a test- tube with three or four times as much distilled water, and boiled. If no change of color is produced, the urine is added drop by drop until a slight reduction of the copper occurs, as indicated by a yellow color, or until the quantity of added urine equals that of the reagent. The mixture is again heated, and if no reduction occurs the test is set aside for several hours. If there is still no reaction, sugar is absent. The test is one of the most delicate. If the reagent change color in the preliminary boiling, new solutions must be obtained. Haines's Test. — Formula: Copper sulphate 30 grains, distilled water ,<.MMlif,„/,., Fig. 34. — Rosette and rays of phenylglucosazone crystals. a half ounce; make a perfect solution and add glycerin a half ounce; mix thoroughly and add liquor potassae 5 ounces. Boil about a dram of the solution in a test-tube, add not more than 6 or 8 drams of the urine, and boil gently. If sugar be present, a copious yellow or orange precipitate is thrown down. Bottger's Bisjnuth Test. — Add to the urine in a test-tube an equal volume of sodium-hydroxid solution and a very small quantity of pure bismuth subnitrate. Boil gently for one or two minutes. If sugar be present, the mixture turns gray, brown, or black, according to the quan- tity of sugar. If the quantity be very small, only the bismuth is dis- colored. Albumin and other sulphur compounds must first be removed. The test must not be made in a test-tube that has been previously used for either of the copper tests. Fhenylhydrazin Test. — To 25 c.c. of urine in a capsule add i gm. phenylhydrazin hydrochlorid, 0.75 gm. sodium acetate, and 10 c.c. dis- tilled water. Warm the mixture for an hour on a water-bath, remove, and let cool. If sugar be present, a yellowish deposit is formed, which the microscope shows to be composed of fine, brilliant yellow crystals arranged singly or in stars (Fig. 34). This phenylglucosazon melts EXAMINATIOX OF THE URINE 733 at 204° C. Yellow scales or spheres do not denote sugar. Care must be taken not to allow the phenylhydrazin to come in contact with the hands. Fermejitation Test. — The simplest accurate method of performing this test is by filling a test-tube about half full of mercury, and completely filling the remainder of the tube with the urine, introducing a small piece of compressed yeast and inverting the tube over a vessel of mer- cury. Then set the tube in a warm place for several hours. If fermen- tation occur, the carbonic-acid gas collects in the upper extremity of the tube. A special apparatus may be purchased, or it may be easily made by passing a doubly bent tube through a cork nearly to the bot- tom of a bottle containing the urine and yeast, hermetically sealing the cork. If sugar be present, the urine is expelled through the tube, its place being taken by the carbonic-acid gas. A control test should be made with distilled water and }^east from the same piece, for yeast sometimes undergoes spontaneous fermentation, probably due to the presence of sugar in it. A second control may be made with a weak solution of glucose, in order to prove the vitality of the yeast. Heller-Moore Test. — To a little urine in a test-tube add half its volume of sodium-hydroxid solution and heat to boiling; if the precipitation of earthy phosphates is abundant, filter. As the mixture becomes hot, a yellow, yellowish brown, or brownish black color appears if sugar be present. Now add a few drops of nitric acid. The color vanishes and an odor of molasses (caramel) is given off. Albumin must first be re- moved. Highly colored urine should be decolorized by filtration through animal charcoal. Picric-Acid Test. — To a small quantity of urine add two-thirds as much saturated solution of picric acid, and the same quantity of liquor potas- sae. An orange color results from the incipient reducing action of creat- inin on the picric 'acid. Turbidity denotes albumin, but does not in- terfere with the test. Boil the mixture for one minute; if sugar be present, a deep mahogany-color is produced, much deeper than that which occurs in normal urine. Quantitative Determination.— /'wr^/v'j- Method.— T\it formula of the standard solution is: Cupric sulphate, C.P., 4.742 gm. ; potassium hydroxid, C.P., 23.50; glycerin, C.P., 38 c.c. ; strong ammonia, U. S. P. (sp. gr. 0.9), 450 c.c; distilled water, to make 1,000 c.c. Dissolve the copper and glycerin in 200 c.c. of distilled water with the aid of gentle heat. In another 200 c.c. of the distilled water dissolve the potassium hydroxid. Mix the two solutions, and when cold add the ammonia with enough distilled water to bring the whole volume up to 1,000 c.c. Place exactly 35 c.c. of this test solution in the flask, dilute it with two volumes of distilled water, and bring the whole thoroughly to the boiling-point. Fill the burette to the zero mark with the urine to be tested, and slowly discharge it into the test-solution, drop by drop, until the blue color begins to fade, then more slowly until the color permanently disappears and leaves the fluid perfectly clear and trans- lucent. The blue color may return after some time, but it is due only to the absorption of oxygen. The percentage of sugar is thus calcu- lated : If the 35 c.c. of solution were reduced by 2 c.c. of urine, the 734 PRACTICE OF MEDICINE latter contained i per cent of sugar; if by i c.c, 2 per cent of sugar; if by 0.75 c.c, 3 per cent; if by 0.5 c.c, 4 per cent, etc Bile Acids. — Pettenkofer' s Test. — Concentrated sulphuric acid free from nitric or sulphurous acid is very slowly added in nearly equal volume to the urine, the test-glass being held in ice-water to prevent rise of temperature above 60° C. A 10 per cent solution of cane-sugar is then added drop by drop, with constant stirring. A beautiful red color in- dicates the presence of bile acids. The color becomes a bluish violet in the course of a few days. Bile Pigmeni. — Gmelin's Test. — Place in a test-tube a little strong nitric acid containing some commercial yellow nitrous acid, and flow over it the urine to be tested. A layer of green will form at the line of con- tact, surmounted from below upward by layers of blue, violet, red, and yellow, the green being distinctive of the bile pigment. Rosenbach modifies the foregoing test by passing the urine through a fine, thick filter, then applying a drop of the nitrous-nitric acid to the filter. A pale yellow spot is formed, surrounded by rings of yellowish red, violet, blue, and green. Hener''s Test. — About a dram of pure hydrochloric acid is placed in a test-tube, and just enough urine mixed with it to distinctly color it. The mixture is then flowed upon a column of nitric acid, and a beautiful play of colors is produced. If the nitric acid be now stirred with a glass rod, the colors are distributed in layers throughout the mixture. Ultzmann^s Test. — Ten c.c of urine are treated with 3 or 4 c.c. of a strong potassium-hydroxid solution and acidified with hydrochloric acid. If bile pigment be present, a beautiful green color is produced. Indican (Indoxyl-Sulphuric Acid). — Heller^ s Test. — To a dram of HCl in a small wine-glass add slowly, with constant stirring, about 20 drops of urine. If the color produced be a pale yellow, th^ indican is normal in quantity ; if blue or violet, it is increased. The addition of a drop or two of nitric acid renders the test more delicate. McMimn's Test. — Equal parts of urine and HCl with a few drops of nitric acid are boiled together, cooled, and agitated with chloroform. If much indican be present, the chloroform takes a violet color. Diazo Reaction. — Two solutions are required: (i) Sulphanilic acid 2 gm., and hydrochloric acid 50 c.c, in 1,000 c.c. of distilled water; (2) a 0.5 per cent solution of sodium nitrate. Mix one part of No. 2 with 50 parts of No. i, add to the mixture an equal volume of the urine, render strongly alkaline with ammonia, and shake well. The characteristic reaction consists in the production of a carmine color both in the mixture and in the foam. Normal urine yields a yellow color. The test may be performed by the contact method, by carefully flowing the ammonia upon the surface without mixing. A brownish-red ring is formed at the junction of the fluids. DRUGS IN THE. URINE. Arsenic— Reinsch's Test.—kA^ to the urine in a test-tube a few drops of hydrochloric acid, then introduce a piece of pure, bright copper foil y^, inch square, and boil for several minutes. If arsenic be present, a EXAMINATION OF THE URINE. 735 dark gray coating is deposited on the copper. The test is more delicate if the urine be concentrated by slow evaporation. Lead. — Wood's Test. — For four or five days before securing the speci- men, the patient takes 5 to 10 grains of potassium iodid three times a day. A liter of urine is then obtained, evaporated to dryness, and fused in a crucible with a little pure potassium nitrate until it becomes white. When cool, the residue is extracted with hot dilute hydrochloric acid, filtered, the filtrate rendered alkaline with ammonia to precipitate the phosphates and iron. Ammonium sulphid is now added to precipitate the lead, the precipitate is washed three times with hot distilled water and decanted, water acidified with hydrochloric acid is added, and the whole is allowed to stand until the next day. It is then filtered through a small filter, the precipitate is washed, and a little nitric acid is added drop by drop to dissolve the lead and carry it through as a nitrate. The filtrate is collected in a watch-glass and evaporated to dryness, and the final test is made by adding a drop of water and a crystal of potassium iodid. The formation of a yellow precipitate denotes the presence of lead. Mercury. — To a liter of urine add 10 c.c. of hydrochloric acid, intro- duce a little piece of copper foil, and apply heat. After letting the urine stand for twenty -four hours, remove the copper foil, wash it with water, alcohol, and ether, and let it dry. Then introduce it into a long test- tube and heat it to redness. If mercury be present, it condenses on the cool part of the tube. If fumes of iodin be now introduced, the mer- cury is changed into mercuric iodid, having a red color. Bromin and Iodin. — Add to the urine a little fuming nitric acid or some freshly prepared chlorin-water, and shake with chloroform. If bromin be present, the chloroform assumes a brownish yellow color. If iodin be present, a carmine or purple color is produced. If the urine be ammoniacal, potassium-hydroxid solution should be added to the urine before making the test (Gillett). Quinin. — To about 10 c.c. of urine in a test-tube add a drop or two of HCl, then 2 drops of chlorin-water and an excess of ammonia. An emerald-green color is produced, which corresponds to the quantity of quinin present. Carefully neutralize the mixture, and the color turns to blue; add an excess of an acid and it becomes purple or red; again add an excess of ammonia, and the green color is restored. Acetanilid. — Evaporate the urine to about half its volume, add HCl and boil for a few minutes; extract with ether, evaporate the ether, treat the residue with distilled water, add a few c.c. of an aqueous solution of phenol and half as much of a i per cent solution of calcium hypochlorite. A pale green (onion-peel) color is produced, which changes to blue on the addition of ammonia. If the urine is pale, the extraction with ether may be omitted. Antipyrin. — The addition of ferric chlorid to urine containing anti- pyrin produces a red color. If antipyrin be also present in the test for quinin, the urine acquires a red color on the first addition of ammonia. Morphin. — Add to the urine a little chloroform containing one or two drops of iodic acid. As the chloroform sinks to the bottom, it takes up iodin and acquires a pink color corresponding in depth to the quantity 736 PRACTICE OF MEDICINE of morphin present. Now render the mixture alkaline with ammonia; the pink color is discharged from the chloroform, and the supernatant fluid becomes deep brown. Salicylic Acid. — To lo c.c. of urine add i c.c. of strong ferric-chlorid solu- tion. Salicylic acid (salicyluric acid) produces a violet color. Diabetic urine may give the same reaction without the presence of this substance. Santonin. — The bright yellow urine becomes red on the addition of an alkali, and the color gradually fades. Rhubarb and senna give the same color-change on the addition of an alkali to the urine, but the color is permanent. Add baryta-water to the fluid, and filter ; if the color pass through with the filtrate, it is due to santonin ; if it remain with the precipitate, it is due to rhubarb or senna. Pine Acids. — The acids and salts of pine appear in the urine after the ingestion of balsams, cubebs, and sometimes after turpentine has been taken. The addition of strong nitric or hydrochloric acid pro- duces a precipitate like that of albumin, but it is dissolved by strong alcohol. Urine containing turpentine often has the odor of violets. URINARY SEDIMENTS. To obtain the sediment from a specimen, the fluid should stand about seven hours in a conical glass. The supernatant portion may then be decanted slowly; the last cubic centimeter will usually contain a representative quantity of the sediment. A much quicker and better method is by means of the centrifuge, since time is not thus allowed for the destruction of the anatomical elements by bacteria. Chemical Sediments.- — Uric-acid crystals are found almost exclusively in acid urine, and they constitute the only ingredients of acid urine which have a yellow color. They fre- quently crystallize upon the side of the vessel They are for the most part rhomboidal, but may be rectangular, or having rounded ends may appear ovoidal or circular. They are usually flattened, but may be cubical and often form stars or clusters (Fig. 35). Urates. — The urates of sodium and potassium may be found in acid urine, rarely also that of calcium. Ammonium urate is nearly always Fig. 35. — Uric-acid crystals. A, Crystallization on a cot- ton fiber. or upon foreign bodies. Fig. 2)^. — Crj'stals of ammonium urate. found in alkaline urine. Sodium urate appears as an amorphous, " brick- dust" deposit, and is very insoluble, sometimes in the form of fan-shaped EXAMINATION OF THE URINE 737 ^ <> or stellate clusters or needles. Potassium acid-urate appears only in amorphous form, more soluble than the sodium salt. Calcium urate occurs m acid urine as an amorphous white or gray deposit. Ammonium urate occurs in the form of dark brown crystalline spheres studded with fine spiculae, which are known as mulberry crystals (Fig. 36). Calcium Oxalate. — These crystals occur in either acid or alkaline urine, as small, highly refracting octahedra, " envelope" crystals, or as circular or ovoid disks with central depres- sions, "dumbbell" crystals (Fig. 37). Phosphates. — Only the alkaline phosphates are found in urinary sedi- ment. They occur as triple ammonium-magnesium phosphates or as calcium phosphates. The most frequent appearance is that of triangular Fig crystals. Ij. — Calcium-oxalate Fig. Ty?s. — Cr\fstals of ammonium-magnesium phosphate (from a camera-iucida sketch). The cr_vstal at the extreme left is probably calcium phosphate. prisms having beveled ends, the "coffin-lid" crystals (Fig. 38), rarely that of rosettes or star-shaped bunches of feathery crystals resembling fern leaves. They are found only in alkaline urine. Leucin and Tyrosin.—Leucm occurs in yellowish, highly refracting spheres, resembhng fat-globules, but in a pure state it crystallizes in irregular scales or rosettes having a greasy feel. The spherules are insoluble in ether. Tyrosin crystallizes in the form of fine needles arranged in' sheafy bundles; some- times, in alkaline urine, in the form of ro- settes (Fig. 39). It is readily soluble in hot water, acids and alkalis, insoluble in alco- hol or ether. Melanin. — The urine may be dark colored when voided, or becomes so after exposure to the air, or upon the addition of sulphuric or hydrochloric acid or ferric chlorid. The addition of bromin-water produces a yellow pre- cipitate which turns to black. (See also Alkapton test, p. 731.) The microscope reveals small granules insoluble in cold alcohol, ether, acetic acid, or dilute mineral acids, but soluble in strong solutions of ammonium, sodium, or potassium hydroxid, and in boiling acetic, lactic, and mineral acids. Fat appears in the urine as small, highly refracting granules with dark margins, which are soluble in ether, chloroform, benzol, carbon disulphid, and hot alcohol. 47 Fig. 39. — Leucin spherules and tyrosin crystals. 738 PRACTICE OF MEDICINE ANATOMICAL SEDIMENTS. Epiihelium is almost invariably found in the sediment, whether the urine be normal or pathological. Each division of the urinary tract has its typical surface epithelium, but of no cell can it be said that it a be o © @@o^@ Fig. 41.— Blood cells and blood-casts. Fig. 40. — Types of epithelium found in the sediment of urine, a, From the kidney and ureter; b, from the bladder; c, from the vagina. originates in one division alone, especially in pathological urine, for im- mature and transitional forms from the deeper layers often appear. The three principal types of cells are shown in Fig. 40. Pus. — Purulent urine is often cloudy or milky. Under the microscope pus-cells appear as pale, finely granular spherical cells about the size of leucocytes, containing from one to three nuclei. Water and acetic acid cause them to swell and become more delicate in outline, the acid at the same time causing the granular matter to disappear and rendering the nuclei more distinct. The pus- cells in urine are dead and show no ameboid movement. In alkaline urine they usually fuse into a glairy mass at the bottom of the speci- men, and cannot be recognized with the micro- scope. Blood. — When abundant, blood gives to the urine a color varying with its quantity from a dark red or smoky hue in acid urine to a bright red in alkaline urine, or there may be a reddish brown granular sediment. Coagula may be found. Albumin is always to be detected. The corpuscles are usually scattered singly over the field of the microscope, rarely forming rouleaux. When the blood originates in the kidney, casts are usually present (Fig. 41). Gum- Fig. 42.— Peculiar forms of blood-corpuscles found in hematuria of renal origin, (After Gumprecht.) precht has shown that in renal hematuria the red cells are fewer in number than in that of vesical origin ; the corpuscles usually undergo fragmentation and often assume peculiar forms (Fig. 42). URINARY CASTS. The urine should be examined as fresh as possible, and for this rea- son centrifugal precipitation is to be preferred. It is better to place a EXAMINATION OF THE URINE 739 piece of hair under the cover-glass in order to avoid forcing the casts out from under it. A moderately low power should first be used in order to determine the presence of casts, then a high power (^) to determine their character. The light should not be too strong. Oblique illumination is often better, especially for the hyalin-cast. Fig. 43.— Renal casts, a, Hyalin; b, granular; c, epithelial. The principal forms of casts are : hyalin, granular, epithelial, waxy, fatty, and blood casts. These are shown in Figs. 43 and 44. Amor- phous urates and foreign matter sometimes assume the form of false casts (Fig. 44, c). Spermatozoa axe little threadlike bodies about 1-600 inch in length and have flattened, oval heads. Under favorable conditions of heat and Fig. 44.— Renal casts, a. Waxy; b, fatty; c, amorphous urate and other false casts. moisture they exhibit a vermicular motion, 'but are usually motionless when found in the urine. Fragments of tumors are sometimes found in the urine, but they are seldom of sufficient size to permit of proper hardening and cutting. A diagnosis should not, as a rule, be based upon their appearance under the microscope. ANIMAL PARASITES. Distoma Hematobium.— Theova of this parasite are oval, about 1-200 inch long, with a sharp, projecting anterior extremity and containing a distinctly visible embryo. They are usually accompanied with blood, and sometimes with fat. Filaria Sanguinis Hominis.— This parasite is usually found in chylous urine. It is about as wide as a red blood-corpuscle and about fifty times as long. It has a short, rounded head and a long, pointed tail. The body is granular and has transverse striations. 740 PRACTICE OF MEDICINE Echinococcus. — The booklets and scolices of the echinococcus rarely find their way into the urine. They may appear, however, entire or in fragments, and may be accompanied bv pieces of the chitinous mem- brane, usually with blood, pus, and cellular debris. Other parasites rarely found in the urine are the trichomonas, oxy- uris vermicularis, and the strongylus gigas. A peculiar ameba and an infusorium have also been described. VEGETABLE-PARASITES. Nearly forty varieties of bacteria have been recognized in the urine. These belong to the two classes of pathogenic and nonpathogenic or- cco Fig. 45.— Yeast plant. Fig. 46.— Sarcinse of Fig. 47.— The micrococcus urine. urese. ganisms. Molds seldom form, except when sugar is present. The yeast plant (Fig. 45) is occasionally found, in single cells or in chains. Sar- cinae (Fig. 46) have been found in acid urine. They are sometimes larger than those found in the stomach. The micrococcus ureae is a rather large micrococcus, growing in chains in alkaline urine. All these nonpathogenic bacteria are found, for the most part, in connection with retention due to stricture, cystitis, enlarged prostate, paralysis, etc. Pathogenic Bacteria. — The pathogenic bacteria may be described under the heads of micrococci and bacilli. The micrococci belong chiefly to the pus-formers and include the streptococci ureae, pyogenes, and rugosus; the staphylococci pyogenes albus, aureus, and citreus; several diplococci and many others. The gonococcus belongs to this class. The most important bacilli are the coli communis, tuberculosis, and typhosus. The micrococci, as a rule, require no special methods of staining, all that is necessary being to place a drop of the sediment on a slide, add Fig. 49. — Tubercle bacilli. a drop of any anilin stain, remove the excess of coloring matter after a few minutes, and examine with a high power. The gonococcus is hemispherical, and so arranged in pairs that the inner, flat or slightly concave side of each is separated from that of its BACTERIOLOGICAL METHODS 741 fellow by a narrow interval (Fig. 48). They are sometimes grouped as tetrads, and are generally found in pus-cells or attached to epithehum. Anilin blue or violet is the best stain. The Bacillus tuberculosis (Fig. 49) is detected in the urine with much difficulty, as a rule, owing to the uncertainty of securing the specimen from so great a quantity of fluid, and still greater difficulty of fixing it. The method of staining is the same as that employed in examination of sputum. Bacillus Typhosus. — This organism may be stained by Ziehl's method, acetic acid being used to decolorize instead of sulphuric or nitric acid. Better results are obtained by staining for twenty-four hours in Lof- fler's alkaline methylene-blue solution. The Bacillus coli commutiis is differentiated from the B. typhosus with much difficulty, and chiefly by its behavior upon different culture-media, which the student will find fully described in his textbook on bacteri- olog>^ CRYOSCOPY. The apparatus necessary for the determination of the freezing-point of urine consists of a double test-tube, a stirrer, a freezing-bath, and a thermometer capable of registering the hundredths, or, better, the thousandths, of a degree centigrade. A lens is necessary to recognize these minute variations. The test-tube may be made by placing a flat- bottomed test-tube one inch in diameter and seven inches long within a slightly larger tube, preventing contact by placing rubber bands around the inner tube. The stirrer is made by bending a loop five-eighths of an inch in diameter at a right angle on the end of a stiff wire of suita- ble length, to serve as a handle. To the outer edge of the loop is then fastened with fine wire a strip cut from the side of a goose-feather. This must fit into the inner tube with sufficient accuracy to prevent the clinging of ice crystals to its sides. The thermometer is placed within the inner tube. An approximate test of the freezing-point is made by immersing the tube in a freezing-mixture. A mixture of shaved ice and water is then prepared in a felt-covered vessel, and enough salt is added to reduce the temperature of the slush to that of the approximated freezing-point of the urine. The test-tube is filled one-third full of the urine and placed in the freezing-mixture until the temperature falls to 0.3° or 0.4° C. below that of the freezing-point just determined. The tube is then transferred to the mixture of ice and water, and a minute crystal of ice is dropped into the urine in order to start the crystallization. The tem- perature rises slightly as the urine congeals, and in about one minute it may be read from the thermometer. In order to secure the slightest variation it is necessary to tap the top of the thermometer with rapid but delicate blows. The stirrer must be kept in motion during the entire process. BACTERIOLOGICAL iMETHODS. Success in bacteriological work can be attained only at the expense of considerable time and with precise methods. The more elaborate investigations can be made only in a fully equipped laboratory, but 742 PRACTICE OF MEDICINE there is much that can be done in a small way with comparatively lit- tle expense and in leisure moments. Preparation of the Specimen.— A very small portion of the culture, blood, pus, mucus, or other discharge to be examined is picked up on the platinum loop after it has been passed through the Bunsen or al- cohol flame, or on a sterilized cotton swab, and smeared on a perfectly clean slide or cover-glass. For permanent mounts the film should be made upon the cover-glass, but for diagnostic purposes the use of the slide is more rapid and attended with less breakage. Cultures should be mixed with a small drop of water in order to spread the bacteria over a larger field. The film is then allowed to dry in the air, then fixed to the glass by being passed rather slowly three times through the Bunsen flame. It is then ready to be stained. It is always well to ex- amine an unstained specimen in the hanging drop before drying, in order to recognize motile bacteria and other peculiarities. The hanging drop is made by placing a drop of the culture or other fluid, or a drop of water to which the bacteria have been added, on a cover-glass, and in- verting it over the depression in the slide made for this purpose. Staining.— For ordinary staining, the film is simply covered with a cold solution of one of the anilin dyes and allowed to stand for five or ten minutes. For this and all manipulations of the cover-glass, Stewart's forceps (Fig. 50) or similar device is exceedingly convenient. Fig. 50. — Stewart's self retaining cover glass forceps. In many instances the stain is more quickly and more fully taken up with the aid of heat. The specimen is held over the flame, at a little distance, until vapor can be seen arising from it; or the cover-glass smear maybe floated, film side downward, upon the surface of the staining fluid in a watch-glass, while this is held over the flame, until evaporation can be recognized. The fluid should not be raised to the boiling-point. After this the specimen is thoroughly washed in distilled water and dried, first upon cigarette-papers and then for a few minutes in the air, or it may be held at a little distance from the side of the flame. It can then be mounted in the usual manner with a drop of balsam, or the examina- tion may be made with a drop of water. Preparation of Sections. — When it is desired to examine the bacteria in the tissues, a small piece of the organ must be obtained as fresh as possible, and hardened in alcohol for a few days. The pieces should riot be more than a centimeter in diameter. After they have become suifi- ciently hard they are cut in the usual manner, in cork, liver hardened with Muller's fluid, or with the microtome after being embedded in cel- loidin or paraffin. Staining Solutions.— For simple staining, an aqueous solution of one of the anilin dyes, as methylene blue, fuchsin, or gentian violet, is gen- BACTERIOLOGICAL METHODS ' "■ 743 erally employed. For convenience, a saturated alcoholic solution should be kept in stock. This is made by placing in the bottle a little more of the dye than will dissolve in enough alcohol to fill the bottle. The quantity of the dye is usually about one-fourth of the capacity of the bottle. The alcohol is then added, and the bottle is well shaken and set aside for 24 hours. A few crystals should remain undissolved. For use, enough of the stock solution is added to a small bottle about two-thirds full of distilled water to make a solution which is barely transparent. The proportion is usually about 5 c.c. of the saturated solution to 95 c.c. of water. Some varieties of bacteria are slow to take up the stains, and for these special solutions must be employed. In some instances the stain- ing is so strongly retained that the resistance to the action of bleaching- fluids is a distinguishing feature of the organism, as is notably the case with the Bacillus tuberculosis. Loffler's Alkaline Methylene-Blue Solution. — The formula is : Saturated alcoholic solution of methylene blue 30.0 Solution of potassium hydroxid in water (i :ioooo) 100. o This solution is especially applicable to the staining of the diphtheria bacillus. Koch-Ehrlich Anilin Water-Fuchsi?i Solution: Anilin-water 50.0 Saturated alcoholic solution of fuchsin 5.0 The anilin-water is made by adding about 5 c.c. of anilin oil to 100 c.c. of distilled water, a few drops at a time, and shaking well after each addition; then, after allowing the mixture to stand for several hours, filtering it through a moistened filter-paper. The specimen must remain several hours in this solution. Anilin solutions of gentian-violet or anilin blue may be made in the same manner. Kuhne's Methylene Blue: Methylene blue r.5 Absolute alcohol 10. o Carbolic-acid solution (i :2o) 100. o This stain requires about five minutes for films. Carbol-Thionin Blue. — Thionin' blue, i gm. ; carbolic-acid solution (i :4o), 100 c.c. For use, dilute with three times as much water, and stain from three to five minutes. ZieliVs Carbol-Fuchsin Solution: Fuchsin 0.5 gm. Absolute alcohol 5.0 c.c. Carbolic-acid solution (1:20) 50.0 c.c. This solution may be made also from the stock solution of fuchsin by slowly adding it to the 5 per cent carbolic-acid solution until an opal- escent hue is produced or until the surface acquires a metallic luster. Grain's lodin Solution: lodin o. 10 Potassium iodic! 0.20 Distilled water 30.00 This solution is employed as a bleach after staining with a gentian 744 PRACTICE OF MEDICINE violet, especially for the pneumococcus, and may be followed with a counter-stain of carmin or Bismarck brown. After staining with the gen- tian-violet solution, the specimen should be immersed for a few moments in the Gram solution, then washed in alcohol. If the cover-glass still retain a trace of violet color, it must be immersed in the iodin solution until thoroughly bleached. The method is valuable also for staining the capsules of certain bacteria. Welches Capsule Stain. — Another method of staining the capsules of bac- teria thus enveloped is to cover the film with glacial acetic acid for a few seconds, then drain it off and replace it with gentian violet-anilin solution, repeating the application several times. Then wash in a 2 per cent sodium-chlorid solution, and mount in the same fluid. Gabbefs Blue. — This is a solution of 2 grams of methylene blue in a 25 per cent solution of sulphuric acid. It is employed chiefly as a com- bined bleach and counter-stain. It should be allowed to stand for sev- eral hours to become perfectly cooled before it is used. Specimens in- tended for permanent mounts must be thoroughly washed after being immersed in it. In case the counter-stain is not sufficiently deep, the specimen may be immersed in the ordinary aqueous solution of methyl- ene blue. Staining the Spores.— ^<5<5cal impaction in t}'phoid ft-ver. 60 Feces, examination of, 724 Fehleisen's streptococcus, 151 zones in erysipelas, 152 Fehling's test for sugar, 731 Ferment, glycogenic, in diabetes. 595 Fermentation, 34 fever, 147 Ferments, chemical, 34 forms of, 35 in urine, tests for. 729 Fever, 19 aseptic, 7 in acute uremia, 561 in appendicitis, 493 in hepatic abscess, 525 in syphilis, 164 in trichinosis, 273 in tubercular adenitis. 183, 184 of pneumonia, 119 reactionary, 91 simple continued, 224 Fibrin, test for, 731 Fibrinous bronchitis, 391 pneumonia, 115 Fibroblasts, 31 Fibroid phthisis, 204 Fibroma moluscum. 623 Fibrosis, arteriocapillary. 37 • Fifth nerve, diseases of, 626 Filaria Bancrofti, 276 bronchialis, 278 hominis oris, 27S labialis, 278 lentis, 278 loa, 276, 278 perstans, 276 sanguinis hominis, diurna et nocturna, 276 in urine, 739 Filariasis, 276 Fingers, clubbed, in tuberculosis, 197 Fish and shellfish-poisoning, 614 Fistula, gastrocutaneous, in peptic ulcer^ 460 in ano, tubercular. 206 Fits, epileptic, 684 Flagella, staining of, 744 Fleas and the plague, 94 as hosts of tenia, 280 as parasites, 288 Flies and the plague, 94 and tuberculosis, 172 as carriers of germs. 2>7 Flint murmur, 345 Floating spleen, 313 Florida fever, 618 Fluctuation in ascites, 550 Fluid of pancreatic cyst, 542 Flukes, 269 Flux, bloody, 249 Food, infection by, in typhoid fever, 48 -poisoning, 614 Foot and mouth disease, zt^j Foreign bodies, calcareous incrustation of, 25 in esophagus, 445 in stomach, 468 Formic acid in urine, 560 Formication in locomotor ataxia, 648 " Fourth disease," 1 10 nerve, diseases of, 626 Fractures, green-stick, in rickets, 594 Frank pneumonia, 123 Friction redux, in pleurisy, 420 Friedlander's bacillus. 116 in pleurisy, 41 8 Friedreich's ataxia. 652 Fumigation treatment of syphilis, 168 Funnel-chest in tuberculosis, 441 Furunculosis in cholera, 88 in diabetes, 599 in jaundice, 531 in scarlatina, 104 in typhoid fever, 67 Gabbet's blue, 744 Gait, ataxic, 649 Galactotoxismus, 614 Gall-bladder, calcification of, 26, 53S cancer of, 539 diseases of, 530 dropsy of, 538 empyema of, 53S perforation of, by typhoid bacilli, 62 Gallop rhythm, 364 Galloping consumption. 192 Gall-stones, 536 after typhoid fever, 62 physical properties of, 536 remote effects of, 538 Ganglia, basal, tumors of, 673 Gangrene, 28 after scarlet fever, 104 forms of, 2^ in cerebrospin,il meningitis, 112 762 INDEX Gangrene in cholera, 88 in typhoid fever, 59 of the lung, 414 in noma, 433 Gas in the urine, 560 Gastralgia or gastrodynia. 474 in peptic ulcer, 461 Gastrectasia or gastrectasis, 455 Gastric contents, microscopic examina- tion of, 723 fever, 448 ulcer, 459 Gastritis, acute, 447 after typhoid fever, 60 chronic, 450 croupous, in pneumonia, 126 infectious, 448 interstitial or sclerotic, 45 i membranous, 449 mycotic or parasitic, 450 phlegmonous or suppurative. 44S polyposa, 451 toxic, 449 Gastroenteritis, 481 Gastrointestinal catarrh in hepatic cirrho- sis, 519 symptoms in chronic nephritis, 568, 570 in diabetes, 598 in lead poisoning, 611 in uremia, 561, 562 Gastrorrhagia, 468 Genitourinar\- tuberculosis, 2o3 Geographical tongue, 435 German measles, log Giant-cells in tubercle, jj^ Gibraltar fever, 97 Gigantorhynchus, 279 Gilles de la Tourette's disease, 682 Gin drinker's liver, 517 Girdle pains in locomotor ataxia, 64S in myelitis, 640 Glanders. 229 Glandular fever, 226 Glaucoma in smallpox. 262 Glenard's disease, 507 Globulin in the urine. 558 test for, 731 Globus hystericus, 444, 694 Glomerulonephritis in scarlatina, 103 Glossitis, acute and chronic, 434 desiccans, 435 Glossolabiolaryngeal paralysis, 646 Glossopharyngeal nerve, disease of, 629 Glycogen in urine, 599 Glycosuria, alimentary, 596 in exophthalmic goiter, 319 in calculi of the pancreas, 543 in pancreatitis, 541 transitory, 596 Goiter, 316 exophthalmic, 317 Gonococcus in urine, 740 Gonorrheal infection, 160 forms of, 161 Gout, 587 acute, 590 chronic, 591 irregular, 591 retrocedent, 591 saturnine, 612 sodium-biurate deposits in, 589 theories of, 588 tophi or chalk-stones in, 590 uric-acid showers in, 591 Goutiness, 591 Grain-poisoning, 615 Gram's iodin solution, 743 Grand or haut mal, 685 Gravel, 576 Graves's disease, 317 Gray hepatization, 117 Green cancer, 299 -sickness, 292 Gregarmidse, 268 Grip, the, 82 Guanin, 6 Guinea-worm, 277 Gumma, syphilitic, 164 of spleen, 315 Habit-chorea, 682 from tonsilitis, 441 Habit-spasm of the face, 628 Haffkine's serum, 97 Hames's test for sugar, y^2 Hair-tumor of stomach, 468 Hallucinations in alcoholism, 607 Hammerschlag's method of estimating specific gravity of the blood, 717 Hammond's disease, 682 Hanot's disease, 521 Hansen's bacillus, 220 Haptophore groups of cells, 41 Harvest-bug as parasite, 287 Haut mal, 684 Hay asthma, ^8^ fever, 383 Headache in acute uremia, 561 in chronic nephritis, 570 in typhoid fever, 6^ Head-tetanus, 224 Heatstroke, 616 Heart-action in pneumonia, 121 acute dilatation of, 355 aneurism of, 361 changes in emphysema, 410 congenital defects of. 369 cysticercus of, 283 degenerations of, 361 dilatation of, in alcoholism, 607 diseases of, 329 -failure in diphtheria, 135 foreign bodies in, ;i62 hurry, 365 hypertrophy of. 351 and dilatation of, in tubercular pericarditis, 187 in chronic nephritis, 568, 571 INDEX 763 Heart, hypertrophy of, in gout, 590 lesions in acute rheumatism, 156 in cerebrospinal meningitis, 1 1 1 in diphtheria, 131, 132 in scarlatina, 104 neuralgia of, 366 neuroses of, 363 new growths of, ^62 palpitation of, 363 parasites of, 362 rapid (see Tachycardia), 365 rupture of, 362 slow (see Bradycardia). 366 valvular disease of, 334. 335 wounds of, 362 Heartburn, 452, 473 Heat-exhaustion, 616 Heberden's nodosities, 583 theories of angina, 367 Hebetude in typhoid fever, 63 Hectic fever in pneumonic tuberculosis, 193 Heller's test for albumin, 730 for hemoglobin, 731 Hematemesis, 468 feigned, 469 in hepatic cirrhosis, 519 in peptic ulcer, 461 vicarious. 469 Hematobia Bilharzia, 269 Hematochyluria, 277 Hematoma, 15 calcification of, 26 Hematoporphyrinuria, 558 Hematozoa of malaria, 239 Hematozoon of spotted fever, 228 Hematuria, 557 endemic, 557 in cerebrospinal meningitis, 112 in typhoid fever, 65 malarial, 246 Hemeralopia in disease of optic nerve, 625 in jaundice, 531 in scurvy, 307 Hemianopia, 625 Hemicrania, 689 Hemiglossitis, 435 Hemiplegia, 104 after typhoid fever, 64 in mumps, 145 in pneumonia, 125 in whooping-cough, 143 Hemoglobin, estimation of, 714 Hemoglobinemia, blood-test for, 718 Hemiglobinuria, 557 epidemic, 305, 557 in malaria, 246 paroxysmal, 557 toxic, 557 Hemolysins, 41 Hemopericardium, 329 Hemophilia, 304 Hemoptysis, 199, 399 filarial, 277 in tuberculosis, 196 Hemoptysis in typhoid fever, 63 of parasitic origin, 400 recurrent, 400 treatment of, 219 vicarious, 400 Hemorrhage, 14 cerebral, 661 in acute yellow atrophy, 516 in cancer of stomach, 465 in diphtheria, 135 in icterus neonatorum, 5;^2 in peptic ulcer, 461 in septicemia, 148 in whooping-cough, 143 internal, 15 intestinal, in typhoid fever, 61, ^j into angular gyrus, 663 into cerebellum, 664 into crus cerebri. 663 into fusiform lobule, 663 into lateral ventricles, 663 into liver, 514 into medulla, 664 into occipital lobe, 663 into pons, 663 into spinal cord, 638 into temporal convolutions, 663 intracranial, 661 of esophagus, 445 of intestine, 48S of lungs, 399 of mesentery, 511 of pancreas, 539 of stomach, 468 Hemorrhages in hepatic cirrhosis, 519 in hypertrophic cirrhosis, 522 in pernicious anemia, 291 in scurvy, 307 of yellow fever, 92 Hemorrhagic diathesis, 14 diseases of new-born, 305 infarct of lung, 401 Hemorrhoids, 505 in hepatic cirrhosis, 519 Henoch's disease, 302 Hepatalgia, 515 Hepatic artery and vein, diseases of, 515 fever, 534 intermittent fever, 533 due to ball-valve calculus, 538 Hepatitis, acute parenchymatous, 515 fibrinous, 517 in syphilis, 164 interstitial, 517 suppurative. 524 Hepatization of lung in pneumonia, 117 Hereditary syphilis, treatment of, 168 Heredity in rheumatism, 155 Hernia, duodenojejunal, 498 in whooping-cough, 144 intra-abdominal, 498 omental, 498 Herpes in acute tuberculosis, 179 in cerebrospinal meningitis, 112 764 INDEX Herpes in gastritis, 448 in jaundice, 531 in typhoid fever, 66 zoster, 692 Herudo Ceylonica, 270 vorax, 270 Hiccough, 632 in choleHthiasis. 537 in enteralgia, 510 in intestinal obstruction, 500 in peritonitis, 545 Hippocratic facies after perforation of peptic ulcer, 461 in peritonitis, 545 in tubercular peritonitis, 188 fingers, 197 Hirschsprung's disease, 507 Hirudinea, 270 Hobnail liver, 517 Hodgkins's disease, 299 Homogentisinic acid in urine, 560 Hooklets of echinococcus, 284 Hospital fever. 78 Hour-glass contraction of stomach. 449 in peptic ulcer, 460 Huntington's chorea, 682 Hutchinson teeth, 166 Hydatid C3'st (see Echinococcus). 283 Hydatid purring, 285 Hydremia, 9 Hydrencephaloid, 483 Hydrocephalic cry, 112 Hydrocephalus, 179, 675 chronic, in cerebrospinal meningitis, III, 113 pathology of, 12 Hydronephrosis, 575 intermittent. 576 Hydropericardium, 32S pathology of, 12 Hydroperitoneum, 549 Hydrophobia, 230 preventive inoculation, 232 Hydropneumothorax, 427 Hydrops articulorum intermittens, 707 vesica; felleae, 538 Hydrorrhachis, 655 Hydrotherapy, Brand method of. 74 Ziemmsen method of, 75 Hydrothorax, 12, 426 Hymenolepsis diminuta, 280 nana, 280 Hyperacusis, 629 Hyperchlorhydria, 471 Hyperemia, active, 1 1 collateral, 12 local. 1 1 of brain, 66 r of kidneys, 554 of liver, 513 of spinal cord, 637 passive, 12 Hyperesthesia, gastric, 474 of esophagus, 444 Hyperglycemia in diabetes, 596 Hyperkinesis, 473 Hyperleucocytosis (see Leucocytosis), 9 Hyperorexia, 475 Hyperosmia, 384. 624 Hyperpyrexia. 19 in erysipelas, i 53 in malaria. 246 in pneumonia. 120 in rheumatism, 157 in typhoid fever, 56 Hyperthyria in goiter, 31S Hypertrophic cirrhosis, 521 Hypertrophy of the heart, 351 concentric. 346, 352 eccentric, 351 Hypochlorhydria. 471 Hypoglossal nerve, diseases of, 632 Hypoleucocj'tosis, 10 Hypoplasia, 21 Hypostatic congestion, 10 of lung. 398 in typhoid fever, 63 Hypotonia in locomotor ataxia, 649 Hypoxanthin, 6 Hysteria, 693 major and minor, 694 traumatic, 700 Ichthyosis lingua% 435 Irhth\ otoxismus. 614 Icterus (see Jaundice) gravis, 515 in hypertrophic cirrhosis, 522 neonatorum, 532 physiological, of new-born, 532 Idiocy, amaurotic family, 652 IleocoHtis, 476 Ileus, 498 Imbecility after cerebrospinal meningitis, 113 Immunity, 42 artificial, 42 complete and partial. 42 Ehrhch's theory of, 43 from scarlatina, loi from yellow fever, 90 mechanism of, 42 natural and acquired, 42 Incoordination in locomotor ataxia, 649 Indican, test for, 734 Indicanuria, 559 in empyema, 421 in gastritis, 44S Indol, 6 a bacterial jjroduct. 36 Inebriety, 605 Infantile paralysis, 666 spinal, 642 Infantilism, syphilitic, 166 Infarct, bilirubin, calcium, hematoidin, 19 changes in the hemorrhagic. 18 hemorrhagic, in yellow fever, 90 melanin; sodium-urate, 19 INDEX 765 Infarct, uric acid. 19 in gout, 590 Infarction, 18 hemorrhagic, of intestine, 488 in scurvy, 307 Infection, n antagonism of, 39 cellulohumoral theory of, 40 Chauveau's theory of, 43 chemical theory of. 40 cryptogenic. 38 double, in typhoid fever, 50 Ehrlich's theory of, 40 lymph glands in, 43 Metchnikoff's theory of, 40 mixed, in tuberculosis, 177 in typhoid fever, 50 splenic enlargement in, 41 Infections associated with typhoid fever, 68 Infectious diseases common to man and lower animals, 229 of doubtful nature, 224 Infiltration, calcareous, 25 dropsical, 25 Inflammation, 29 chronic, 31 diphtheritic, 31 fibrinous, 30 hemorrhagic, 30 necrotic, 31 of brain, 667 ptirulent, 30 secondary, in tuberculosis, 177 serous, suppurative, 30 Influenza, ^2 bacillus of, 82 in pneumonia, 1 16 catarrhal or epidemic, 82 Infusoria, 268 Inhalation pneumonia, 403 Insanity after mumps, 145 after typhoid fever, 64 in aortic incompetency, 344 Insects as means of infection, ^^'j in etiology of plague, 94 in typhoid fever, 172 of yellow fever, 90 Insolation, 616 Insomnia from alkaline treatment, 158 Intermittency of heart, 364 Intermittent fever, 239 quartan, 243 tertian, 242 Interstitial pneumonia, 406 Intestinal discharges, examination of, 724 hemorrhagein typhoid fever, 6r, yj obstruction, 498 acute and chronic, 500 by abnormal contents, 499 by worms, 271 diagnosis of, 500 perforation, in typhoid fever, 61. yj poisoning, 147 sand, 511 Intestine, amyloid disease of, 489 diseases of the, 476 hemorrhage of, 488 hemorrhagic infarction of, 488 lesions of, in typhoid fever, 50 neuralgia of, 509 neuroses of, 508 stricture and tumors of, 499 tuberculosis of, 206 knots and twists of, 499 vicarious hemorrhage of, 488 Intoxication, acid, 6 Intoxications, 605 Intubation in diphtheria, 141 Intussusception, intestinal, 498 Inunction treatment of syphilis. 168 Invagination of bowel, 498 Invasion, stage of, 20 lodin, test for, 735 Iridoplegia, 625 Iritis in acute rheumatism, 158 scarlatinal, 104 in smallpox, 262 in syphilis, 164 Ischemia, 1 1 Islands of Langerhans in diabetes, 597 Island of Reil, tumor of, 673 Itch mite, 287 Ixodes, 287 albipictus; bovis; ricinis, 287 Jaeger's bacillus, 225 Jail fever, 78 Jaundice, 530 acute febrile, 225 in acute pancreatitis, 541 in cancer of liver, 529 in cholelithiasis, 537 in hepatic cirrhosis, 519, 520 in pneumonia, 126 in typhoid fever, 62 malignant, 515 obstructive, 530 toxemic, 532 Jigger as a parasite, 288 Joint lesions in acute rheumatism, 156 in cerebrospinal meningitis, r n in gout, 589 in scarlatina, 104 in typhoid fever, 67 Jumpers, 682 Kakki, 98 Kidney, amyloid, 572 in tuberculosis, 195 anomalies of form and position, 552 of secretion, 555 cystic, 579 diseases of, 552 fatty degeneration of, 567 floating, 553 gouty, 569 granular, 569 hyperemia of, 554 766 INDEX Kidney lesions in cerebrospinal meningitis, III in malaria, 242, 245 in scarlatina, 103 in smallpox, 258 in typhoid fever, 50 movable, 552, 553 palpable, 553 sclerosis of, 569 stone in the, 576 surgical, 573 syphilis of the, 165 tuberculosis of the, 209 tumors of, 579 waxy or lardaceous, 572 Kitasato's bacillus, 94 Klebs-Loffler bacillus, 129 in membranous gastritis. 449 Knife-grinder's phthisis, 407 Koch-Ehrlich fuchsin solution, 743 Kophk's bacillus of pertussis, 142 spots in measles, 107 Kreotoxismus, 614 Kuhne's methylene blue, 743 Lactic-acid intoxication, 6 Laennec, metallic tinkle of, 428 La grippe, 82 Landry's paralysis, 644 La perleche, 434 Laryngeal catarrh in measles, 108 diphtheria, 133 Laryngismus stridulus, 386 in rickets, 594 of thymus origin, 321 Laryngitis, acute and chronic, 385 edematous, 386 in chronic tuberculosis, 196 in smallpox, 262 spasmodic, 386 tubercular, 190 Larynx, ascaris in, 271 diseases of, 385 lesions of, in typhoid fever. 62 neuroses of, 386 spasm of, 386 stenosis of, tubercular, 190 tuberculosis of, 190 Latah, 682 Lateral sclerosis, 651 Lateropulsion in paralysis agitans, 679 Lathyrism, 615 Laveran's plasmodium, 239 Lead palsy, 611 -poisoning, 610 test for, 735 Leeches as parasites, 270 Leontiasis of leprosy, 222 ossea, 707 Lepra, 220 alba, 222 Leprosy, 220 anesthetic, 222 Leptomeningitis, cerebral, 657 Leptomeningitis, epidemic, 1 1 1 spinal, 636 Leptothrix pulmonum, 421 Leptus autumnalis, 287 Leucin in urine, yT^y Leucocytes, enumeration of, 714 in inflammation, 29 in pernicious anemia, 291 Leucocythemia, 295 Leucocytosis, 9 absence of, in tubercular peritonitis, 18& in typhoid fever, 57 in acute meningeal tuberculosis, 181 in appendicitis, 494 in cerebrospinal meningitis, 1x3 in chlorosis, 293 in convalescence of typhoid fever, 57 in diphtheria, 132 in distomiasis, 269 in empyema, 421 in pneumonia, 122 in septicemia, 148 in smallpox, 258 in trichinosis, 273 Leucoderma in Addison's disease, 312 in exophthalmic goiter, 319 Leucomaines, 6, 35 Leukemia, 295 lymphatic, 298 splenomyelogenous or splenomedul- lary, 297 Leukoplakia buccalis, 435 Lice, 287 Lightning pains in locomotor ataxia, 648 Lineae albicantes after ascites, 550 Lingual corns, 435 psoriasis, 435 tonsils, enlargement of, 441 Linguatilina, 287 Linguatula rhinaria, 287 serrata, 287 Lip, tuberculosis of, 206 Lipaciduria, 560 Lipuria, 560 in chronic pancreatitis, 541 Lithuria, 558 Liver, abscess of, 524 acute yellow atrophy of, 515 amyloid disease of, 527 in tuberculosis, 195 anemia of, 513 angioma of, 530 anomalies of form and position, 512 cirrhosis of, 517 capsular, 522 hypertrophic, 521 portal obstruction in, 519 syphilitic, 164 cancer of, 528 with cirrhosis of, 5 28 chronic congestion of, 513 diseases of the, 512 of blood-vessels of, 514 disturbances of circulation of, 513 INDEX 767 Liver, echinococcus or hydatid of, 285, 530 fatty, 526 flukes, 269 large solitary tubercle of, 208 lesions of, in cerebrospinal meningitis, III in diphtheria, 131 in syphilis, 164 in typhoid fever, 50, 62 in valvular heart disease, ;i3t) malarial, 242, 245 malformations and malpositions of, 512 massive cancer of, 528 nodular cancer of, 52S parasites of, 530 pyemic abscess of, 525 sclerosis of, 517 solitary or tropical abscess of, 524 tuberculosis of, 208 tumors of, 529 Lobar pneumonia, 115 Lobular pneumonia, 402 Lockjaw, 22;^ Locomotor ataxia. 647 ataxic stage of, 649 paralytic stage of, 650 preataxic stage of, 648 Loffler's methylene-blue solution. 743 Long thoracic nerve, disease of, 633 Ludwig's angina, 434 Lues venerea, 162 Lumbago, 587 Lumbar plexus, disease of, 634 puncture in cerebrospinal meningitis, 112 Lumbricoid worms, 270 and intestinal perforation, 61, 270 abscess of, 413 chronic fibrosis (sclerosis) of, 406 diseases of, 397 echinococcus of, 286 edema of, 398 gangrene of, 414 hemorrhagic infarction of, 401 hyperemia of, 397 hypostatic congestion of, 398 lesions of, in diphtheria, 131 neoplasms of, 415 parasitic disease of, 416 sclerosis of, 406 splenization of, 398 tuberculosis of, 192, 194 Lung fever, 115 Lupinosis, 615 Lustgarten's bacillus, 162 Lymph-glands as filters, 43 condition of, in leukemia, 296 scrotum, 277 Lymphadenitis, 278 tubercular, 182 Lymphatic leukemia, 298 Lymphatism, 310 Lymphocytes in lymphatic leukemia, 298 Lymphosarcoma of stomach, 468 Lj'sis, 20 Lysophobia, 231 McBurney's point, 494 Macroglossia, 435 Maidismus, 615 Main en griffe in ulnar paralysis, 633 Malacia, 475 Malaria, 239 clinical forms of, 242 chronic, 243 influence of heat and light upon, 241 latent, 247 pernicious, 242 stages of, 245 Malignant edema, 233 endocarditis, 331 in pneumonia, 125 in pyemia, 150 in scarlatina, 104 septic type of, 332 typhoid type of, 333 lymphoma, 299 pustule, 2^3 scarlatina, 102 Mallein, 230 Malnutrition, 21 Malta fever, 97 Mammary gland, tuberculosis of, 211 Mania, acute, 677 a potu, 607 after typhoid fever, y^ in mumps, 145 in scarlatina, 104 Marasmus in cerebrospinal meningitis, 1x3 Marmorek's serum, 149 Marriage of consumptive, 214 of syphilitic, 167 Massive pneumonia, 123 Measles, 106 atypical, 108 German, 109 hemorrhagic or black, 108 malignant, 108 Meat-measles of beef and pork, 281" poisoning, 614 Median nerve, paralysis of, 634 Mediastinitis, 378 Mediastinopericarditis, 328 Mediastinum, diseases of, 378 tumors of, 380 Mediterranean fever, 97 Megaloblasts in pernicious anemia, 291 Megastria, 455 Megrim, 689 Melanin in urine, y^y Melanogen in urine, 559 Melanuria, 559 Membranous croup, 141 Meniere's disease, 629 Meningitis, iii, 179, 635, 656 basilar, 179, 658 cerebrospinal, 1 1 1 in erysipelas, 152 in pneumonia, 125 768 INDEX Meningitis in scarlatina, 104 in syphilis, 165 in t3'phoid fever, 6^ Meninges, cerebral, diseases of, 656 lesions of, in cerebrospinal meningitis. in spinal, diseases of, 635 Meningocele, 655 Meningoencephalitis, 669 Meningom}-elitis in typhoid fever, 64 Mercury, test for, 735 Merycismus, 473 Mesentery, diseases of. 511 Metabolism, defective, 21 disturbances of. 7 Metachromatic bodies of Babes, ^2 Metaplasia, 32 Metasj'philitic affections, 165 Metchnikoff theory, 40 Meteorism in typhoid fever, 60 Methemoglobin in urine, 557 Micrococci in urine, 740 Micrococcus lanceolatus, 115 in bronchopneumonia, 402 melitensis. 97 of rheumatism, 155 pneumonije, types of, 116 ureae, 740 Micromegaly, 706 Micro-organisms (see Bacteria, Bacini,etc.) Migraine, 689 Migratory pneumonia, 123 Miliary fever, 228 Milk culture-medium, 746 -poisoning, 614 -sickness, 237 Millon's albumin test, 731 Mind-blindness, 625 -deafness, 675 Miner's lung, 407 Miosis in myelitis, 640 spinal, in locomotor ataxia, 649 Miscellaneous diseases, 605 Mitchell (Weir) method in obesity, 604 Mitral incompetency, ^37 stenosis, 340 Mohr's test for chlorids, 729 Monophobia, 697 Monostoma lentis, 270 Morbilli, 106 Morbus coxae senilis, 583 maculosus, 301 neonatorum, 305 VVerlhofi, 303 Morning diarrhea in rectal ulcer, 487 Morphea, 705 Morphia habit, 608 Morphin, test for, 735 Morphinomania, 608 Morvan's disease, 654 Mosquito, extermination of, 248 in etiology of dengue, 84 of filariasis, 276 malarial, 240 Mosquito of yellow fever, 90 Motor area, tumors of, 67 t, Mountain fever, 227 Mouth-breathing, 440 Mouth, care of, in typhoid fever, 74 diseases of the, 430 tuberculosis of. 206 Mucous patches, 164 Mumps, 144 Murmurs, cardiac, functional, 348 musical, 347 Muscles, degenerations of, in typhoid fever, 67 diseases of the, 618 Muscular atrophy in acute rheumatism, 158 Musculocutaneous nerve, disease of, 633 Musculospiral nerve, disease of, 633 Mushroom-poisoning, 616 Mussel poisoning, 615 Myalgia, 386 Mycosis nitestinahs, 234 Myelitis, acute, 638 central, 639 compression, 641 diffuse, disseminated, 639 general or transverse, 639 syphilitic, 165 Myelocele, 655 Myelocytes in splenic leukemia, 298 Myocarditis, acute, 356 chronic, 357 in acute rheumatism, 157 in influenza, 83 in smallpox, 262 in typhoid fever, 51, 58 in typhus fever, 78 Myocardium, diseases of, 356 Myoidema in tuberculosis, 202 Myositis, 618 infectious, 618 ossificans progressiva, 619 trichinous, 273 Myotonia congenita, 619 Mytilotoxismus, 615 Myxedema, 320 operative, 321 Nails, incurved, in bronchiectasis, 394 in tuberculosis, 197 Nasopharyngeal obstruction, chronic, 440 Nauheim method in myocarditis, 361 Neapolitan fever, 97 Necrosis, causes and forms of, 27 Nematodes, 7 diseases caused by, 270 Nephritis, acute, 563 in diphtheria, 136 in scarlet fever, 103 in typhoid fever, 65 uremic symptoms in, 565 acute diffuse, acute parenchymatous, 563 chronic, 567 diffuse or desquamative, 567 INDEX 769 Nephritis, chronic interstitial, 569 parenchymatous, 567 tubal, 567 uremic symptoms in, 571 Nephrolithiasis, 576 Nephroptosis, 552 Nephrotyphoid fever, 65 Nerves, diseases of, 621 Nervous diarrhea, 508 dyspepsia, 470 system, central, tuberculosis of, 205 diseases of, 621 functional, 677 in diphtheria, 131, 132 in scarlatina, 104 in typhoid fever, 63 Nervus abducens, disease of, 627 Neuralgia, 690 intercostal, 691 intestinal, 509 lumbar, 691 metatarsal and plantar, 692 of pharynx, 437 phrenic, 691 red, 703 tender points in, 691, 692 trifacial, 691 Neurasthenia, 696 Neuridin, 6 Neuritis, 621 acute febrile multiple, 622 alcoholic, 606 arsenical, 613 ascending, 622 endemic, 98 in beriberi, 99 in diabetes, 599 in diphtheria, 131 in typhoid fever, 64 localized, 621 migratory, 622 multiple, 621, 622 in typhoid fever, 64 optic, 624 in basilar meningitis, 658 in meyelitis, 640 peripheral, in erysipelas, 153 in pneumonia, 126 in smallpox, 262 progressive interstitial hypertrophic, 653 Neuromata, 623 Neuroretinitis, 104 Neuroses, nasal, 384 occupation, 699 of esophagus, 444 of gastric motion, 472 of gastric secretion, 470 of gastric sensation, 474 of heart, 363 of intestine, 508 of larynx, 386 of stomach, 470 traumatic, 700 Neurosis, pathology of, 4 Night-blindness (see Nyctalopia) Night-sweats in tuberculosis, 197 treatment of, 218 Nodding spasm, 631 Nodosities, subcutaneous, in acute rheu- matism, 158 Noma, 432 in diphtheria, 136 in measles, 108 in scarlatina, 104 in typhoid fever, 59 Nose, diseases of, 381 neuroses of, 384 -bleed, 384 Nutmeg liver, 513 atrophic, 514 Nutrition, disturbances of, 7 Nyctalopia in disease of optic nerve, 625 in jaundice, 531 in scurvy, 307 Nystagmus in cerebrospinal meningitis, 112 in hereditary ataxia, 653 in insular sclerosis, 672 Obermeier, spirillum of, 80 Obesity, 603 Obstipation, 498 Occipital lobe, tumors of, 6^;^ Oculomotor nerves, diseases of, 625 Oertel's method in myocarditis, 361 in obesity, 604 Olfactory nerve and tract, disease of, 623 Oligemia, 9 Omental bursa, hernia of, 498 Omodynia, 586 Ophthalmoplegia, 627 Opisthotonos in meningitis, 112 in tetanus, 223 Opium habit, 608 Optic nerve, atrophy of, 624 and tract, disease of, 624 Optic neuritis, 624 malarial, 247 in acute rheumatism, 158 in pericarditis, 323 Orthotonos in tetanus, 223 Osteitis deformans, 706 Osteoarthritis, 581 Osteoarthropathy, hypertrophic pulmo- nary, 706 Osteoblasts, 32 Osteosclerosis, 582 Osteoscopic pains, 164 Otitis media in diphtheria, 134 in measles, 108 in pneumonia, 126 in scarlatina, 104 in smallpox, 262 in typhoid fever, 59 syphilitic, 164 Oxaluria, 559 Oxybutyric acid in urine, 560 Oxyuris vermicularis, 271 77° INDEX Oyster- and clam-poisoning, 615 Ozena, 382 Pachymeningitis, cerebral, 656 spinal, 635 Pains, fulgurant, in locomotor ataxia, 649 in aortic aneurism, 375 in appendicitis, 493 in cancer of stomach, 465 in cholelithiasis, 537 in chronic tuberculosis, 199 in nephrolithiasis, 577 in pancreatic cyst, 542 in peritonitis, 544 in pneumonia, 120 in pyelitis, 574 Painter's colic, 611 Palpitation, 363 cardiac, treatment of, 351 Paludism, 239 Pancreas, diseases of, 539 in diabetes, 596 hemorrhagic, 539 tuberculosis of, 208 tumors of, 543 Pancreatic calculi, 543 cyst, 542 duct, obstruction by ascaris, 270 Pancreatitis, acute, 540 chronic, 541 gangrenous, 541 hemorrhagic, 540 suppurative, 540 Pandemic, 5 Panophthalmitis in exophthalmic goiter, 319 Papilloma of stomach, 468 Papular syphilid, 164 Paracentesis in pleurisy, 424 Para- infections, 71 Paralysis, acute, 644 agitans, 678 antibrachial, 611 Aran-Duchenne, due to lead, 612 arsenical, 613 brachial, due to lead, 611 bulbar, 646 cerebral, of childhood, 666 crossed, spinal, 643 diphtheritic, 135 Erb's juvenile, 646 essential or atrophic, 642 functional, 701 general, due to lead, 612 glossolabiolaryngeal, 646 in cerebrospinal meningitis, 113 in malaria, 247 infantile, 666 Landry's, 644 of esophagus, 444 of facial nerve, 627 of larynx due to lead, 612 of oculomotor nerve, 625 periodical, 701 Paralysis, peroneal, 612 progressive, of the insane, 669 scapulohumeral, 611 spastic spinal, 651 spinal, 642 Paralytic stroke, 661 Paramyoclonus, 620 Paraplegia, ataxic, 652 congenital, 666 due to myelitis, 640 hereditary toxic, 652 hysterical spastic, 652 Parasite, estivo-autumnal, 240 quartan, 240 tertian, 239 Parasites, animal, 7 diseases due to, 239 in urine, 739 facultative, 32 vegetable, in urine, 740 Parasitic disease, 5 Paraxanthin, 6 " Parchment crackling" in rickets, 593 Paresis, general, 669 Parietal region, tumor of, 673 Parkinson's disease, 678 Paronychia, syphilitic, 166 Parorexia, 475 Parosmia, 385, 624 Parotid bubo, 436 gland, gaseous distention of, 436 lesions of, in typhoid fever, 59 Parotitis, chronic, 436 epidemic, 144 suppurative, in peptic ulcer, 461 in typhoid fever, 59 symptomatic or secondary, 436 Paroxysmal disease, 4 Parry's disease, 317 Pediculosis, 287 Pediculus capitis, 287 corporis, 288 vestamentorum, 288 Peliosis rheumatica, 302 Pellagra, 615 Pentastoma tenioides, 287 Pentastomum constrictum, 287 denticulatum, 287 Pepsin, test for, 721 Peptic ulcer, 459 gastralgia in, 461 hemorrhage in, 461 perforation of, 461 Pepton in stomach-contents, test for, 721 Peptonuria, 421 in pernicious anemia, 292 Perforation of the bowel, 61, yy in appendicitis, 492 Pericarditis, acute, 322 adhesive, 323 cancerous, 328 chronic, 327 external, 328 gonorrheal, 162 INDEX 771 Pericarditis in acute rheumatism. 157 in erysipelas, 152 in influenza, 83 in pneumonia, 125 in scarlatina, 104 purulent, 325 tubercular, 186 with effusion, 323 Pericardium, adherent, ;i2y calcification of, 25 empyema of, 325 diseases of, 322 Perihepatitis, acute, 522 chronic, 523 in chronic gastritis, 451 Perinephric abscess, 578 Periodic disease, 4 Periosteal hemorrhage in infantile scurvy, 309 Perisplenitis in chronic gastritis, 451 Peristalsis, reversed, in dilatation of stom- ach, 457 Peristaltic unrest, 473 Peritoneum, cancer of, 549 diseases of, 543 tuberculosis of, 187 Peritonitis, acute, 543 appendicular, 546 chronic, 548 from peptic ulcer, 461 general adhesive, 548 in chronic gastritis, 451 in leukemia, 297 in pneumonia, 126 in scarlatina, 104 in typhoid fever, 62 local adhesive, 548 localized, 546 pelvic, 547 primary, 543 proliferative, 548 secondary, 544 subphrenic (see Perihepatitis) tubercular, 187 localized, i88 Perles of Laennec, 396 Pernicious anemia, 290 Pertussis, 142 Pestis — major, minor, siderans, 95 Petechia, 15 Petit mal, 686 Pfeiffer, bacillus of, 82 Pfuhl's sign, 523 Phagocytosis, 40 in malaria, 240 Pharyngeal diphtheria, 133 tonsil, enlargement of, 440 Pharyngitis, acute, 437 chronic, 438 granular, 438 tubercular, 190, 206 ulcerative, 438 Pharynx, anemia and hyperemia of, 436 and uvula, edema of, 437 Pharynx, diseases of, 436 hemorrhage of, 437 spasm and paralysis of, 437 tuberculosis of, 190 ulcers of, 436 Phenol, 6 a bacterial product, ^6 Phenylhydrazintestin chronic pancreatitis, 541 Phlebitis in pyemia, Phlegmon, acute infectious, 438 Phlegmonous enteritis, 468 phosphates in urine sediment, ;^;iy test for, 729 Phosphoric-acid intoxication, 6 Phosphatic diabetes, 559 Phosphaturia, 559 Phrenic nerve, disease of, 632 Phthiriasis, 287 Phthirius pubis, 288 Phthisical chest, 201 habit, 174 Phthisiophobia, 213 Phthisis, chronic, 194 fibroid, 204 florida, 192 pneumonic, 192 pulmonum (see Tuberculosis), 191 Pica, 475 Pigeon-breast in rickets, 594 in tonsilitis, 441 Pigmentation, varieties of, 26 in Addison's disease, 312 in pseudoleukemia, 301 Piles, 505 Pine acids, test for, y^6 Pinworm, 271 Plague, the, 94 clinical forms of, 95 Plasmodium malariae, 239 staining of, 716 Plate-cultures, 747 Plethora, 9 Pleura, diseases of, 417 echinococcus of, 286 tuberculosis of, 185 Pleurisy, acute, 417 adhesive or "dry," 425 chronic, 425 with effusion, 426 diaphragmatic, 423 encysted, 422 fibrinous, 417 hemorrhagic, 422 in chronic tuberculosis, 196 in pneumonia, 125 interlobular, 423 primary, 417 pulsating, 422 purulent, 420 secondary, 417 serofibrinous, 418 Special forms of, 422 treatment of, 424 772 INDEX Pleurisy, tubercular, 185, 422 Pleurodynia. 586 Pleuropericarditis, 32S Pleuropneumonia, 125 Pleurothotonos in tetanus, 22;^ Plica polonica, 287 Plumbism, 610 Pneumatosis, 472 Pneumaturia, 560 in diabetes, 599 Pneumococcus, 115 in pleurisy, 417, 418 Pneumogastric nerve, diseases of, 629 Pneumokoniosis, 407 Pneumonia, 115 afebrile, 124 after pleurisy, 123 after surgical operations, 1^1. alcoholic, 123 apyretic, 124 caseous, 176 catarrhal, 402 central, 123 cerebral, 121 chronic interstitial, 406 crossed, 118 double, 118 fibrous, 406 epidemic, 123 in diphtheria, 135 in erysipelas, 152 in infants, 124 in influenza, 83 in leukemia, 297 in smallpox, 262 in the aged, 124 in typhoid fever, 62, 6,^ in whooping-cough, £43 lobular, 402 relapse in, 125 varieties of, 123 Pneumonitis, 115 Pneumopericardium, 329 Pneumothorax, 427 Podagra, 587 Poikilocytosis in chlorosis, 293 in pernicious anemia, 291 Poliomyelitis, acute anterior, 642 in adults, 644 in children, 642 in typhoid fever, 64 chronic, 645 Polyarthritis, chronica villosa, 584 Polycythemia, 289 with chronic cyanosis, 289 Polydipsia, 602 Polyneuritis, 621 Polyphagia, 475 Pons and medulla, tumors of, 6ys Popoff's micrococcus of rheumatism, 155 Porencephalus, 666 Pork tapeworm, 279 Porocephalus constrictus, 287 I514 Portal vein, embolism and thrombosis of, Portal vein, stenosis of, 515 Postepileptic state, 686 Posthemiplegic chorea, 682 Post-mortem wart, 173 Potato culture-medium, 746 Pox (see Syphilis), 162 Prefrontal region, tumor of, 673 Pressure symptoms in aneurism, 374, ;i28 in hepatic abscess, 525 in mediastinal disease, 379 Priapism in enteralgia, 510 in leukemia, 297 Progressive bulbar paralysis, 646 muscular atrophy, 645 acute, 618 facial typ>e of, 646 peroneal type of, 646 paralysis of the insane. 669 Propepton, test for, 721 Propionic acid in urine, 560 Proptosis in infantile scurvy, 309 Propulsion in paralysis agitans, 679 Prosopalgia, 691 Prostate, tuberculosis of, 210 Prostration, nervous, 696 Proteids in gastric contents, test for, 721 Proteins, 35 Protozoa, 7 Protozoan diseases, 239 Protozoon in leukemia, 295 of smallpox, 257 Prune-juice expectoration, 121 in acute tuberculosis, 193 in tumors of the lung, 416 Pruritus in chronic nephritis, 571 in jaundice, 530 Psamomata, 25 Pseudoangina, 368 Pseudocrisis in pneumonia, 120 Pseudodiphtheria, 141 Pseudohydrophobia, 231 Pseudoleukemia, 299 splenic, 315 Pseudomembrane — pultaceous, punctate, 133 in diphtheria, 130 in measles, 108 in scarlatina, 102 Pseudotrichinosis, 274 Psilosis, 485 Psittacosis, 236 Psorospermiasis, 268 Psorosperms, 7 in empyema, 421 Psychical centers, tumors of, 6yi Psychical state in tuberculosis, 201 Ptomain-poisoning, 147, 614 Ptomains, 6, 35 Ptosis in cerebrospinal meningitis, ii2 in diphtheria, 135 Ptyalism, 433, 435 Pulex irritans, penetrans, 288 Pulmonary apoplex}', 401 collapse, 412 INDEX 773 Pulmonary collapse in diphtheria, 135 erysipelas, 153 hemorrhage, 399 valve lesions, 348 Pulsation, capillary, 344 expansile in aneurism, 375 Pulse, delayed, in aneurism, :^y6 of acute tuberculosis, 192, 193 of acute uremia, 561 of aortic incompetency, 344 of cerebrospinal meningitis, 112 of chronic tuberculosis, 201 of pneumonia, 121 of pyemia, 151 of tubercular peritonitis, 188 of typhoid fever, 58 of yellow fever, 92 paradoxical, 364 water-hammer, 344 Pulsus paradoxus in pericarditis, 2,22,. :i2?, Purpura, 301 arthritic, 302 fulminant, 303 hemorrhagica, 303 in cerebrospinal meningitis, 112 in scarlatina, 104 in typhoid, 66 infectious, 302 rheumatica, simplex, 302 symptomatic, urticans, 302 Pus, acid, in pyelitis, 575 in urine, 738 Putrescin, 6 Putrid sore throat, 129 Pyelitis, 573 Pyemia, 150 in malignant endocarditis, 2,7,2 Pylephlebitis, adhesive, 514 due to peptic ulcer, 461 in typhoid fever, 62 suppurative, 515 Pylorus, relaxation of, 473 spasm of, 473 stricture of, 460 Pyonephrosis, 573 Pyopneumothorax, 427 in tubercular pleurisy, 186 in typhoid fever, 63 subphrenic or subdiaphragmatic, 522 in peptic ulcer, 460 Pyrexia, 19 Pyrosis, 473 in chronic gastritis, 452 Pyuria, 558 in typhoid fever. 65 Quartan intermittent fever, 243 Quinin, test for, 735 Quinsy (see Tonsilitis, suppurative), 439 Quotidian intermittent fever, 243 Rabies, 230 Rachitis, 593 Rag-pickers' disease, 232 Railway spine, 700 R3Ie, crepitant, in pneumonia, 122 Ray fungus, 235 Raynaud's disease, 701 Rash (see Eruption) Reaction of degeneration, 643 Reactionary fever, in cerebral hemorrhage, 663, Receptors, Ehrlich's theory ol, 40 Recrudescence, 4 in typhoid fever, 68 Recurrent fever, 80 Red-corpuscles, enumeration of, 711 Red hepatization, 117 neuralgia, 648 Reflexes in locomotor ataxia, 648 in multiple neuritis, 622 Regeneration, normal, pathological, 31 Regurgitation, gastric, 473 Relapsing fever, 80 Remittent fever, 243 bilious, 246 Renal colic, 577 . intermittent fever, 577 Rennet, test for, 721 Resolution, 31 delayed, in pneumonia, 124 in pneumonia, 122 Resorption fever, 147 Respiration, cog-wheel, 202 in cerebral hemorrhage, 662 in cerebrospinal meningitis, 112 in chronic tuberculosis, 201, 202 in peritonitis, 545 Respiratory system, diseases of, 381 lesions of in typhoid fever, 62 Retinitis in chronic nephritis, 571 syphilitic, 164 Retrograde processes, 20 Retropharyngeal abscess, 438 Retropulsion in paralysis agitans, 679 Rhabdomyoma of kidney, 5,79 Rhabdonema intestinahs, 278 Rheumatic fever, 154 Rheumatism, acute, 154 in children, 157 acute articular, 154 acute inflammatory, 154 chronic, 584 gonorrheal, 161 in erysipelas, 153 in pneumonia, 126 inflammatory, 154 muscular, 586 scarlatinal, 104 subacute, 157 theories of, 155 Rhexis, 14 Rhinitis, acute, 381 atrophic, 382 chronic h}'pcrtrophic, 3 fibrinous, 134 sj'philitic, 166 tubercular, 190 774 INDEX Rice-water dejecta, 87 Rickets, 593 acute (infantile scurvj"^), 30S rosar}' of, 594 Riga's disease, 434 Rigidit}^ in paralysis agitans, 678 of rectus in appendicitis, 494 post-paralj^tic, 664 Rigors (see Chills) Risus sardonicus, 112 Roberts's test for globulin, 731 Romberg's symptom, 649 Rose cold, 383 -spots in cerebrospinal meningitis 112 in typhoid fever, 66 Roseola of syphilis, 164 Rotheln, 109 Round ulcer of stomach, 459 Rubella, 109 scarlatinosa, no Rubeola, 106 notha, 109 Rumination, 473 Rusty sputum in pneumonia, 121 St. Anthony's or St. Vitus's dance, 682 Sable intestinalis, 511 Saccharomyces albicans in thrush, 431 Sacral plexus, diseases of, 634 Sago spleen, 315 Salicylic acid, test for, 736 Saline injections in cholera, 89 Saliva of acute rheumatism, 156 Salivary glands, diseases of, 435 Salpingitis, tubercular, 211 Sanarelli, bacillus of, 89 Sand-flea, 288 Santonin, test for, 736 Sapremia, 147 Saprin, 6 Saprophytes, 32 Sarcinas, ^^^ in urine, 740 ventriculi, in cancer of stomach, 466 in dilatation of stomach, 457 Sarcoblasts, 32 Sarcolactic-acid intoxication, 6 Sarcoma of adrenals, 311 " Sarcoma of leucocytes," 295 Sarcoma of lung, 415 of spleen, 315 Sarcoptes, 287 Saturnism, 610 Scapulodynia, 586 Scarlatina, 100 anginose type of, 103 forms of, 102 foudroyant, 103 hemorrhagic, 103 malignant, 102 miliaris, loi puerperal, 103 sine eruptione, 102 Scarlatina surgical, 103 Scarlet fever, 100 rash, 100 Schlammfieber, 226 Schonlein's disease, 302 Schott's method in myocarditis, 361 Sciatica, 634 Scirrhus of stomach, 464 Scleroderma, 704 Sclerose en plaques, 671 Sclerosis, amyotrophic lateral, 645 disseminated, 671 insular, 671 multiple cerebrospinal, 671 of brain, 671 of kidney, 569 posterolateral, 652 primary lateral, 65 1 spinal, 647 toxic combined, 65;^ ventriculi, 451 Scolex of echinococcus, 284 Scorbutus, 306 Scotoma in amblyopia, 625 Scrivener's palsy, 699 Scrofula (scrofulosis), 182 Scrofulous frame, 174 Scurvy, 306 dysentery, 307 in infants, 308 sclerosis, 307 Sepsis, 146 in diphtheria, 136 in smallpox, 262 Septicemia, 146 true or progressive, 147 typhoid, 49 varieties of, 147 Septicopyemia, 150 Serum, antitetanic, 224 Haffkine's, 97 reaction in cholera, 88 in typhoid fever (see Widal test) in yellow fever, 90 treatment of acute rheumatism, 160 of cholera, 89 of diphtheria, 139 of plague, 97 of pneumonia, 127 of septicemia, 149 of typhoid fever, 76 Yersin-Roux, 97 Seven-day fever, 80 Shaking" pals\', 678 Shaved beard appearance of bowel, 479 Shiga's bacillus, 250 in gastroenteritis, 48 1 Shingles, 692 Ship fever, 78 Shock, diastolic, in aneurism, 375 Sick headache, 6S9 Siderosis, 407 Sinus-thrombosis, autochthonous, 659 Siriasis, 616 INDEX 775 Sitotoxismus, 615 Sixth nerve, disease of, 627 Skatol, 36 Skoda's resonance in pleurisy, 419 Smallpox, 256 malignant, 261 protozoon of, 257 Smoker's tongue, 435 Snuffles in congenital syphilis, 166 SoUtary ulcer of bowel, 487 Solutions for staining bacteria, 742 Somnambulism, 684 Sordes, 59 Sore mouth, fetid or putrid, 431 Sore throat, 437 Spasm, carpopedal, in rickets, 594 nodding, 631 of cardia, 473 of pylorus, 473 professional, 699 Spastic paralysis, Erb's syphilitic, 652 secondary, 652 paraplegia, hereditary, 651 hysterical, 652 Speech, scanning, in insular sclerosis, 672 Spermatozoa in urine, 739 Sphacelinic-acid poisoning, 615 Sphacelus in pulmonary gangrene, 414 Sphenoid, chronic disease of, 438 Spina bifida, 655 Spinal accessory nerve, diseases of, 630 cord, affections of blood-vessels and circulation of, 637 compression of, 641 diseases of, 635 inflammation of, 639 malformations of, 655 tumors of, 654 white softening of, 639 meninges, diseases of, 635 nerves, diseases of, 632 paralysis, 642 sclerosis, 647 Spirilla, 33 Spirocheta of relapsing fever, 80 Spleen, abscess of, 314 amyloid disease of, 315 diseases of, 313 features of, in diphtheria, 131 in hepatic cirrhosis, 519 in leukemia, 296 in lymphatic leukemia, 299 in malaria, 242, 245 in pseudoleukemia. 301 in smallpox, 258 in typhoid fever, 50, 59 infarction of, 314 movable, 313 rupture of, 313 tuberculosis of, 208 tumors of, 315 Splenic anemia, 315 fever, 232 Splenitis, acute and chronic, 314 Splenomegaly, 315 Splenoptosis, 313 Spondylitis deformans, 583 Sporagenous granules of Ernst, 32 Spores, staining of, 744 Sporozoa, 268 Sporulation, 33 Spotted fever, 78, 1 1 1 of Rocky mountains, 227 Sprue or psilosis, 485 Sputum, albuminous, in pleurisy, 425 examination of, 748 in acute tuberculosis, 193 in chronic tuberculosis, 198 in gangrene of the lung, 414 in pneumonia, 121 nummular, 198 of bronchial asthma, 396 of bronchiectasis, 394 of fetid bronchitis, 390 of pneumokoniosis, 408 Stab-culture, 747 Staccato speech in insular sclerosis, 672 Staining, bacterial, 742 blood specimens, 715 malarial plasmodia, 716 Stains: Plehn's, 716 Whitney's, 716 bacterial, carbol-fuchsin (Ziehl's), 143 carbol-thionin, 743 for flagella, 744 for spores, 744 Gabbet's blue, 744, 748 Gram's iodin, 743 Koch-Ehrlich anilin water fuchsin, 743 Kuhne's methylene blue, 743 Lofifler's methylene blue, 743 Welch's capsule stain, 744 basophile, 716 of blood specimens : Biondi's, 715 Ehrlich's, 715 eosin and methylene blue, 715 Staphylococci in pneumonia, ri6 Stasis, venous, 12 Status epilepticus, 686 lymphaticus, 310 Stegomyia fasciata, 90 Stenocardia, 366 Stenosis of esophagus, 442 Steppage gait, 622 Stercoral ulcers, 487 Stigmatization, 14 Stomach, absorptive power, test, 724 atony of, 474 atrophy of, 450 cancer of, 463 capacity of, 445 cirrhosis of, 451 -contents, examination of, 719 in chronic gastritis, 452 qualitative tests of, 720 quantitative tests of, 722 776 INDEX Stomach, dilatation of, 455 after typhoid fever, 60 diseases of, 445 examination of, 446 foreign bodies in, 468 hemorrhage of, 468 hour-glass contraction of, 449 hypertrophic stenosis of, 468 motor power, test, 724 neuroses of, 470 nonmalignant tumors of, 468 normal secretion of, 445 -tube, introduction of, 719 tuberculosis of, 206 ulcer of, 459 volvulus of, 456 washings, examination of, 724 Stomatitis, aphthous, 430 catarrhal, 430 diphtheritic or croupous, 433 epidemic, 237 follicular or vesicular, 430 gangrenous, 432 in chronic uremia, 562 in diabetes, 598 in typhoid fever, 59 membranous, 433 mercurial, 433 parasitic or mycotic, 431 syphilitic, 164 ulcerative, 431 Stone in the kidney, 576 Stools, disinfection of, 727 examination of, 724 in cholera infantum, 483 in cholera morbus, 480 in jaundice, 531 Strabismus in cerebrospinal meningitis,ii2 in diphtheria, 135 Strangulation, intestinal, 498 Strangury in enteralgia, 510 Strapping in hemoptysis, 219, 401 Streptococci, ^^ Streptococcus of Fehleisen, 151 diphtherias, 141 pj'Ogenes in pneumonia, 116 Streptothrix actinomyces, 235 Stricture of the bowel, 499 of esophagus, 442 of stomach in toxic gastritis, 449 Stroke cultures, 747 Strongyloides intestinalis, 278 Strongylus duodenalis, 275 Strongylus paradoxus, 278 Strumitis, 316 Stuttering, 632 Subacidity, gastric, 471 Subsultus tendinum, 64 Succussion of dilated stomach, 457 Sudamina in typhoid fever, 67 Suffusion, 15 Sugar, tests for, 731 quantitative estimation of, ya Sulphates, tests for, 729 Sulphuric-acid intoxication, 6 Summer diarrhea, 481 Sunstroke, 616 Superacidity, gastric, 471 Supermotility, gastric, 473 Supersecretion, gastric, 470 of salivary glands, 435 Suprarenal atrophy, 311 disease, 310 Surgical kidney, 573 Susceptibility, ;iy Swamp fever, 239 Sweating in trichinosis, 273 in tuberculosis, 201 in typhoid fever, 67 Sweating sickness, 228 Sydenham's chorea, 680 Syphilis, 162 acquired, 163 congenital, 167 hemorrhagica neonatorum, 305 insontium, 163 of digestive system, 164 of lung, 165 of nervous system, 165 stages of, 163 Syringomyelia, 653 Schlesinger's classification of. 654 Tabes dorsalis, 647 Tache c^rebrale, 66 in tuberculosis, 181 Tachycardia, 365 in exophthalmic goiter, 318 in influenza, 8s in pneumogastric disease, 630 Tapeworms, 279 Teeth in congenital S3'philis, 166 Telegrapher's cramp, 699 Temperature, normal control of, 19 of acute meningitis, 181 of acute rheumatism, 156 of acute yellow atrophy, 5 16 of cerebrospinal meningitis, 112 of diphtheria, 132 of erysipelas, 153 of German measles, 109 of measles, 107 of pneumonia, 119 of pyemia, 151 of rotheln, 109 of scarlatina, 102 of typhoid fever, 55 Temperature-sense lost in s^ririgomyelia, subnormal, in appendicitis, 493 • in cerebral hemorrhage, 663 in hydrophobia, 231 in lead-poisoning, 611 in malaria, 245 in tubercular peritonitis, 18S in tuberculosis, 200 in spotted fever of Rocky Moun- tains, 228 INDEX 777 Tenderness in appendicitis, 404 Tenia, 279 armata, 279 confusa, 280 cucumerina, 280 diminuta, 280 echinococcus, 28J elliptica, 280 flavopunctata, 280 lata, 280 Madagascarensis, 280 mediotanellata, 280 nana, 280 saginata, 280 solium, 279 Tenioidea, 279 Tenosynovitis, 162 Terminal pneumonia, 123 Test-Meals, 719 Testicle, tuberculosis of, 211 Testis, involved in mumps, 145 Tests: alizarin, 722 Boas's, 720 Bottger's, for sugar, 732 Bremer's, of diabetic blood, 71 S Fehling's, for sugar, 732 fermentation, for sugar, 7:^3 for blood, 718 Gmelin's, for bile pigment, 7 5 |. guaiacum, 718 Giinzburg's, 720 hemin, 718 Haines's, for sugar, 2:^2 Heller's, for bile, 734 for iodin, 734 Heller-Moore, for sugar, y,^^ McMunn's, for indican, 734 murexid, 728 of stomach-contents, 719 of stomach-contents, for albumin, 721 for albumose, 721 for blood, 721 for fatty acids, 721, 723 for free acids, 720, 722 for hydrochloric acid, 720, 722 for lactic acid, 720, 723 for organic acids, 720, 723 for pepsin, 721 for pepton, 721 for propepton, 721 for proteids, y2i for rennet, 721 of urine, for acetanilid, 735 for albumin, 730 for alkapton, 731 for antipyrin, 735 for arsenic, 734 for bile, 734 for bromin and iodin, 735 for carbonates, 730 for chlorids, 729 for creatinin, 729 for ferments, 729 for fibrin. 731 Tests: of urine, for globulin, 731 for hemoglobin, 731 for indican, 734 for lead, 735 for mercury, 735 for morphin, 735 for phosphates, 729 for pine-acids, 736 for quinin, 735 for rhubarb and senna, j;i6 for salicylic acid, 736 for santonin, 736 for sugar, 731 for sulphates, 729 for urea, 728 for uric acid, 728 for xanthin, 728 Pettenkofer's, for bile-acids, 734 phenylhydrazin, 732 picric-acid, for albumin, 730 for sugar, 733 Reinsch's, for arsenic, 734 Rosenbach's, for bile, 734 salol, for gastric motion, 724 Topfer's, 720 Trommer's, 731 Ultzmann's, for bile, 734 Williamson's, of diabetic blood, 71S Wood's for lead, 735 Tetanilla, 688 Tetany, 688 in cholera infantum, 483 in dilatation of stomach, 457 in rickets, 594 rheumatic, 688 Tetanus, 223 Tetrads, ;i3 Thermic fever, 616 Thomsen's disease, 619 Threadworms, 271 Thrill, aneurismal, ;i76 basic, in aortic stenosis, 346 of mitral incompetency, 339 suprasternal, in aortic lesions, 344 Thrombosis, 15 in high altitudes, 227 in influenza, 83 in pyemia, 151 in scarlatina, 104 in typhoid fever, 58 marantic, of brain, 659 marasmic, 17 of brain, 666 of cerebral sinuses and veins, 659 of spinal cord, 6;^^ Thrombus, 15 ante-mortem, 340 ball, 340 varieties of, 16 Thrush, 431 Thymus gland, diseases of, 321 Thyroid gland, diseases of, 315 tumors of, 321 Thyroiditis, 315 778 INDEX Thyroiditis, after typhoid fever, 59 Tibial curvature in rickets, 594 Tic, convulsive, 682 douloureux, 691 Tick as a parasite, 287 Tinnitus, 629 Tongue, diseases of, 434 eczema of, 435 epithelioma of, 435 features of, in diphtheria, 132 in influenza, 82 in scarlet fever, loi in typhoid fever, 59 "raspberry," loi "strawberry," loi Tonsils, diseases of, 439 tuberculosis of, 206 Tonsilitis, acute, 439 catarrhal, follicular, ulcerative, 439 chronic, 440 herpetic, 439 in endocarditis, 330 suppurative, 439 Tophi in gout, 590 Torticollis, 586 acquired, 631 congenital, 631 in spinal accessory disease, 631 Toxalbumins, 35 Toxins, 35 affinities of, 41 Toxoid, 41 Toxon, ;i6 Toxophore groups of cells, 41 Tracheal tugging, 376 Tracheotomy in diphtheria, 141 Traube's theory of angina, 367 of uremia, 560 Traumatic hysteria, 700 Treitz's hernia, 498 Trematodes, 7, 269 "Trembles" of cattle, 237 Tremor, hereditary, 680 hysterical, 680 in alcoholism, 607 in arsenical-poisoning, 613 in exophthalmic goiter, 318 in insular sclerosis, 672 in paralysis agitans, 678 postparalytic, 664 senile, 680 simple, 679 toxic, 679 Trichina spiralis, 272 Trichiniasis, 271 Trichinosis, 271 Trichomonas, caudata, elongata, 268 flagellata, intestinalis, vaginalis, 268 Tricuspid insufficiency, 347 stenosis, 347 Trigeminus nerve, diseases of, 626 Trigemism of heart, 364 Trismus from disease of fifth nerve, 262 neonatorum, 223 Trommer's test for sugar, 731 Trophic disturbances in neuritis, 622 Trousseau's mark in acute meningeal tuber- culosis, 181 symptom in tetany, 688 Tubercle, formation of, 175 large solitary* of aorta, 206 of brain, 205 of liver, 208 Tubercula dolorosa, 623 Tubercular infiltration, 176 Tuberculin test, 212 Tuberculosis, 169 acute, 177 typhoid form, 178 acute disseminated, 177 acute meningeal, 179 acute miliary, 177 acute pneumonic, 192 after measles, 108 bronchopneumonic, 193 by ingestion, 172 by inhalation, 172 by inoculation, 173 chronic, of lung, 194 diagnosis of, 212 environment in, 174 from meat, 172 from milk, 172 general, 169 general treatment of, 215 hereditary, transmission of, 171 in diabetes, 599 localized, 182 modes of infection in, 170 of arytenoid cartilages, 190 of. central nervous system, 205 of cerebellum, 205 of circulatory system, 205 of digestive system, 206 of epiglottis, 190 of fauces, 190 of female generative organs, 211 of genitourinary system, 208 of intestine, 206 of kidney, 209 of larynx, 190 of liver, 208 of lung, 191 typical course of, 196 of lymphatic system, 187 of mammae, 211 of nose, 190 of pancreas, 208 of pericardium, 186 of peritoneum, 187 of pleura, 185 of respiratory system, 190 of serous membranes, 185 of spleen, 20S of vocal cords, 190 physical signs of, 201 predisposing causes of, 173 prognosis of, 213 INDEX 779 Tuberculosis, prophylaxis of, 214 pulmonary, 191 sources of infection in, 191 specific treatment of, 220 Tufnell's diet, t^-j-j Tunnel-anemia, 275 Tussis convulsiva, 142 Typhoid bacillus, 49 in pleurisy, 418 in pneumonia, 116 pneumonia, 123 spine, 64 Typhoid fever, 47 abortive, 54 afebrile, 54 ambulatory, 54 associated acute infections, 68 complications of, 55 diagnosis of, 69 eruption of, 66 facial aspect in, 55 fulminant form of, 54 general course of, 51 hyperpyrexia in, 56 immunity from, 48 in children, 55 in pregnant women, 55 in the aged, 55 inoculation treatment of, "jS preventive inoculation, "j^i pulse in, 58 recrudescence of, 68 relapses in, 68 sudoral, 67 susceptibility to, 48 symptoms of, 51 temperature of, 55, 76 treatment of, 72 types of, 49, 54 "walking," 54 Typhomania, 677 Typhus, abdominal, 47 exanthematic, 47 Typhus fever, 78 relapsing, 80 Tyrosin, a bacterial product, ^6 in the urine, y^^j Tyrotoxicon-poisoning, 614 Twists and knots of bowel, 499 Ulcer, corneal, in measles, 108 esophageal, 442 follicular or catarrhal, of bowel, 487 peptic, 459 perforating, in diabetes, 599 in leprosy, 222 or rodent, of stomach, 459 rectal, in locomotor ataxia, 649 stercoral, 487 Ulceration, intestinal, in typhoid fever, 50 Ulcerative colitis, 487 endocarditis, 331 due to gonorrheal infection, 162 Ulnar nerve, disease of, 62tJt Uncinaria duodenalis, 275 Undulant fever, 97 Urates in lithuria, 558 in urine, J2fi Urea, tests for, 728 Uremia, 560 acute and chronic, 561 theories of, 560 treatment of, 572 Ureter, tuberculosis of, 210 Urethra, tuberculosis of, 210 Urethritis in gout, 592 in typhoid fever, (y6 Uric-acid crystals, 736 excess of, in urine, 558 in acid intoxication, 6 tests for, 728 Urinary sediments, •J2>^ Urine, character of, in acute rheumatism, in amyloid kidney, 573 in chronic nephritis, 568, 570 in diabetes, 599 in jaundice, 531 in pyelitis, 574 in pyemia, 151 in renal tuberculosis, 209 in scarlatina, 102 examination of, y2j retention of, in peritonitis, 545 toxicity of, in sunstroke, 617 in typhoid fever, 65 Uroleucinic acid in urine, 560 Uroxanthic acid in urine, 560 Urticaria in jaundice, 531 Uvula, paralysis of, in diphtheria, 135 Vaccination, 265 complications of, 266 Vaccinia, 265 generalized, 266 Valvular disease of heart, 335 remote effects of, 2>2fi lesions, association of, 348 treatment of, 349 Varicella, 266 Variola, 256 benigna, 261 maligna, 261 vera, 259 Varioloid, 261 Varix of esophagus, 445 Vasomotor and tropic disorders, 701 Vegetations, endocardial, 330 verrucose, in malignant endocarditis, 332 Vertigo, auditory, 629 labyrinthine, 629 Visceroptosis, 507 Vocal cords, tuberculosis of, 190 Volvulus of intestine, 499 of stomach, 456 Vomiting in acute uremia, 561 in peptic ulcer, 461 780 INDEX Vomiting in typhoid fever, 60 nervous, 473 stercoraceous, in intestinal obstruction, 500 Vomitus, examination of, 724 in cancer of stomach, 465 in cholera infantum, 483 in dilated stomach, 457 Vulvovaginitis in mumps, 145 Wandering spleen, 313 Wasting palsy, 645 Water and other fluids, examination of, 749 infection by, in typhoid fever, 48 Weil's disease, 225 Welch's capsule stain, 744 Westphal's symptom, 648 Weyl's test for creatinin, 729 Whooping-cough, 142 associated with measles, 108 Widal's serum test, 717 Winckel's disease, 305 Winter cough, 390 Wool-sorters' disease, 232 Word-deafness, 629, 675 Word-dumbness, 674 Worms, 270 Wound diphtheria, 135 septicemia, 150 Wrisberg, nerve of, injury of, 628 Wrist-drop due to lead-poisoning, 611 Writer's cramp. 699 Wry-neck (see Torticollis), 5S6 Xanthelasma in jaundice, 531 Xanthin, 6 test for, 728 Xanthopsia due to santonin, 271 in jaundice, 531 Xerostomia, 436 Yeast-fungus in cancer of stomach, 466 in dilated stomach, 457 in the urine, 740 Yellow fever, 89 varieties of, 92 Yersin-Roux serum, 97 Ziehl's carbol-fuchsin solution, 743 Zona, 692 V'?.'^